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 Avalon Villa Care Center during CMS and state inspections, most recent first.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
A cognitively intact, quadriplegic resident who was dependent on staff for ADLs reported that a CNA became upset when the call light was used and directed profanity toward the resident during care. The resident informed the AD the next day, stated the treatment and language were disrespectful, and requested to speak with the SSD. The AD texted the SSD about the complaint, but the SSD did not meet with the resident that day due to other duties and did not speak with the resident until two days later. This sequence of events shows the facility did not follow its grievance policy requiring the Administrator and staff to make prompt efforts to resolve grievances submitted orally or in writing.
A resident with COPD, asthma, diabetes, and influenza, and a POLST allowing selective treatment and possible hospital transfer, experienced repeated episodes of O2 desaturation, vomiting, coughing, and respiratory distress. Earlier in the evening, an RN supervisor administered O2 via non-rebreather and nasal cannula, improved the resident’s O2 saturation, and notified the physician, who ordered comfort measures and continued monitoring. Later that night, documentation showed the resident became partially arousable, unresponsive to commands, and unable to accept medications, and was later observed with labored breathing and on O2, with vital signs unobtainable, before being found unresponsive with no pulse. During these later changes, staff did not document any further interventions or physician notification, despite facility policies and nursing job descriptions requiring prompt reporting and documentation of significant changes in condition.
A resident with mobility limitations and intact cognition required one-person assistance for bathing and had documented preferences for morning showers on specific days and shaving every two days. Staff instead followed a bed-based shower schedule on the evening shift, repeatedly telling the resident they were too busy or not assigned when he requested daytime showers and shaving. The resident reported not being offered showers on multiple occasions, including after returning from an out-of-facility pass on a scheduled shower day. CNAs and an LVN described a paper shower-sheet system that was not integrated into the EHR, did not clearly verify whether showers occurred, and was maintained by the DSD outside the medical record; missing shower sheets for the resident on scheduled days, along with the DSD’s acknowledgment that staff did not accommodate the resident’s preferences and that communication about showers was unclear, demonstrated the failure to provide and document ADL care as planned.
Incomplete ROM Assessments and Missed Restorative Services: The facility failed to complete full OT/PT ROM measurements and to provide ordered RNA restorative care for multiple residents with stroke-related weakness, paraplegia, contractures, and limited mobility. Ordered PROM, splinting, PRAFO use, and exercise programs were not consistently documented or carried out, and one resident’s ankle ROM worsened after therapy discharge. The DOR and PT stated ROM measurement is part of therapy practice and that the RNA program was intended to maintain joint mobility.
A resident with TBI, SAH, bipolar disorder, and later schizophrenia had repeated aggressive behaviors toward staff and others, including hitting, punching, throwing feces, kicking a CNA, and striking a charge nurse. Although a PASRR II report recommended MH rehab activities, psychotherapy counseling, psychology consultation, and social services consultation, the record lacked evidence of a psychologist order or visit, meaningful social services documentation, PASRR reevaluation, or IDT care conferences after each behavioral episode. The DON and DONT stated the resident needed a psychologist consult and PASRR reevaluation after the continued aggression.
A resident with a recent hemorrhagic stroke and scalp surgical incision had no care plan for neurological needs or incision care, and staff observed staples still present with no dressing while the site was not being monitored or treated. Another resident receiving Apixaban also had no individualized care plan for anticoagulant therapy, despite staff stating such plans should include bleeding monitoring, fall precautions, medication precautions, and notification parameters.
Failure to monitor a resident’s post-stroke cranial incision and arrange neurology follow-up. A resident with a history of intracerebral hemorrhage, CVA, and prolonged ICU care was observed with scalp staples and no dressing, while staff confirmed the incision had not been assessed or treated since admission. The treatment nurse and RN stated the facility lacked documentation of incision monitoring and had not scheduled a neurology appointment, despite notes deferring the issue to neurology.
A resident with TBI, bipolar disorder, schizophrenia, and brief psychotic disorder had severely impaired decision-making and total dependence for ADLs, yet continued to have repeated verbal and physical aggression, including hitting, kicking, throwing feces, and striking staff. The record showed ineffective redirection and medication, no documented IDT care conferences after each aggressive episode, no psychologist consult order or documented psychologist visits, and no meaningful social services or psychotherapy documentation despite PASRR recommendations for mental health rehab, psychotherapy, psychology, and social services support.
Licensed staff failed to administer meds as ordered for multiple residents. One resident did not receive vitamin D3 when it was unavailable, had lidocaine cream and patches applied at the same site with unclear orders and missing patch-removal documentation, and a nurse documented a patch as refused even though it was applied. Another resident missed several IV meropenem doses for sepsis, and the MD was not notified. A third resident received amlodipine without BP parameters in the order.
Dietary staff failed to follow approved recipes and texture-modified diet instructions. A cook added green bell peppers to beef patties even though they were not listed in the recipe, another cook prepared a texture-modified beef patty using a different beef and omitted eggs, milk, and breadcrumbs, and a second cook added parsley garnish to three Soft-and-Bite-Sized trays despite the spreadsheet indicating no garnish for texture-modified diets.
Texture-modified diets were not prepared as directed when a cook added a parsley garnish to Soft-and-Bite-Sized plates even though the spreadsheet called for no garnish, and when pork for a Soft-and-Bite-Sized meal was processed into a minced texture instead of being chopped to the specified size. The DSS stated the garnish posed a choking risk and that the pork appeared more like Minced-and-Moist than Soft-and-Bite-Sized.
Kitchen sanitation was deficient when a stand mixer had dried debris on the safety guard and under the splash guard, a countertop near the trayline was covered with crumbs, and the steam table still had egg debris from breakfast while food was being held for lunch. The DSS stated the mixer was rarely used, that it should be deep cleaned on delivery days, and that the debris on the countertop and steam table was a risk for contamination.
The facility had incomplete and inaccurate documentation for several residents’ records. A resident’s lidocaine patch was charted as refused even though it was applied, a resident’s GACH transfer lacked a nursing progress note and completed COC/transfer documentation, another resident’s IV meropenem doses and IV dislodgement were not documented, and two residents’ RNA services were signed by a different RNA than the one who provided the care.
Hand hygiene was not performed before and after direct resident contact during restorative nursing care. An RNA provided ROM and splint care to one resident with paralysis and contractures, then cared for two other residents with hemiplegia, dysphagia, contractures, anxiety disorder, and movement disorder without cleaning hands after glove removal or between resident contacts. The RNA acknowledged forgetting to wash or sanitize hands, and the IPN stated the facility was in a flu outbreak with 10 positive residents and that hand hygiene was required before and after resident contact and after glove removal.
A resident with an indwelling urinary catheter had the drainage bag left uncovered during observation, and an LVN confirmed there was no dignity cover in place. The resident had diagnoses including acute kidney failure, UTI, neuromuscular dysfunction of the bladder, MI, and DM, and the facility policy stated staff were to treat residents with dignity and help keep urinary catheter drainage bags covered.
Failure to Provide Timely Toileting Assistance and Privacy: A resident with hemiplegia, hemiparesis, and diabetes requested help to use the restroom, but an LVN dismissed the request, gave tissue instead of promptly assisting, and sent a CNA for toilet paper while both staff returned to other tasks. The resident became frustrated, then independently entered a shared bathroom without staff help or privacy protection, while the adjoining door remained open and another resident reported often helping because staff were busy.
A resident with severe cognitive impairment, no speech, and nonverbal communication needs was observed in bed with the call light dangling out of reach. The resident indicated he could not reach it, and an LVN acknowledged it was not within arm’s reach. The DON stated the call light was the resident’s lifeline for emergencies, and the facility policy required call lights to be accessible at all times.
Failure to notify MD of significant behavioral change: A resident with TBI, schizophrenia, brief psychotic disorder, and bipolar disorder exhibited inappropriate sexual behavior toward staff, including grabbing a CNA's buttocks and private area. The CNA reported the incident to an LVN and the DSD, but the LVN did not notify the physician or complete a change-of-condition note. The DON trainer stated the behavior should have been reported so the resident could receive a psych eval.
Inaccurate MDS Coding of Recent Neurosurgical Procedure: A resident with intracerebral hemorrhage, encephalopathy, and chronic respiratory failure had an MDS that failed to identify a recent ventriculostomy with EVD placement after an ICU stay for intraventricular hemorrhage. The QAN stated the MDS incorrectly showed no major surgical procedure during the prior hospital stay, which prevented the appropriate care area assessment from being triggered and contributed to the absence of care planning for the resident’s post-surgical and neurological needs.
Failure to Provide Communication Boards for Residents With Language and Speech Barriers: The facility did not provide communication boards for three residents with communication barriers, including a Korean-speaking resident, a Spanish-speaking resident, and a nonverbal resident with severe cognitive and speech impairment. Observations and interviews showed no communication board in the rooms, and staff relied on gestures, yes-or-no responses, or finding bilingual staff. Records and care plans identified the residents’ communication limitations and, for the nonverbal resident, the need for a communication board.
Failure to Report and Document Repeated Shower Refusals A resident with impaired cognition, physical debility, obesity, weakness, and mobility limitations was found repeatedly wearing soiled clothing and appearing unkempt while refusing showers. The care plan identified bathing and hygiene needs and noted a preference for sponge baths, but staff did not ensure the resident received bathing assistance as needed. A CNA stated the resident consistently refused showers and clothing changes but did not report the refusals to the charge nurse. An LVN said she was unaware the resident had gone without a shower and that refusals should have been reported and documented, while the DON trainer stated the refusal should have been communicated so the IDT or family could be involved.
Incorrect Low Air Loss Mattress Settings: Two residents with DM and impaired cognition had LALM orders tied to skin maintenance or wound management, but observations found the mattresses set above their recorded weights. Staff stated the LALM should be set according to the resident’s weight and physician’s order, and that incorrect settings would not be beneficial.
A resident's lighter was found on his bedside table in a shared room with another resident who was receiving continuous oxygen via concentrator. The resident had smoking-related care instructions stating his lighter and cigarettes were to be kept with Activities, but staff observed the lighter in the room and the assigned nurse was unaware he had it. Facility policy prohibited residents without independent smoking privileges from keeping smoking items and required removal of flammable items from the area where oxygen was administered.
A resident with intracerebral hemorrhage, encephalopathy, and chronic respiratory failure with hypoxia was ordered continuous O2 at 2 LPM, but the oxygen concentrator regulator lacked a visible flow indicator during repeated observations. An LPN stated she had not checked the concentrator and could not determine how much oxygen the resident was receiving; the facility policy required nursing staff to verify oxygen equipment was in good working order.
An LVN worked with an expired CPR certification, despite facility staff stating licensed staff should not work without current CPR credentials. The facility also administered tramadol to a resident when the documented pain level was above the ordered parameter, and it had an incomplete insulin sliding scale order for another resident that did not specify a dose for certain blood sugar ranges. Staff stated medication orders and parameters should be clarified for resident safety.
A facility failed to keep a medication cart clean and sanitary when a sticky liquid spill with crusty residue was found in the bottom drawer beneath multiple prescription and nonprescription bottles. The facility also failed to ensure an LVN stayed with a resident who was not approved for self-administration; the LVN left oral meds on the bedside table, and the resident took them independently despite having significant physical limitations and a medication assessment showing the resident was not a safe candidate for self-administration.
A resident with hemiparesis, cerebrovascular disease, prior TBI, and hand contracture did not receive OT and PT in accordance with the ordered treatment plans. The OT plan called for therapy 5x/week and the PT plan called for therapy 3x/week, but the DOR stated the resident did not receive OT and PT from the start of the plans until several days later. The resident was also observed sitting in a wheelchair with marked right-hand finger deformity and had documented ROM impairments, a recent fall, and decline in ADLs and mobility.
IPN Did Not Complete Required Annual Infection Control CE: The facility failed to ensure the IPN completed the required 10 hours of annual CE in infection prevention and control. Record review showed the IPN received only 1 hour of CE in one year and 2 hours in another, with no infection control training in the prior year. The IPN stated she did not know the annual 10-hour requirement, and the facility job description and AFL 20-84 both identified ongoing CE expectations for the IPN.
A resident who lacked decision-making capacity was administered Depakote for behavioral symptoms without documented informed consent from their responsible party. Staff interviews and record reviews confirmed that the required process for obtaining and verifying informed consent was not followed, despite facility policy mandating involvement of the resident's representative in medication decisions.
A resident with schizoaffective disorder, schizophrenia, and depression was prescribed Depakote for mood disorder with angry outbursts, but staff discontinued required behavior monitoring and documentation, preventing proper assessment of the medication's effectiveness as outlined in the care plan and facility policy.
Two residents with mobility impairments who used wheelchairs were not provided with enough space in their shared room to maneuver safely and comfortably. This resulted in their wheelchairs frequently bumping into each other, causing frustration and difficulty moving around, as confirmed by staff observations and resident interviews.
Three residents with significant care needs were left soiled for extended periods due to staff delays, lack of prompt response to call lights, and inadequate communication among staff. These delays occurred despite facility policies requiring prompt toileting assistance and placed residents at risk for discomfort and loss of dignity.
A resident admitted with hemiplegia and muscle weakness was identified as at risk for skin breakdown using the Braden Scale, but the care plan to address this risk was not initiated until nearly a month after admission. As a result, interventions such as repositioning, nutrition, and skin care were not formally documented or tracked in a timely manner.
A resident with a diabetic heel ulcer and multiple comorbidities was repeatedly observed bearing weight on both legs despite a non-weight bearing order. Nursing staff and the wound care specialist provided education, but the care plan was not updated to address the resident's ongoing noncompliance, as confirmed by the treatment nurse, RN, and DON. Facility policy required care plan revisions when a resident's condition changed, but this was not done.
A resident with diabetes, osteomyelitis, and impaired cognition had a non-weight bearing order for the right foot documented by a wound care specialist, but this order was not transcribed into the electronic health record. The order was communicated verbally and in writing to the treatment nurse, and the medical records and QA nurse were also responsible for reviewing and notifying staff of new orders. However, the order was not entered, resulting in the resident's care plan lacking this essential instruction.
A nurse held a scheduled dose of a muscle relaxant for a resident with multiple health conditions after administering a narcotic pain medication, without notifying the physician or documenting the reason. Facility policy required physician notification and order clarification before altering medication regimens, but this was not followed, resulting in an unapproved change to the resident's prescribed medications.
Licensed nursing staff failed to accurately document medication administration and blood pressure readings for a resident with complex medical needs. Midodrine was documented as given when blood pressure was above ordered parameters, and doses that were held were sometimes recorded as administered. Additionally, the reason for holding a muscle relaxant was not documented when it was withheld due to concurrent administration of a narcotic. These actions did not meet facility policy for accurate and complete documentation.
Hemodialysis Emergency Kit Not at Bedside: A resident with ESRD and a permacath for HD treatment did not have the required E-kit at the bedside. The care plan called for the kit to be available in the event of bleeding at the access site, and an LVN observed that it was missing and stated the absence of the kit could delay life-saving measures during an emergency. The facility policy required an emergency kit at the bedside of a dialysis resident containing a clamp, tape, 4x4s, and kerlix.
A kitchen staff member was observed working in the dishwashing area near food preparation without properly secured facial hair covering, as required by facility policy. The staff member was unaware that his hair netting had slipped out of place, and the Assistant Dietary Supervisor acknowledged the risk of hair contamination in food or on clean dishes.
A live cockroach was observed in a hallway near the kitchen, an area regularly used by residents, indicating the facility failed to maintain an effective pest control program. Although the pest control company provided regular services focused on the kitchen, pest sightings in the hallway were not addressed, and there was no documentation that recommendations were implemented or that problem areas were treated.
A resident who was cognitively intact but dependent on staff for ADLs was left in a soiled diaper for more than five hours, despite expressing discomfort and requesting to be changed. Staff failed to provide timely assistance, with one CNA stating she was too busy and another only notifying the assigned CNA. This inaction violated facility policy requiring prompt care and resulted in the resident feeling undignified.
A resident with multiple medical conditions and requiring maximum assistance with ADLs experienced a significant delay in call light response, remaining in a soiled diaper for over five hours. Staff failed to answer the call light within the facility's required timeframe, and care was not provided promptly despite the resident's visible discomfort and requests for assistance.
The facility did not provide pharmaceutical services to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in noncompliance with regulatory requirements.
A staff member was hired and worked as an LVN without a valid nursing license, administering controlled substances to several residents, including one with osteomyelitis. The facility failed to verify the staff member's credentials as required by policy, and this was acknowledged by the DSD, DON, and Administrator.
A staff member was hired and worked as an LVN without a valid license, administering controlled substances such as Norco, Oxycodone, Percocet, and Tramadol to multiple residents with serious conditions including fractures, osteomyelitis, and paraplegia. The facility failed to verify the staff member’s credentials, instead relying on a license belonging to another individual, and did not follow its own policy requiring license verification before employment.
A resident with major depressive disorder and moderate cognitive impairment was prescribed escitalopram, but staff did not implement or document required behavior monitoring to assess the medication's effectiveness. Interviews with nursing staff and the DON confirmed that behavior monitoring was not ordered or conducted, despite facility policy requiring such monitoring for psychotropic medication use.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A resident with major depressive disorder and moderate cognitive impairment did not have a care plan addressing their MDD, including non-pharmacological interventions, despite being dependent on staff for most activities and receiving antidepressant medication. Staff interviews and policy review confirmed the lack of a required, person-centered care plan for this diagnosis.
Two nurses were unable to demonstrate competency in the facility's abuse reporting policies, including not knowing the abuse coordinator or their mandated reporter responsibilities, despite having completed required training and documentation. This was identified through interviews and record reviews, revealing a gap between training and staff understanding of abuse reporting procedures.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Failure to Promptly Address Resident Grievance About Disrespectful CNA Behavior
Penalty
Summary
The deficiency involves the facility’s failure to follow its grievance/complaint filing policy requiring the Administrator and staff to make prompt efforts to resolve resident grievances. A resident with quadriplegia and other neurologic and musculoskeletal conditions, who was cognitively intact and dependent on staff for ADLs, reported that a CNA became upset when the resident pressed the call light and used profanity (“f***”) while providing ADL care. The resident stated this occurred in the evening and that he felt the CNA’s language and behavior were disrespectful. The next day, the resident reported this incident to the Activities Director (AD), stating he did not like how the CNA treated him and that the language used around him was disrespectful, and he requested to speak with the Social Services Director (SSD). The AD acknowledged that the resident reported the CNA’s use of the F word during care and that such behavior was not acceptable. The AD texted the SSD the same day, informing her that the resident wanted to speak with her regarding a complaint involving a nurse, and the SSD responded that she was in a meeting. The AD did not know whether the SSD spoke with the resident or whether the Administrator was informed. The SSD later stated she did not see the resident that day because she was very busy with new admissions and meetings and did not have the opportunity to speak with the resident until two days later. The DON stated that resident complaints should be addressed immediately and grievances resolved in a timely manner. The facility’s written grievance policy stated that the Administrator and staff will make prompt efforts to resolve grievances submitted orally or in writing, but in this case the resident’s grievance about staff behavior and language was not promptly addressed.
Failure to Intervene and Notify Physician for Resident With Respiratory Decline and Altered Consciousness
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services that met professional standards of practice for a resident with COPD, asthma, diabetes, and influenza, who had a POLST indicating DNR status but allowing selective treatment, including IV therapies, non-invasive positive airway pressure, and hospital transfer if comfort needs could not be met. The resident’s care plan directed staff to observe for signs and symptoms of respiratory insufficiency such as anxiety, confusion, and shortness of breath and to refer to the physician as needed. Physician orders allowed oxygen at 2 L/min via nasal cannula as needed for oxygen saturation below 93% on room air. On one day, a Change in Condition (COC) evaluation documented that the resident’s O2 saturation dropped to 88%, and oxygen was administered via non-rebreather mask, then changed to nasal cannula when stabilized. Progress notes later that evening documented another O2 desaturation to 88%, with oxygen via non-rebreather at 3 L/min improving saturation to 96%, then changed to nasal cannula with O2 saturation at 95–96%. The RN supervisor reported notifying the physician of the low O2 saturation and oxygen administration, and the physician ordered to make the resident comfortable and continue monitoring. Additional progress notes indicated that around 6:00 p.m. the resident had an episode of vomiting and continuous coughing, with O2 saturation less than 94%; the RN supervisor was notified and oxygen was administered, and the resident was monitored for decline. Later that night, progress notes documented that the resident was unable to accept medication due to partial waking and was unresponsive to commands, but there was no documentation of any interventions provided or physician notification regarding this change in condition. A subsequent note around 11:46 p.m. stated that on initial rounds the resident was observed on a non-rebreather mask at 8 L/min with labored breathing, and attempts to obtain vital signs were unsuccessful; on reassessment at approximately 11:46 p.m., the resident was unresponsive with no palpable pulse and no chest rise, and no code was initiated due to DNR status. This note also did not document any interventions for the labored breathing or physician notification at that time. A CNA reported observing the resident with labored breathing around 11:00 p.m. and notifying an LVN, who responded that the resident was a DNR. The physician later stated he had been informed earlier of the low O2 saturation that stabilized with oxygen and had instructed staff to continue monitoring, and that he was surprised to receive a later call informing him of the resident’s death, stating the resident should have been transferred to the hospital if the condition had not improved. The DON acknowledged that the resident had another significant change in condition and should have been transferred. Facility policies and job descriptions required prompt physician notification of significant changes in condition and documentation of such changes, which were not followed in this case.
Failure to Honor Resident Shower Preferences and Document ADL Care
Penalty
Summary
The facility failed to ensure that a resident received showers and grooming in accordance with his assessed needs and stated preferences. The resident was admitted with multiple mobility- and strength-related diagnoses, including generalized muscle weakness, abnormal gait and mobility, prior stroke, lumbar spondylosis, prior right femur fracture with internal fixation, and right hip osteoarthritis. His care plan for activities of daily living indicated he required one-person assistance with most bathing tasks due to decreased strength, limited balance, and reduced functional independence. An MDS assessment documented intact cognition, independence with eating and personal hygiene, and a need for maximal assistance with bathing and dressing. An IDT conference note recorded that the resident preferred showers before 10:00 a.m. on Mondays, Tuesdays, Wednesdays, Thursdays, and Saturdays, and preferred to be shaved every two days. Despite these documented needs and preferences, staff followed a shower schedule based on bed assignment rather than the resident’s individualized preferences. A CNA reported that residents in Bed A were scheduled for showers on Mondays and Thursdays during the 3 p.m. to 11 p.m. shift and that she reminded the resident his showers were scheduled for that shift when he requested showers during the day. The CNA stated the resident frequently asked for showers during the day and became upset when told of the evening schedule. The resident reported that he was not offered showers on several specific dates and that when he reminded staff, they told him they were too busy or not his assigned nurse, and they also refused to shave him when requested. He stated that on one scheduled shower day he left the facility in the morning and returned before lunch but was not offered a shower upon his return. The facility’s documentation and communication practices contributed to the missed showers and grooming. The CNA stated she was required to complete paper shower sheets and an ADL task flowsheet in the EHR, but the flowsheet did not indicate whether a shower was actually completed, and if a shower sheet was not completed and turned in, nursing staff would not know if a resident received a shower. An LVN confirmed that showers were documented only on shower sheets, which were reviewed and then sent to the Director of Staff Development (DSD), and that showers were not documented in the EHR; if a shower sheet was missing, there was no way to verify in the medical record that a shower occurred. The DSD stated that shower sheets, which listed multiple residents per page, were kept in her office and were not part of the resident’s medical record, and that there were no shower sheets for the resident for certain dates when showers were due. The DSD acknowledged that the CNA assigned on one of those dates did not offer the resident a shower, that staff were not accommodating the resident’s shower preferences, and that staff communication regarding showers was not clear. Facility policies on dignity, resident rights, and ADL support required that residents be groomed as they wished and receive appropriate assistance with hygiene in accordance with their plan of care.
Incomplete ROM Assessments and Missed Restorative Services
Penalty
Summary
The facility failed to provide services to maintain or improve range of motion and mobility for five sampled residents with positioning, mobility, and restorative nursing concerns. The deficiency involved incomplete joint range of motion assessments during OT and PT evaluations and missed restorative nursing services ordered to maintain function, including PROM, splinting, and orthotic use. The report identified residents with diagnoses such as stroke-related hemiparesis, paraplegia, muscle weakness, contractures, and reduced functional mobility, and described that the facility’s own policy required residents with limited ROM or mobility to receive treatment and services to increase or prevent further decrease in ROM and to maintain or improve mobility unless reduction was unavoidable. For one resident with paraplegia, contractures of both hands and the right thigh, and ROM limitations in both arms and legs, the OT evaluation did not include ROM measurements of both arms and the PT evaluation did not include measurements of both hips, the left knee flexion, and both ankles. After therapy discharge, physician orders and the care plan directed RNA services for PROM to both arms and legs and application of both hand splints and both leg splints/PRAFOs. The RNA flow sheets documented PROM to both arms and legs and hand splint use on multiple dates, but did not document application of the leg splints/PRAFOs. During observation, the resident’s middle, ring, and small fingers remained bent, both ankles were positioned in plantarflexion, and the resident stated the exercises and splints were not consistently provided. The DOR and PT later measured worsening ankle ROM compared with the PT discharge summary. For the other sampled residents, the facility also failed to document complete ROM measurements during therapy evaluations and failed to carry out ordered restorative exercises. One resident with hemiparesis and muscle weakness had PT and OT evaluations that did not fully measure ROM in both legs and both arms, and bicycle exercises ordered three times weekly were not provided during the identified period. Another resident with stroke-related weakness and contractures had OT and PT evaluations that did not include ROM measurements in both arms and both legs, and PROM to both arms and legs ordered three times weekly was not provided for several months. Two additional residents had OT and/or PT evaluations that did not include ROM measurements in both arms, and one of those residents also had PT evaluations that did not measure both arms. The DOR stated that ROM measurements are part of therapy practice and that the residents’ RNA programs were intended to maintain joint mobility after therapy ended.
Failure to Coordinate PASRR Findings With Ongoing Behavioral Assessment and Care Planning
Penalty
Summary
The facility failed to coordinate Resident 27’s PASRR Level II determination with ongoing assessment, interdisciplinary review, and care planning after the resident developed repeated and escalating behavioral incidents. Resident 27 was admitted with traumatic brain injury, traumatic subarachnoid hemorrhage with loss of consciousness, and bipolar disorder, and later was diagnosed with disorganized schizophrenia and brief psychotic disorder. The record also showed severe cognitive impairment on the MDS and total dependence for ADLs. Despite these findings, the resident’s history included multiple episodes of aggression toward staff and others, including hitting, punching, throwing feces and meal trays, ripping curtains, yelling profanities, grabbing and kicking a CNA, striking a charge nurse, and reaching toward another resident. The documentation showed that after these behavioral events, the IDT notes did not reflect care conferences after each episode of physical and verbal aggression. Following the resident’s readmission from the acute care hospital for striking out at staff, there was no documentation of reassessment of behavioral management needs, consideration of increased interventions, initiation of PASRR Level II re-evaluation, or discussion of discharge to a more specialized setting despite continued aggression. The most recent Behavioral Management IDT had occurred before the PASRR individualized determination report, and the nursing notes did not show that a PASRR reevaluation was requested. The PASRR individualized determination report recommended specialized add-on services including mental health rehabilitation activities, psychotherapy counseling, psychology consultation, and social services consultation. However, the order summary did not include a psychologist consultation order, physician progress notes did not show a psychologist visit, and social services notes did not document meaningful visits, mental health rehabilitation activities, or psychotherapy counseling. The DON and DONT stated the resident would have benefited from a psychologist consult and that a PASRR reevaluation should have been conducted after the continued aggression and verbal issues. The facility policy stated PASRR findings and required services were to be incorporated into the care plan and communicated to the IDT.
Missing Care Plans for Stroke, Surgical Incision, and Anticoagulant Therapy
Penalty
Summary
The facility failed to initiate and implement care plans for a resident with a recent intracerebral hemorrhage, encephalopathy, chronic respiratory failure with hypoxia, and a cranial surgical incision with staples. The resident had been admitted after a prolonged ICU stay for intraventricular hemorrhage, intubation, ventriculostomy, and EVD placement and removal. During observation, the resident was seen with three staples along a scalp incision and no dressing in place, and the resident stated staff had not assessed or treated the incision site. An LVN stated she was not aware of the recent surgical incision and that the facility had not been providing treatment or monitoring for the post-surgical incision. Record review and staff interviews showed there were no care plans addressing the resident’s stroke diagnosis or wound care needs. An RN reviewed the resident’s records and confirmed that no care plans were in place for the stroke or surgical incision. The RN stated care plans should have been started upon admission because the conditions were present at that time. The QAN also reviewed the resident’s MDS assessments and stated they inaccurately indicated the resident had not had any major surgical procedure during the prior inpatient hospital stay requiring active SNF care, and that this inaccuracy contributed to the absence of care planning for the resident’s post-surgical and neurological needs. The facility also failed to develop a care plan for another resident receiving Apixaban for acute embolism and thrombosis of unspecified deep veins of the lower extremities. Record review showed the resident was receiving Apixaban 5 mg twice daily, but the medical record did not contain a care plan addressing anticoagulant use. Staff stated that residents on anticoagulants should have individualized care plans including monitoring for signs and symptoms of bleeding, medication precautions, fall precautions, and notification parameters for abnormal findings. Staff acknowledged the omission and stated the care plan should have been developed and implemented to guide monitoring and interventions.
Failure to Monitor Post-Surgical Cranial Incision and Arrange Neurology Follow-Up
Penalty
Summary
The facility failed to provide necessary care and services to a resident with a history of intracerebral hemorrhage, encephalopathy, chronic respiratory failure with hypoxia, and stroke-related cognitive impairment. The resident had been admitted after a prolonged ICU stay for intraventricular hemorrhage and had undergone ventriculostomy with external ventricular drain placement and later removal. Facility records reviewed during the survey showed the resident remained dependent on staff for toileting, showering, and lower body dressing, and had an active CVA diagnosis. During observation, the resident was found in bed with three staples along a surgical incision on the scalp and no dressing was present. The resident stated staff had not assessed or treated the incision site. The treatment nurse stated she was not aware the resident had a recent surgical incision related to neurosurgical intervention and confirmed the facility had not been providing treatment or monitoring for the post-surgical incision. She stated it was important to monitor surgical incisions and ensure timely staple removal because skin could grow over the staples or infection could occur, and that a care plan should have been initiated to address wound care and follow-up orders for staple removal. Record review and staff interviews also showed there was no documentation that the resident’s post-surgical incision and staples had been assessed or monitored since admission. The RN stated there was no documentation that a neurology follow-up appointment had been scheduled, despite psychiatrist notes indicating the issue should be deferred to neurology. The RN stated licensed nursing staff should have advocated for a neurologist follow-up and should have appropriately assessed the resident’s skin on admission and ongoing thereafter. The facility policy on care plans stated assessments were ongoing and care plans were revised as resident conditions changed, and the RN supervisor job description stated the RN supervisor was to review new admissions and the plan of care.
Failure to Provide Mental Health and Psychosocial Services for a Resident with Repeated Aggression
Penalty
Summary
The facility failed to provide appropriate mental health and psychosocial treatment for Resident 27, who had a history of traumatic brain injury, traumatic subarachnoid hemorrhage with loss of consciousness, bipolar disorder, and later diagnoses of disorganized schizophrenia and brief psychotic disorder. The resident’s MDS showed severely impaired cognitive skills for daily decision making and total dependence on staff for ADLs. Although the H&P stated the resident had capacity to understand and make decisions, the record documented repeated episodes of verbal and physical aggression, including hitting, punching, throwing feces and meal plates, ripping curtains, yelling profanities, grabbing and kicking staff, striking a charge nurse, and reaching toward another resident. The record showed that redirection and medication for agitation and anxiety were not effective, and the resident continued to display aggressive behaviors across multiple nursing progress notes. On one occasion, 911 was called for increased agitation, and on another, the Psychiatric Mobile Response Team evaluated the resident for a possible 5150 hold and agreed the resident was not fit to be in the facility, though he was not transferable at that time. Despite these events, the interdisciplinary team notes did not show care conferences after each episode of aggression, and there was no documentation of reassessment of behavioral management needs, increased interventions, PASRR Level II re-evaluation, or discussion of discharge to a more specialized setting. The resident’s PASRR II individualized determination recommended specialized add-on services, including mental health rehabilitation activities, psychotherapy counseling, psychology consultation, and social services consultation. However, the order summary did not include a psychologist consultation order, physician progress notes did not show psychologist visits, and social services notes lacked documentation of meaningful visits, mental health rehabilitation activities, or psychotherapy counseling. Facility staff stated the resident would have benefited from a psychologist consult and that the lack of IDT meetings and psychological health resources resulted in missed opportunities to address the resident’s behavioral and mental health needs.
Medication Administration Errors and Missing Order Parameters
Penalty
Summary
Licensed staff failed to follow physician orders and medication administration requirements for multiple residents. For one resident with generalized muscle weakness and gait/mobility abnormalities, the record showed active orders for vitamin D3, lidocaine cream, and two lidocaine patch orders. During a medication pass, the nurse did not have vitamin D3 available and held the dose. The nurse also applied a lidocaine patch to the lower back while documenting it as refused, and the record showed repeated instances in which lidocaine cream and lidocaine patch were administered at the same location and around the same time. The chart also lacked documentation showing removal of the lidocaine patch 12 hours after application, and the orders did not clearly specify the location of application for the lidocaine products to prevent duplication of therapy. For another resident with dementia and COPD, the order summary directed meropenem IV every 12 hours for sepsis, but the IV MAR did not show doses given on multiple scheduled times. Nursing staff stated the missed doses were not reported to the physician, and the antibiotic course was not extended because the physician was not notified. The infection prevention nurse stated she was not aware of the missed doses and that the resident did not receive the ordered treatment as scheduled. For a third resident with diabetes, hyperlipidemia, and polyneuropathy, the physician order for amlodipine 10 mg daily did not include blood pressure parameters. The MAR showed the medication was administered without documented hold parameters. Nursing staff stated the order lacked the information needed to determine when the medication should be given or withheld based on blood pressure readings, and that antihypertensive medications require clearly defined parameters for safe administration.
Dietary staff failed to follow approved recipes and texture-modified diet instructions
Penalty
Summary
The facility failed to follow recipes for menu items prepared for residents. During a kitchen tour and interview, a cook was observed preparing beef patties with large chunks of green bell peppers mixed into the ground beef, even though the recipe for Southern Style Pattie did not list green bell peppers as an ingredient. The Dietary Services Supervisor stated he did not know why the peppers were included, and the cook stated she added them to give the patties more flavor. The supervisor also stated this could create a risk for an allergic reaction or result in serving a food item that may be listed as a dislike. The facility also did not follow the recipe for texture-modified versions of the beef patty. During lunch service, the texture-modified beef patty was observed to be a different texture than the ground beef, and the cook stated it was the same recipe with a different beef that was already chopped. The recipe required the regular texture version to be made with ground beef, egg, milk, breadcrumbs, and spices, then chopped into 1.5 x 1.5 cm pieces, but the Dietary Services Supervisor stated the facility substituted cubed beef stew meat and omitted the eggs, milk, and breadcrumbs. In addition, another cook placed parsley sprigs on three Soft-and-Bite-Sized plates even though the Cooks Spreadsheet indicated no garnish was to be included for any texture-modified diets. The supervisor confirmed the spreadsheet called for no garnish, and both cooks had signed an in-service on following recipes and spreadsheets.
Texture-Modified Diets Not Prepared as Directed
Penalty
Summary
The facility failed to provide appropriate texture-modified diets when a cook used a parsley sprig as garnish on three Soft-and-Bite-Sized plates even though the Cooks Spreadsheet indicated that no garnish was to be included for any texture-modified diets. During lunch service observation in the kitchen, the cook was seen assembling the plates with the garnish in place. The Dietary Services Supervisor stated that adding a parsley sprig posed a risk for choking and confirmed that the spreadsheet the cook was intended to follow indicated no garnish. The facility also failed to prepare pork for a Soft-and-Bite-Sized diet as directed. During observation, the cook sliced cooked pork and then placed it into a food processor, pulsing it to produce a minced texture, while stating it was being prepared for Soft-and-Bite-Sized texture. The recipe reviewed by surveyors directed staff to follow the original recipe for regular texture and then chop the pork into 1.5 x 1.5 cm pieces. The Dietary Services Supervisor stated the texture provided appeared more like Minced-and-Moist than Soft-and-Bite-Sized. An in-service dated 9/5/2025 indicated kitchen staff were instructed to follow recipes and spreadsheets, and the cook had signed that she attended the training.
Kitchen Food Debris Observed on Mixer, Countertop, and Steam Table
Penalty
Summary
Safe and sanitary food preparation practices were not maintained in the kitchen when a stand mixer, countertop, and steam table were observed with food debris during survey observations. On 1/5/2026, the stand mixer had dried light-yellow debris on the safety guard and similar debris with dried white powdery substances underneath the splash guard, which faced toward the mixing bowl where food was prepared. The Dietary Services Supervisor stated the mixer was rarely used, that cooks usually whisked by hand, and that the mixer was supposed to be deep cleaned on delivery days; however, the deep cleaning log did not identify the stand mixer as an item to be deep cleaned. The DSS also stated the debris could fall into the mixing bowl and potentially contaminate food served to residents. During additional kitchen observations, the countertop near the steam table where meal trays were assembled was covered with crumbs, and the steam table itself had chunks of yellow debris that the DSS identified as eggs from breakfast service. These conditions were observed while food was being held on the steam tables in preparation for lunch service. The cleaning log for the trayline area was signed off after each meal, but the debris remained visible during the survey observations. The DSS stated the debris on the countertop and steam tables was a risk for contamination.
Incomplete and inaccurate resident records for medications, transfers, IV therapy, and restorative services
Penalty
Summary
The facility failed to maintain complete and accurate medical records for five sampled residents. For Resident 63, who was admitted with generalized muscle weakness and gait and mobility abnormalities and was documented as cognitively intact and able to make decisions, an LVN prepared a lidocaine 5% patch for pain and applied it to the resident’s lower back after the resident refused application to the left shoulder. The eMAR, however, showed the lidocaine patch as refused rather than administered, and the record did not show removal of the patch after 12 hours as ordered. The LVN stated the patch should have been documented as administered and that the refusal entry was incorrect. For Resident 12, who had diagnoses including sepsis, PVD, DM, a chronic ulcer of the left foot with necrosis of bone, and traumatic amputation of a right lesser toe, the record did not contain a nursing progress note documenting the transfer to the GACH on 1/2/2026. The COC and transfer documentation were initiated but remained unsigned and not viewable in the medical record. Nursing and medical records staff stated the transfer documentation was expected to be completed and signed the same day, but the resident’s record did not include the required completed documentation describing the reason for transfer, the time the resident left, or the actions taken. For Resident 138, who had dementia and COPD and was described as alert and oriented times two with intact cognitive skills for daily decision making, the IV MAR did not show administration of meropenem at multiple scheduled times. The electronic record also did not document that the resident pulled out his IV line or that he missed doses because the IV was dislodged. Staff stated the resident removed his IV line, refused another one, and missed medication doses because he did not have IV access, but the progress notes did not document the medication error, the reason for the missed doses, or the physician notification. For Resident 37 and Resident 110, the RNA flow sheets showed another RNA signed for services provided on 1/6/2026 rather than the RNA who performed the treatments. Resident 37 had diagnoses including paralytic syndrome following cerebral infarction, paraplegia, muscle weakness, and contractures, and was observed receiving ROM exercises and hand splints. Resident 110 had hemiparesis following cerebral infarction, paralytic syndrome, a history of TBI, and hand contracture, and was observed receiving ROM exercises and a right-hand splint. Staff stated the RNA providing the treatment was supposed to document in the resident’s clinical record, but the records showed a different RNA’s signature for the sessions.
Hand Hygiene Not Performed Between Resident Contacts During Flu Outbreak
Penalty
Summary
The facility failed to perform hand hygiene before and after direct contact with three sampled residents during restorative nursing care. Resident 37 was admitted with paralytic syndrome following cerebral infarction, paraplegia, muscle weakness, and contractures to both hands and the right thigh, and had physician orders for restorative nursing aide services including hand splints, leg splints, and passive range of motion to both arms. Resident 114 was admitted with hemiplegia following a cerebral infarction affecting the right dominant side, dysphagia, and multiple contractures, and had an order for passive range of motion to both legs. Resident 48 was admitted with anxiety disorder and extrapyramidal and movement disorder. During observation, RNA 3 wore disposable gloves while providing range of motion and splint care to Resident 37, then discarded the gloves without performing hand hygiene. RNA 3 then provided care to Resident 114, discarded gloves, adjusted the resident in bed, retrieved a paper towel from the nursing station, returned to open a package of crackers, and then went to Resident 48's room to turn on the lights, speak briefly with the resident, and readjust the pillow, all without performing hand hygiene. RNA 3 stated she forgot to wash or sanitize her hands between contact with the residents and acknowledged that germs, including the flu virus, could transmit between residents without hand hygiene. The IPN stated the facility had a flu outbreak identified on 1/3/2026 with 10 residents testing positive, and the facility policy required hand hygiene immediately before touching a resident, after touching a resident, after touching the resident's environment, and immediately after glove removal.
Uncovered Urinary Catheter Drainage Bag
Penalty
Summary
The facility failed to ensure dignity, privacy, and respect were maintained for one resident when the indwelling urinary catheter drainage bag was left uncovered and without a dignity bag. During a concurrent observation and interview, the resident was seen with an uncovered urinary catheter drainage bag in the room, and the LVN confirmed that the bag did not have a dignity cover. The LVN stated the resident should have a dignity bag because other residents, visitors, and staff could see the catheter, and identified the lack of coverage as a dignity issue that could make the resident feel different, out of place, or embarrassed. The resident had been admitted and later readmitted to the facility and had diagnoses including acute kidney failure, UTI, neuromuscular dysfunction of the bladder, MI, and DM. The resident's H&P stated the resident had the capacity to understand and make decisions, while the MDS indicated severely impaired cognition and dependence for toileting, bathing, and personal hygiene, with an indwelling catheter in place. The facility policy on dignity stated residents were to be treated with dignity and respect at all times and that staff were to help residents keep urinary catheter drainage bags covered.
Failure to Provide Timely Toileting Assistance and Privacy
Penalty
Summary
The facility failed to ensure dignity, privacy, and respectful treatment for one resident during a toileting request. The resident had diagnoses including hemiplegia, hemiparesis following cerebral infarction, history of falling, syncope and collapse, and diabetes mellitus. The resident’s H&P indicated capacity to understand and make decisions, while the MDS indicated severely impaired cognitive skills and that the resident required maximal assistance for toilet hygiene and toilet transfer and moderate assistance for oral and personal hygiene. The care plan indicated the resident required extensive assistance by one staff member for toileting and that staff were to anticipate needs and support functional independence through safety-awareness. During lunch service, the resident, who was Spanish speaking, independently propelled his wheelchair into the hallway and repeatedly called out for the restroom. A Spanish-speaking visitor translated that the resident needed to use the restroom and that there was no toilet paper in the bathroom. In the resident’s presence, an LVN shook her head and rolled her eyes, stated that because he wore briefs he could not use the restroom, and retrieved facial tissue from a closet. The resident declined the tissue. The LVN then asked a CNA to get toilet paper, returned to the medication cart, and the resident went back to his room to wait. The CNA resumed passing meal trays and did not assist the resident further, and the LVN remained at the medication cart. The resident became frustrated, threw his hat to the floor, and then independently maneuvered to the bathroom using his cane to open the door. He entered the shared bathroom without staff assistance, with the adjoining bathroom door open so residents from the other room could look directly into the restroom. No staff member entered to assist with toileting or ensure privacy. The resident’s roommate stated he often helped the resident into the restroom because staff were busy and that the resident sometimes got locked inside and needed help opening the door. An LVN later asked if assistance was needed, but the resident had already completed toileting without assistance.
Call Light Not Within Reach for Nonverbal Resident
Penalty
Summary
The facility failed to ensure Resident 118 had access to a call light system to summon assistance. Resident 118 was admitted with diagnoses including compression of the brain, cerebral infarction, encephalopathy, encephalitis, encephalomyelitis, dysphagia, and major depressive disorder. The resident’s H&P noted fluctuating capacity to understand and make decisions, and the MDS indicated severely impaired cognitive skills, short-term and long-term memory problems, no speech, and rare or no ability to be understood to express ideas and wants. The care plan identified the resident as nonverbal, with difficulty communicating needs verbally, and stated that the resident communicated needs through nonverbal methods such as eye contact, touch, and pointing, and required a flat call light to communicate needs. During a concurrent observation and interview, the resident was lying in bed and unable to respond verbally. The call light was observed dangling on the left side of the bed, and the resident shook his head no when asked if he could reach it. The LVN acknowledged the call light was not within the resident’s reach and stated it should always be within arm’s reach, especially because the resident was nonverbal. The DON trainer stated the resident could not call for help if needed and that the call light was the resident’s lifeline for emergencies. The facility policy stated call lights were to be plugged in, functioning, and accessible to residents at all times.
Failure to Notify Physician of Significant Behavioral Change
Penalty
Summary
The facility failed to ensure the physician was notified of a significant change in condition when Resident 27 exhibited inappropriate sexual behavior toward staff. Resident 27 was admitted with diagnoses including traumatic brain injury, traumatic subarachnoid hemorrhage with loss of consciousness, disorganized schizophrenia, brief psychotic disorder, and bipolar disorder. The resident's MDS indicated severely impaired cognitive skills for daily decision making and total dependence on staff for ADLs, while the H&P stated the resident had the capacity to understand and make decisions. During interview, a CNA stated Resident 27 grabbed her buttocks and private area and laughed during the incident, and that she notified an LVN and the DSD. The LVN stated the physician should have been notified because the behavior represented a serious change in behavioral condition that required psychiatric evaluation, possible medication adjustment, or a 5150, but she did not complete a change of condition note or notify the physician because she did not think of it. The DON trainer stated the behavior should have been reported to the physician so the resident could have a psychiatric evaluation, and that the lack of physician notification placed residents and staff in danger of physical harm by Resident 27 and placed the resident at risk of worsening behavior.
Inaccurate MDS Coding of Recent Neurosurgical Procedure
Penalty
Summary
The facility failed to accurately assess and code a resident’s recent surgery on the MDS for Resident 65. Resident 65 was admitted with diagnoses including nontraumatic intracerebral hemorrhage, encephalopathy, and chronic respiratory failure with hypoxia. The MDS dated 9/16/2025 and 12/16/2025 indicated the resident’s cognitive skills for daily decision making were moderately impaired, that the resident was entirely dependent on staff for toileting, showering, and lower body dressing, and that the resident had an active diagnosis of CVA or stroke. The MDS also indicated the resident did not have any major surgical procedures during the prior inpatient hospital stay that required active care in the facility. Record review showed the hospital documentation identified that Resident 65 was admitted to the ICU for intraventricular hemorrhage, required immediate intubation, and underwent ventriculostomy with EVD placement on 8/6/2025, with removal on 8/12/2025. During interview and record review, the QAN stated the MDS Nurse inaccurately indicated the resident did not have any major surgical procedures during the prior inpatient hospital stay requiring active skilled nursing care. The QAN stated the MDS should have reflected the resident’s recent surgery so the appropriate care area assessment could have been triggered and used in care planning, and that the inaccurate assessment contributed to the absence of care planning for the resident’s post-surgical and neurological needs.
Failure to Provide Communication Boards for Residents With Language and Speech Barriers
Penalty
Summary
The facility failed to provide communication boards for three residents with communication barriers: one resident who spoke Korean, one resident who spoke Spanish, and one resident who was nonverbal. The deficiency was identified through observation, interview, and record review, and involved residents whose records reflected language barriers, impaired cognition, or inability to speak. Facility staff and family members stated that the residents had difficulty communicating their needs without an effective communication tool. Resident 6 was admitted with diagnoses including DM, HTN, visual hallucinations, depression, dysphagia, and muscle weakness. The H&P stated the resident did not have capacity to understand and make medical decisions, and the MDS indicated severely impaired cognition. During observation, no communication board was present in the room. The resident stated “Korean” and was unable to answer other questions. The resident’s family member stated the resident was [NAME]-speaking and could understand only very basic English words, not enough to explain needs, symptoms, or concerns. Resident 57’s record showed diagnoses including DM, muscle weakness, chronic pulmonary edema, and atrial fibrillation, with the H&P indicating capacity and the MDS indicating intact cognition. During observation, no communication board was present in the room. The resident stated Spanish was her primary language and that she did not understand English. She stated she had not been provided with a communication board and had difficulty communicating with staff who did not speak Spanish. CNA staff stated they used hand gestures, facial expressions, or tried to find Spanish-speaking staff, and acknowledged they were not aware of communication boards in the facility. Resident 118’s record showed diagnoses including compression of the brain, cerebral infarction, encephalopathy, encephalitis, and encephalomyelitis. The H&P indicated fluctuating capacity, and the MDS showed severely impaired cognitive skills, memory problems, no speech, and dependence with toileting, bathing, oral hygiene, and personal hygiene. The care plan identified the resident as nonverbal and stated a communication board was required. During observation, the resident was unable to respond verbally, and LVN staff stated the resident did not have a communication board because staff communicated by yes-or-no responses. The LVN acknowledged that a communication board would have been helpful, and the resident indicated yes when asked if it would have helped. The SSD and DONT stated residents with communication problems should have communication boards, and the facility policy stated communication boards were to be provided to residents who were non-English speaking or aphasic.
Failure to Report and Document Repeated Shower Refusals
Penalty
Summary
The facility failed to ensure Resident 13 received bathing assistance as needed and failed to ensure refusals of showers were reported, documented, and communicated to the interdisciplinary team. Resident 13 was admitted and later readmitted to the facility with diagnoses including encephalopathy, age-related physical debility, morbid obesity, muscle weakness, abnormality of gait and mobility, osteoporosis, and osteoarthritis. The resident’s MDS indicated moderately impaired cognition and that the resident was independent with eating, oral hygiene, toileting, and bathing, oral, but needed setup/clean-up assistance with personal hygiene. Resident 13’s care plan identified bathing and hygiene needs and documented a preference for sponge baths in the bathroom, with refusal of showers. The care plan directed staff to honor the resident’s bathing preferences, provide privacy, and provide soap, washcloths, and towels daily to maintain cleanliness and hygiene. An IDT conference note stated the resident required set-up to limited assistance with ADLs and was placed on an observation period for reevaluation of ADL needs. During observations, Resident 13 was repeatedly seen in bed wearing the same soiled clothing over multiple days and appeared unkempt and confused. The resident stated she had not had a shower recently and said it was difficult to get a shower because the lines were too long. CNA 5 stated Resident 13 was scheduled for showers on Mondays and Thursdays, that the resident consistently refused showers and clothing changes, and that refusals were required to be reported to the charge nurse, but the CNA acknowledged she did not report the refusal. LVN 3 stated she was unaware the resident had not received a shower and that refusals should have been reported on the first day of refusal and documented in progress notes. The DONT stated the CNA should have reported the refusal so the facility could have involved the IDT or family member to encourage bathing.
Incorrect Low Air Loss Mattress Settings
Penalty
Summary
The facility failed to ensure that low air loss mattress settings were accurately set to reflect the residents’ weights for two residents at risk for pressure injuries. Resident 24 was admitted with diagnoses including DM and CKD, had fluctuating capacity to understand and make decisions, and was assessed as moderately impaired in cognitive skills for daily decision making. Resident 24’s records showed a weight of 130 lbs and an order for a low air loss mattress for skin maintenance, but during observation the mattress was set at 250 lbs. Resident 100 was originally admitted and later readmitted with diagnoses including DM and HTN, had fluctuating capacity to understand and make decisions, and was assessed as moderately impaired in cognitive skills for daily decision making. Resident 100’s records showed a weight of 131 lbs and an order for a low air loss mattress for wound management, but during observation the mattress was set at 180 lbs. Staff interviews indicated the mattress should be set according to the resident’s weight and physician’s order, and that if it was not set correctly it would not be beneficial to the resident.
Lighter Left Near Resident on Continuous Oxygen
Penalty
Summary
The facility failed to ensure a safe environment for two sampled residents when Resident 40's lighter was left on his bedside table in a shared room with Resident 65's oxygen concentrator. Resident 65 was admitted with diagnoses including nontraumatic intracerebral hemorrhage, encephalopathy, and chronic respiratory failure with hypoxia, and the MDS indicated moderately impaired cognitive skills for daily decision making and total dependence on staff for toileting, showering, and lower body dressing. Physician orders directed continuous oxygen at 2 LPM. Resident 40 was admitted with diagnoses including a displaced trimalleolar fracture of the lower right leg and schizophrenia. His MDS indicated intact cognitive skills for daily decision making, and the H&P stated he had the capacity to understand and make decisions. His smoking assessment indicated he was able to safely smoke with supervision, and the care plan stated his lighter and cigarettes would be kept with the Activities Department. During observation, Resident 40's lighter and cigarette were seen on his bedside table, and Resident 40 stated he bought the lighter himself. The ADA stated residents who smoked were not permitted to carry their own lighters, and LVN 1 stated she was not aware Resident 40 had possession of a lighter. The facility's smoking policy stated residents without independent smoking privileges may not have or keep smoking items except under direct supervision, and the oxygen administration policy stated staff were to remove potentially flammable items from the immediate area where oxygen is administered.
Oxygen Concentrator Lacked Visible Flow Indicator
Penalty
Summary
The facility failed to ensure oxygen delivery equipment functioned properly for one sampled resident, Resident 65. Resident 65 was admitted with diagnoses including nontraumatic intracerebral hemorrhage, encephalopathy, and chronic respiratory failure with hypoxia. The resident’s MDS indicated moderately impaired cognitive skills for daily decision making and total dependence on staff for toileting, showering, and lower body dressing. Physician orders directed oxygen at 2 LPM continuously every shift, and the care plan included the same oxygen intervention. During observations in the resident’s room, the oxygen concentrator lacked a visible flow indicator. On concurrent observation and interview, an LVN again observed that the oxygen concentrator regulator lacked a visible flow indicator and stated she had not checked the oxygen concentrator for Resident 65. The LVN stated she could not determine how much oxygen the resident was receiving and that the missing flow indicator placed the resident at risk for over- or under-oxygenation. The facility’s Oxygen Administration policy stated licensed nursing staff were to review physician orders or facility protocol for oxygen administration and check equipment such as the mask, tank, and humidifying jar to ensure they were in good working order.
Expired CPR Certification and Unclear Medication Orders
Penalty
Summary
The facility failed to ensure that an LVN maintained current CPR certification. During interview and record review, the Director of Staff Development reviewed the LVN’s employee file and stated the CPR certification had expired. The DSD stated licensed staff should not work without current CPR certification and that the LVN should have been removed from the schedule until the certification was updated. The Director of Nursing Trainer also stated CPR training was required so licensed staff could appropriately respond to a resident’s change in condition, including performing CPR during a medical emergency. Facility policies reviewed stated nursing staff must meet competency and certification requirements and maintain CPR and BLS certification. The facility also failed to clarify a physician order before administering tramadol to a resident with pain. Resident 22 was admitted with diagnoses including right femur internal fixation device and neuropathy, and the record showed fluctuating capacity to understand and make decisions, with the MDS indicating intact cognitive skills for daily decision making. The order summary directed tramadol 50 mg every 6 hours for moderate pain rated 5 to 7 out of 10. The MAR showed the resident received tramadol on two occasions when the pain level was documented as 8 out of 10. The LVN stated she did not know the medication was only indicated for pain rated 5 to 7 out of 10 and said she should not have administered it because the resident’s pain was higher than the ordered parameter. The facility also failed to clarify an incomplete insulin sliding scale order for another resident. Resident 54 had diagnoses including DM and HTN, and the H&P stated the resident did not have capacity to understand and make decisions; the MDS indicated moderately impaired cognitive skills for daily decision making. The order summary directed insulin aspart before meals and at bedtime, but it did not specify how many units to administer for blood sugar levels between 351 and 450 mg/dL. The sliding scale listed doses for 201 to 250, 251 to 300, 301 to 350, and 451 to 500 mg/dL, but not for 351 to 400 mg/dL. The MAR also reflected that the sliding scale was missing for a blood sugar of 351 to 400 mg/dL. An LVN and an RN stated licensed staff were responsible for clarifying physician orders and that all insulin orders must be complete with sliding scales.
Medication Storage and Supervision Deficiencies
Penalty
Summary
The facility failed to maintain a clean, sanitary, and safe environment for medication storage in the bottom drawer of the West Station Medication Cart. During observation, the bottom drawer contained a spillage of sticky liquid, including clear liquid and yellow crusty formation, with nine prescription and nonprescription bottles placed on top of the spill. The Interim Director of Nursing stated the medication carts should have been clean, secure, and well organized, and that charge nurses should proactively check the carts for cleanliness. The facility policy on Medication Labeling and Storage stated nursing staff are responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. The facility also failed to ensure a licensed nurse did not leave medications unattended for Resident 37, who had paralytic syndrome following cerebral infarction, paraplegia, muscle weakness, contractures to both hands and the right thigh, and significant assistance needs for activities of daily living. The resident's MDS indicated intact cognition, but the Self Administration of Medication Assessment stated the resident was not a candidate for safe self-administration of medications. During observation, an LVN placed a cup with multiple medications and a liquid medication on the resident's bedside table and left the room while the resident drank the liquid medication and swallowed the other medications independently. The resident did not know the name or purpose of the liquid medication, and the LVN stated she usually left medications on the bedside table and returned after two to three minutes, although she acknowledged she was supposed to be present while the resident took the medications. The facility policy on Administering Oral Medications stated the licensed nurse was to remain with the resident until all medications had been taken.
Failure to Provide Ordered OT and PT Services
Penalty
Summary
The facility failed to provide specialized rehabilitative services as required for one resident with hemiparesis following cerebral infarction, paralytic syndrome following cerebrovascular disease, a personal history of TBI, and contracture of an unspecified hand. The resident’s MDS indicated unclear speech, difficulty communicating some words or finishing thoughts, intact cognition, and ROM impairments in both arms and legs. The resident also required assistance with dressing and had a decline in ADL and mobility after a fall, according to the OT evaluation. The OT plan of treatment dated 12/14/2025 called for therapy five times per week for four weeks, and the PT plan of treatment called for therapy three times per week for four weeks. OT treatment notes showed services on 12/23, 12/25, 12/26, 12/30, 1/1, and 1/2, and PT notes showed services on 12/23, 12/24, 12/25, 12/26, 12/30, 12/31, 1/1, and 1/2. During interview and record review, the DOR stated the resident did not receive OT and PT treatment from 12/14 to 12/23 in accordance with the treatment plans. During observation, the resident was sitting in a wheelchair with the right-hand fingers bent completely at the knuckles and middle joints and hyperextended at the tip joints.
IPN Did Not Complete Required Annual Infection Control CE
Penalty
Summary
The facility failed to ensure the Infection Preventionist Nurse (IPN) completed 10 hours of continuing education in infection prevention and control on an annual basis. During record review, the IPN’s infection control training certificate dated 12/2025 showed she received 1 hour of CE. In a concurrent interview and record review on 1/7/2026, the IPN stated she received training to become an IPN in 2022, received 16 CE hours in 2023, did not receive infection control training in 2024, received 1 CE hour in 2025, and took another infection control training in 12/2025 totaling 2 CE hours. The IPN stated she did not know there was a requirement for 10 CE hours on an annual basis. She also stated it was important to have those 10 hours to serve residents and train staff on updated infection control practices. Review of California Department of Public Health AFL 20-84 showed IPNs must complete 10 hours of continuing education in infection prevention and control annually and stay updated through a nationally recognized infection prevention and control association. Review of the facility’s 2023 Infection Preventionist job description showed the IPN must receive infection preventionist education, complete certification training, and attend continuing education programs to stay updated on changes in the profession.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain informed consent from the responsible party prior to administering Depakote, an anticonvulsant medication, to a resident diagnosed with schizoaffective disorder, schizophrenia, and depression. The resident was determined to lack the capacity to make healthcare decisions, and a responsible party was designated to make such decisions on their behalf. Despite this, there was no documented verification that the responsible party was informed about the risks, benefits, and alternatives to Depakote before it was administered for mood disorder symptoms, specifically angry outbursts. Interviews with facility staff confirmed that the process for obtaining informed consent required the physician to explain the medication and its effects to the responsible party, with nursing staff responsible for verifying that consent was obtained before administration. Record review showed that while informed consent documentation existed for other antipsychotic medications, none was present for Depakote. Facility policies also required that residents or their representatives be informed and involved in medication management, including the right to refuse treatment, but this process was not followed in this instance.
Failure to Monitor and Document Psychotropic Medication Effectiveness
Penalty
Summary
The facility failed to consistently monitor and document the behaviors of a resident with a history of schizoaffective disorder, schizophrenia, and depression, who was prescribed Depakote for mood disorder manifested by angry outbursts. According to the resident's care plan, staff were required to monitor and document episodes of angry outbursts every shift to assess the effectiveness of the medication regimen. However, behavior monitoring was discontinued on 10/14/2025 and was not reordered, despite ongoing orders for Depakote and the continued need to evaluate behavioral symptoms. Record review and staff interview confirmed that the lack of behavior monitoring meant the healthcare team did not have the necessary information to determine the efficacy of the medication or to make informed decisions about potential dose adjustments. The facility's policy required staff to observe, document, and report on the effectiveness of interventions, including antipsychotic medications, but this was not followed for the resident in question.
Failure to Provide Adequate Space for Wheelchair Mobility
Penalty
Summary
The facility failed to provide adequate space and equipment to meet the needs of two residents who both required wheelchairs for mobility. Observations and interviews revealed that the room shared by these residents did not allow sufficient space for them to maneuver their wheelchairs without bumping into each other. Both residents had medical conditions affecting their mobility, including hemiplegia, hemiparesis, generalized muscle weakness, and foot drop. Documentation indicated that both residents had intact cognition or fluctuating capacity to make decisions, and both required moderate assistance with activities of daily living. The lack of space led to repeated incidents where their wheelchairs collided, causing frustration and making it difficult for them to move around their room safely and comfortably. Staff interviews, including those with the Social Services Director and the Administrator, confirmed that the room arrangement did not accommodate the residents' needs, resulting in miscommunication and disagreements between the residents. The facility's own policy required adaptation of the physical environment to meet individual needs and preferences, but this was not implemented in this case. The deficiency was directly observed by staff and corroborated by resident statements, with specific incidents such as a water pitcher being knocked over due to the lack of space.
Failure to Provide Timely Incontinence Care Compromising Resident Dignity
Penalty
Summary
The facility failed to provide timely incontinence care for three residents who were dependent on staff for toileting and hygiene, resulting in prolonged periods where residents remained soiled. One resident, with diagnoses including muscle weakness, ESRD, and impaired cognitive skills, was left sitting in a soiled incontinence pad for approximately six hours after a bowel movement. The resident had requested assistance multiple times, but after refusing care from the assigned CNA, no alternative staff was arranged in a timely manner. The CNA did not inform the charge nurse when unable to secure another CNA, resulting in a significant delay before care was provided. Another resident, who required partial to moderate assistance for toileting and was at risk for pressure ulcers, experienced a delay of about an hour before receiving incontinence care. The resident had requested to be cleaned and was told by the CNA that care would be provided after attending to another resident. Due to staff shortages, the resident remained soiled for an extended period, which the CNA acknowledged could place the resident at risk for skin breakdown and affect their dignity. A third resident, with hemiplegia and requiring substantial assistance for toileting, also experienced excessive wait times for incontinence care. The resident and a family member reported waiting up to an hour and a half for pericare, with the resident stating that staff did not change her throughout the night shift. The assigned CNA confirmed the delay, citing being occupied with other residents and additional duties. Facility policies reviewed indicated that staff were required to promptly respond to toileting requests and maintain residents' dignity, but these standards were not met in the cited incidents.
Delayed Care Plan for Skin Breakdown Risk
Penalty
Summary
The facility failed to develop a comprehensive care plan in a timely manner for a resident who was at risk for skin breakdown. The resident was admitted with diagnoses including right hemiplegia, hemiparesis, and muscle weakness, and was identified as being at risk for skin breakdown based on a Braden Scale assessment conducted at admission. Despite this assessment, the care plan addressing the risk for skin breakdown was not initiated until nearly a month after admission. Interviews and record reviews confirmed that interventions such as repositioning every two hours, maintaining cleanliness, and providing proper nutrition were not formally documented or tracked due to the delayed care plan. The facility's policy required that a comprehensive, person-centered care plan be developed within seven days of the required assessment, but this was not followed, resulting in a lack of timely preventative measures and monitoring for the resident.
Failure to Update Care Plan for Noncompliance with Non-Weight Bearing Order
Penalty
Summary
The facility failed to update the care plan for a resident with a diabetic ulcer on the right heel, who was noncompliant with a non-weight bearing order. The resident, admitted with diagnoses including osteomyelitis, type-2 diabetes mellitus, and hypertension, was observed multiple times bearing weight on both legs and walking, despite recommendations from the wound care specialist and education provided by nursing staff. Documentation in the resident's records, including the Non-Pressure Injury Skin Problem Report and Skin/Wound Notes, indicated ongoing noncompliance with the non-weight bearing order. Interviews with the treatment nurse, RN, and DON confirmed that the resident's care plan had not been revised to address the noncompliance, even though the facility's policy required care plans to be updated as residents' conditions changed. The lack of care plan revision meant that interventions to address the resident's noncompliance were not implemented, as acknowledged by the staff involved in the resident's care.
Failure to Transcribe Non-Weight Bearing Order for Resident with Diabetic Foot Ulcer
Penalty
Summary
A deficiency occurred when a non-weight bearing order for a resident's right foot, as prescribed by the wound care specialist, was not transcribed into the resident's electronic health record. The resident, who was admitted with diagnoses including osteomyelitis, type-2 diabetes mellitus, and hypertension, had moderately impaired cognition and required significant assistance with activities of daily living. The resident also had diabetic foot ulcers requiring wound dressings. During review, it was found that the wound care specialist's visit note documented the non-weight bearing order, but this order was not entered into the resident's active orders. Interviews with the RN and DON revealed that the process for handling new orders involved verbal and written communication from the wound care specialist to the treatment nurse, who was responsible for entering the orders. Additionally, the medical records and QA nurse were expected to review the wound care notes and notify nursing staff of new orders. Despite these procedures, the non-weight bearing order was not transcribed, resulting in the absence of this critical instruction in the resident's care plan.
Failure to Notify Physician and Clarify Orders Before Holding Scheduled Medication
Penalty
Summary
A deficiency occurred when a licensed nurse failed to notify the physician and obtain clarification before holding a scheduled dose of methocarbamol, a muscle relaxant, for a resident with multiple medical conditions including muscle weakness, end stage renal disease, and impaired cognitive skills. The nurse held the 6 a.m. dose of methocarbamol after administering Norco, a pain medication, believing that muscle relaxants should not be given concurrently with narcotics due to the risk of respiratory compromise. However, there was no physician order or documentation supporting this decision, and the reason for holding the medication was not recorded in the Medication Administration Record or Nursing Progress Notes. Facility policy required that medications be administered as prescribed and that any concerns about medication appropriateness or potential adverse consequences be discussed with the attending physician or medical director. The Director of Nursing confirmed that nurses were expected to assess residents and administer medications as ordered unless otherwise specified by a physician, and that holding a scheduled medication without provider notification and order clarification did not meet facility expectations. This resulted in an unapproved alteration of the resident's medication regimen.
Failure to Accurately Document Medication Administration and Blood Pressure Readings
Penalty
Summary
Licensed nursing staff failed to ensure accurate and reliable documentation of medication administration for a resident with multiple complex medical conditions, including end stage renal disease, muscle weakness, and hypertension. The resident had physician orders for midodrine to be administered only if systolic blood pressure (SBP) was 110 or below, as well as orders for methocarbamol and Norco. However, the Medication Administration Record (MAR) showed that midodrine was documented as given on several occasions when the resident's SBP was above the ordered threshold. Interviews with nursing staff revealed that doses were sometimes held but mistakenly documented as administered, and in one instance, a nurse incorrectly recorded the resident's SBP. Additionally, there was a failure to document the reason for holding methocarbamol. One nurse held the medication due to concurrent administration of Norco, believing it was unsafe to give both at the same time, but did not record this rationale in the MAR or nursing notes. This omission meant that subsequent staff were not informed of the reason for the held dose. The facility's policies required that all services, medication administration, and changes in resident condition be accurately documented to ensure communication among the care team. The Director of Nursing confirmed that all MAR entries, blood pressure readings, and nursing notes should accurately reflect the care provided. The lack of accurate documentation and communication regarding medication administration and resident condition was acknowledged by staff and leadership as not meeting facility policy and professional standards.
Hemodialysis Emergency Kit Not at Bedside
Penalty
Summary
Provide safe, appropriate dialysis care/services for a resident who requires such services was not met when the facility failed to ensure a Hemodialysis Emergency Kit was at the bedside of Resident 1, who had a permacath for hemodialysis treatment. Resident 1 was admitted with diagnoses including ESRD, a cardiac pacemaker, and muscle weakness. The MDS dated 9/19/2025 indicated the resident had clear speech, had difficulty communicating some words or finishing thoughts but was able to do so if prompted or given time, and required supervision or touching assistance with eating, oral hygiene, and personal hygiene. Resident 1's care plan identified a permacath hemodialysis access on the right upper chest related to ESRD and included interventions to monitor the site for signs and symptoms of infection, keep a dialysis E-kit at the bedside in the event bleeding occurred at the access site, apply pressure, call 911, and notify the medical doctor. During a concurrent observation and interview on 11/21/2025 at 12:05 p.m., LVN 1 looked for the Hemodialysis E-kit at the bedside but could not find it and stated that not having the kit at the resident's bedside can cause delay in providing life-saving measures during an emergency. The facility policy titled Hemodialysis Access Care stated that in case of an emergency, an emergency kit should be at the bedside of a dialysis resident and contain a clamp, tape, 4x4s, and kerlix.
Failure to Ensure Proper Hair Covering in Kitchen
Penalty
Summary
During an observation in the facility's kitchen, a staff member working as a dishwasher was seen with facial hair that was not properly covered by the required hair netting or beard restraint while working in the dishwashing area near the food preparation station. The staff member stated he was unaware that his hair covering had slipped out of place and believed his facial hair was still covered. The Assistant Dietary Supervisor confirmed that a hair covering not properly secured could result in hair falling into food, clean dishes, or the food preparation area, which would increase the risk of food contamination. Review of the facility's policy indicated that all food service employees must wear hair nets and/or beard restraints to prevent hair from contacting exposed food, clean equipment, and utensils.
Failure to Maintain Effective Pest Control Program Resulting in Cockroach Presence
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of live cockroaches in a resident-accessible hallway near the kitchen. During an observation with the DON, a live cockroach was seen crawling on the wall in an area regularly used by residents to access the dining room and activity area. The DON acknowledged that the presence of cockroaches in this location created the potential for unsanitary conditions and the spread of pests into food preparation and resident living spaces. The facility's pest control company was reported to provide monthly services, and the maintenance supervisor was responsible for follow-up on pest issues. A review of pest control service invoices showed that weekly services were primarily focused on the kitchen, and pest sightings in the hallway had not been addressed because these areas were not prioritized. The maintenance supervisor could not provide information on the facility's efforts to implement pest control recommendations or ensure elimination of cockroaches. The administrator confirmed that while routine pest control services were conducted, there was no documentation that specific problem areas, such as the main hallway near the kitchen, were evaluated or treated. The facility's policy required maintaining an environment free of pests and rodents.
Resident Left in Soiled Diaper for Over Five Hours, Dignity Not Maintained
Penalty
Summary
A resident with a history of a left tibia fracture, COPD, diabetes mellitus, and schizophrenia, who was cognitively intact but required maximum assistance for activities of daily living, was left in a soiled diaper for over five hours. The resident was observed to be awake, fidgeting, and visibly uncomfortable, and expressed frustration about not being changed. Despite the resident's request for assistance, a CNA informed the resident that she would notify the assigned CNA but did not provide care herself. Another CNA later stated she was too busy with other residents to assist, acknowledging that the resident was not provided dignity or able to exercise her rights. Facility policy required that residents wait no longer than two minutes to be changed and emphasized treating residents with dignity, respect, and kindness at all times. The failure to provide timely incontinence care resulted in the resident feeling upset and undignified, directly contravening the facility's stated policies and procedures regarding resident rights and dignity.
Delayed Call Light Response and Resident Care
Penalty
Summary
Staff failed to answer a resident's call light in a timely manner, as observed when a call light and audible tone outside the resident's room went unanswered for approximately 27 minutes. The resident, who was admitted with diagnoses including a nondisplaced spiral fracture of the left tibia, COPD, diabetes mellitus, and schizophrenia, required maximum assistance with activities of daily living and had intact cognition. During the period of delay, the resident was found awake, fidgeting, and visibly uncomfortable, expressing frustration about having been left in a soiled diaper for more than five hours and requesting to be changed. A Certified Nurse Assistant (CNA) entered the room but did not provide care, stating she would notify the assigned CNA. The facility's policy, as confirmed by the Director of Nursing, required call lights to be answered within two minutes, and the written procedure indicated calls should be answered immediately. The delay in response was directly observed and confirmed through staff interviews and review of facility policy.
Failure to Provide Required Pharmaceutical Services
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place as mandated by regulations. No additional details regarding specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Unlicensed Staff Hired and Functioning as LVN
Penalty
Summary
The facility failed to ensure that its credentialing process was completed prior to hiring a staff member as a Licensed Vocational Nurse (LVN). Staff 1 was hired and worked as an LVN for over a year and a half without a valid nursing license. Review of the personnel file showed that Staff 1 only had a California ID and Social Security card, with no evidence of LVN license verification. The Director of Staff Development (DSD) confirmed that no license verification was conducted at the time of hire, and a subsequent check revealed that Staff 1 did not hold a valid LVN license. The facility's policy required license verification before employment, but this was not followed. During this period, Staff 1 administered controlled substances, including Norco, Tramadol, and Oxycodone, to multiple residents, including a resident with osteomyelitis. The Director of Nursing (DON) and DSD both acknowledged that allowing an unlicensed individual to function as an LVN posed significant risks, including improper medication administration and inaccurate documentation. The Administrator also confirmed that the facility did not follow its own policy and that hiring an unlicensed staff member placed all residents at high risk of harm.
Unlicensed Staff Administered Controlled Substances as LVN
Penalty
Summary
The facility failed to ensure that Staff 1, who was hired as a Licensed Vocational Nurse (LVN), met the required qualifications and held a valid professional LVN license in accordance with state laws. Staff 1 was employed and functioned as an LVN for over a year and a half without proper documentation or verification of a valid LVN license. The personnel file for Staff 1 contained only a California ID and Social Security card, and a copy of an LVN license belonging to an unidentified individual, which did not match Staff 1’s identification. The Director of Staff Development confirmed that Staff 1 was hired using another individual's LVN license and that no verification was conducted through the California Board of Vocational Nursing and Psychiatric Technicians system. During the period under review, Staff 1 administered controlled substances, including Norco, Oxycodone, Percocet, and Tramadol, to multiple residents with serious medical conditions such as osteomyelitis, fractures, and paraplegia. Medication Administration Records showed that Staff 1 administered these medications on numerous occasions to at least four residents, as well as to six additional residents. The facility’s policy required employment background screening and license verification, and stated that employees without a valid license should not be employed. The Administrator acknowledged that the policy was not followed, resulting in the employment of an unlicensed and unqualified individual who provided direct care and administered controlled substances to residents.
Failure to Monitor Behavior for Resident on Psychotropic Medication
Penalty
Summary
The facility failed to conduct behavior monitoring for a resident who was prescribed the psychotropic medication escitalopram for major depressive disorder (MDD). The resident, who had moderate cognitive impairment and was dependent on staff for most activities of daily living, was admitted with a diagnosis of MDD and began receiving escitalopram as ordered by the physician for symptoms manifested by verbalizations of sadness. However, there were no physician orders or documentation in place to monitor the resident's behavior related to the use of this medication. Interviews with nursing staff and the Director of Nursing confirmed that behavior monitoring was required to track the frequency of the resident's symptoms and to assess the effectiveness of the psychotropic medication. Facility policy also required documentation of the rationale for use and monitoring for efficacy when medications were prescribed for behavioral symptoms. Despite these requirements, the resident did not have any active or discontinued orders for behavior monitoring since starting escitalopram, resulting in a lack of monitoring for the continued need or effectiveness of the medication.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Develop Care Plan for Major Depressive Disorder
Penalty
Summary
The facility failed to develop and implement a care plan addressing a resident's diagnosis of major depressive disorder (MDD). The resident, who was admitted with MDD and had moderate cognitive impairment, was dependent on staff for all activities of daily living except eating and required substantial to maximal assistance for mobility. Despite the resident's diagnosis and ongoing treatment with antidepressant medication, there was no care plan in place to address her MDD, specifically lacking non-pharmacological interventions such as redirection, engagement in activities, or opportunities to discuss her feelings with staff. Interviews with facility staff, including an LVN and the Director of Nursing, confirmed that a care plan for MDD was not developed for the resident. Both staff members acknowledged the importance of having a care plan that included non-pharmacological interventions to address the resident's mental health needs. Review of facility policies indicated that comprehensive, person-centered care plans with measurable objectives were required for each resident, and that non-pharmacological interventions should be used to minimize reliance on psychotropic medications. The absence of such a care plan for the resident with MDD constituted the identified deficiency.
Failure to Ensure Nursing Staff Competency in Abuse Reporting Requirements
Penalty
Summary
Registered Nurse (RN) 1 and Licensed Vocational Nurse (LVN) 1 failed to demonstrate competency regarding the facility's abuse reporting policies. Both staff members had signed documents acknowledging their responsibilities as mandated reporters and had completed abuse training post-tests indicating they understood their roles. However, during interviews, both RN 1 and LVN 1 were unable to identify the facility's abuse coordinator and expressed uncertainty about their responsibilities as mandated reporters, despite having attended abuse prevention in-service training where reporting requirements were reviewed. The Director of Nursing (DON) confirmed that all staff were expected to be competent in implementing the facility's abuse policies and procedures, including knowing their mandated reporter responsibilities and the identity of the abuse coordinator. A review of the facility's Abuse Prevention Program policy indicated that staff training should include abuse prevention, identification, and reporting. The failure of RN 1 and LVN 1 to demonstrate this competency was identified through interviews and record reviews, indicating a gap between training provided and staff understanding or retention of critical abuse reporting procedures.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 6,594 citations issued within 25 miles in the last 12 months — including the 29 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
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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) |
|---|---|---|---|---|
| View Heights Conv Hosp | 0.3 mi | ★★★★★ | 24 | 0 |
| Rosecrans Care Center | 1.8 mi | ★★★★★ | 6 | 0 |
| Gardena Convalescent Center | 2.1 mi | ★★★★★ | 16 | 0 |
| Kei-ai South Bay Healthcare Center | 2.3 mi | ★★★★★ | 17 | 0 |
| Lighthouse Healthcare Center | 2.5 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.