Average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Berkley Post-acute during CMS and state inspections, most recent first.
Insulin storage and expiration handling were not followed for Medication Cart #1. Three unopened Humalog pens were kept in the cart drawer instead of refrigerated, even though the packaging said to refrigerate until used, and one opened Humalog pen with an open date had remained on the cart past the 28-day use period. The LVN and DON both acknowledged the correct storage and discard requirements, and the manufacturer directions reviewed by surveyors matched those requirements.
Improper Sanitizer Concentration and Missing Quat Log: The facility failed to ensure three red sanitation buckets were at the proper ppm, with each bucket testing at 0 ppm during observation with the DS. The DS stated the minimum should be 200 ppm and that the solution should be changed every 2 hours or when cloudy. The facility also did not maintain a quat sanitizer log, and the DS stated the log was needed to prove testing was completed.
Meal service failed to follow the approved menu cycle when two residents on CCHO-based diets were served beets instead of the chef’s vegetable of choice listed on the spreadsheet. One resident had a CCHO/NAS order and diagnoses including stroke sequelae, cardiomyopathy, morbid obesity, and DM2; the other had renal CCHO orders with CKD, dialysis dependence, morbid obesity, and DM2. The DS and Cook both confirmed the vegetable served was a mistake, and the RD stated the spreadsheet should have been followed to ensure appropriate nutrients and calories.
The facility failed to ensure that CNAs had the required competencies to provide colostomy care. The DSD reported that all nursing staff are expected to complete annual skills competencies, including colostomy care, and provided an attendance roster for a skills day that covered pressure injury prevention, incontinent care, colostomy care, and indwelling catheter care. Three CNAs confirmed their signatures were not on the roster, stated they did not attend the colostomy care competency, and cited part-time status or working an afternoon shift while training was held on the day shift. One CNA also reported being unsure whether she was allowed to change a resident’s colostomy. Facility documents, including the Facility Assessment Tool and the nursing staff competency policy, stated that staff must demonstrate specific competencies based on resident needs and receive competency evaluations on hire and annually, but these requirements were not met for the sampled CNAs regarding colostomy care.
A resident with COPD, heart failure, lack of coordination, severely impaired cognition, and dependence on staff for eating was observed being assisted with feeding by a CNA who stood over and hovered rather than sitting at eye level. The IP, present during the observation, confirmed the CNA's positioning and stated the CNA should be seated for safety and respect. The CNA later acknowledged she knew she was expected to sit in a chair and be at eye level while assisting. Facility policy on quality of life and dignity requires that residents, including those who are cognitively impaired, be treated with dignity and respect at all times.
The facility failed to follow its meal service policy by not documenting required food temperatures for multiple lunch and dinner meals, including regular, mechanical soft, and puree entrées, side dishes, beverages, and gravy. Review of temperature logs showed entire sections left blank on several days, and the Dietary Supervisor confirmed that cooks are responsible for checking and recording all food temperatures before meal service to ensure compliance with temperature regulations and to demonstrate that checks were performed. This lapse in documentation affected nearly all residents receiving meals during the affected services.
A resident admitted with type 2 DM, hemiplegia/hemiparesis after CVA, and glaucoma had physician orders for bedtime Atorvastatin and Semglee (insulin glargine) starting on the day of admission. The medications were not available at the scheduled bedtime dose and were delivered by the pharmacy early the following morning. The MAR showed the 9 p.m. doses were not administered and were coded as medication not available. Nursing staff did not notify the physician of the missed doses, and there was no documentation of any communication or clarification of orders, despite facility policies requiring timely pharmaceutical services and thorough charting.
A resident with multiple medical conditions, including diabetes and a gastrostomy, was not provided a comprehensive nutritional assessment within seven days of readmission, as required by facility policy. The assessment was completed on the twelfth day, despite documented weight loss and the resident's dependence on staff for daily care. Both the RD and DON confirmed the delay, which did not meet the facility's established protocols.
Failure to maintain resident privacy during care and medication pass. An LVN checked a resident’s blood sugar and gave insulin without closing the privacy curtain, and an RN gave oral meds to two other residents, along with BP checks and eye drops for one resident, without fully closing curtains or shutting the room door. The residents had varying cognitive and functional status, including one cognitively intact resident and another with moderate cognitive impairment, and staff acknowledged the curtains should have been closed to protect privacy and dignity.
A facility failed to develop and implement person-centered care plans for several residents with identified needs. One resident who spoke a non-English primary language had no care plan for communication needs, and the same resident had no care plan addressing Seroquel’s black box warning and related risks. Another resident had bilateral floor mats ordered for injury prevention, but no care plan was in place. A third resident with MS and difficulty walking had an ambulation care plan that staff and leadership described as too general and not specific enough to measure progress.
A resident with severe pain orders received PRN oxycodone on multiple occasions, but the MAR did not show any documented non-pharmacologic interventions before the opioid was given. The resident had orders for interventions such as repositioning, relaxation, music, toileting, and distraction, and an RN stated non-pharmacologic measures should be tried first and documented when used.
Delayed Documentation of Controlled Pain Medications and Incomplete Narcotic Count Signatures: Two residents with orders for PRN pain meds had controlled substances signed out but not documented in the MAR right away, including one dose of Tramadol and one dose of Norco documented two days later. An LVN said she was distracted and forgot to chart the administrations. In addition, a narcotic control sheet on one med cart had a missing incoming nurse signature at shift change, and the DON stated both nurses should sign the count sheet each shift.
Unlabeled and improperly stored medications were found in two medication carts. A box of Artificial Tears for a resident was labeled only with the resident’s last name, and four loose pills were found unpackaged and unlabeled in another cart. The LVN stated the pills could not be identified, and the DON stated medications should be labeled and stored correctly per facility policy.
Improper meatball portioning did not follow the menu recipe. During trayline service, Swedish meatballs were weighed at 4 oz to 4.2 oz each instead of the planned 3 oz total portion for a regular diet. The DS stated the wrong scoop was used, and that residents on Renal and CCHO diets would receive more protein and carbs than ordered, not following their diets.
Cold dessert items were found above the required temperature during tray testing. A regular texture raspberry parfait measured 52 F and a puree raspberry parfait measured 59 F after waiting on the serving area in trayline. The DS stated the items should have been at least 40 F and that they should have been refrigerated longer or kept cold with ice in the container.
Kitchen sanitation and food handling practices were not maintained. Surveyors observed dirt, dust, food residue, ice buildup, rust, and damaged surfaces on multiple refrigerators, freezers, storage areas, utensils, and equipment, and one dented can was stored with regular stock. Staff also failed to follow proper hand hygiene and glove changes when moving between dirty and clean tasks, and some utensils were not fully air dried or stored properly. The Dietary Supervisor acknowledged the conditions and practices observed.
Improper disposal of garbage and refuse was observed when two dumpsters were not fully covered and one was left open, with soiled gloves and food juices on the floor of the dumpster area. The DS stated flies were already going in and out, and the MS stated the dumpsters were overflowing and not fully closed, with one left open by the gardener. Facility policy required trash cans to be inspected daily, lids kept closed, and the trash collection area kept clean.
A resident with chronic pain and another resident with headache pain received PRN analgesics without the pain site being fully documented before administration, and staff later acknowledged the assessments were incomplete. A resident with ESRD also had an inaccurate hemodialysis order entered as Monday through Friday instead of Monday and Friday, while a controlled drug count sheet was signed late without being documented as a late entry and a MAR showed metoprolol given despite BP being below the hold parameter.
Staff failed to follow EBP PPE practices for a resident with a G-tube and severe cognitive impairment when an LVN and CNA entered the room without an isolation gown, and the LVN later moved in and out of the room while still wearing the gown and contacting the med cart. The facility also observed nebulizer tubing for another resident on the floor during respiratory care, and the IPN stated the tubing should not touch the floor because it may be contaminated with germs.
A facility failed to keep the resident environment free from accident hazards for two residents. One resident with a hx of falls had a physician order for a tab alarm while in bed, but the alarm was not in place during observation. Another resident with dementia, weakness, and difficulty walking had orders and care plan documentation for bilateral 1/4 side rails, but staff observed much shorter 1 1/12 rails in the room instead of the ordered rails.
A resident with ESRD, HTN, and DM received hydralazine despite a BP reading below the prescriber’s hold parameter. The MAR showed the medication was administered when the SBP was 100, even though the order said to hold if SBP was 110 or less. An LVN, an RN, and the administering RN all stated the dose should have been held because it was outside the ordered parameters, and the facility policy required safe medication administration and checking contraindications before giving meds.
The facility did not document room temperature checks for three days, as required by their policy, potentially affecting residents' comfort. The Maintenance/Housekeeping Director confirmed the lack of documentation, and the responsible Maintenance Assistant admitted to not performing the checks due to forgetfulness and being busy.
Two unidentified and unlabeled medication tablets were found in a medication cart at Nursing Station 1, violating the facility's medication labeling and storage protocols. The IPN confirmed the labeling requirements, and LVN1 admitted to forgetting to discard the tablets. The DON emphasized the need for proper storage to ensure medication effectiveness.
The facility failed to manage medication administration and fall prevention, leaving medications unattended for two residents without proper assessments and not providing fall mats for a high-risk resident, increasing safety hazards.
The facility failed to document attempts of non-pharmacological interventions before administering PRN opioid medication to two residents, increasing the risk of adverse side effects. Despite care plans requiring such interventions, there was no evidence of their implementation before giving hydrocodone-acetaminophen. Interviews confirmed the lack of documentation and the importance of these interventions to potentially avoid unnecessary opioid use.
The facility failed to screen two visitors for COVID-19 symptoms, a dietary aide did not wash hands after touching a trash can lid, and several resident care items were not properly labeled or maintained, leading to potential infection risks.
A facility failed to ensure staff knocked and asked permission before entering a resident's room, violating the resident's rights to respect and dignity. The resident, with a history of muscle weakness, falls, and chronic kidney disease, had the capacity to make decisions. A nurse entered the room without knocking, acknowledging the oversight and the importance of respecting personal space. The facility's policy mandates knocking and requesting permission before entering.
A CNA failed to fully close a privacy curtain while assisting a resident with dressing, resulting in a privacy violation. The resident, who had intact cognition and required assistance with daily activities, was observed fully undressed with the curtain open. The CNA acknowledged the oversight, and the DON confirmed the expectation for full privacy during care.
A facility failed to maintain a comfortable environment in a resident room, where temperatures exceeded the acceptable range of 71 to 81 degrees Fahrenheit. Four residents, including those with end-stage renal disease and anemia, expressed discomfort due to the warm conditions. The Maintenance Supervisor and DON confirmed the importance of maintaining appropriate temperatures to prevent discomfort and dehydration.
A resident with conditions such as hypo-osmolality and kidney failure was on a strict fluid restriction of 1200 ml per day. Despite this, a water pitcher and additional cups were found at the bedside, contrary to the care plan and physician's orders. The Director of Staff Development confirmed the oversight, acknowledging the risk of fluid overload, while the DON stressed the importance of adhering to the fluid restriction to prevent electrolyte imbalance.
A facility failed to implement a scheduled toileting plan for a resident who was incontinent of bowel, despite being cognitively intact and requiring substantial assistance with walking. The care plan included regular intervals for offering a bedpan or urinal and assisting to the bathroom, but there was no documentation of scheduled bowel elimination. The facility's policy required a voiding diary, which was not maintained, as confirmed by staff interviews.
A facility failed to complete a post-dialysis assessment for a resident with end-stage renal disease, as required by their care plan. The Dialysis Assessment Form was left incomplete, and no vital signs or assessment notes were documented after the resident returned from dialysis. An LVN admitted to forgetting to fill out the necessary documentation, and the DON confirmed that licensed nurses are responsible for ensuring post-dialysis assessments are conducted to check for complications.
A facility failed to remove a lidocaine patch from a resident's knees after 12 hours as per the physician's order, leading to potential excessive dosing. The RN acknowledged the oversight, and the DON confirmed the risk of adverse effects due to prolonged application.
The facility failed to monitor side effects in two residents receiving anticoagulant therapy. One resident on apixaban for DVT prophylaxis had no documentation of monitoring for bleeding or bruising, despite the care plan's requirements. Another resident on heparin also lacked documentation of monitoring for side effects like bleeding and bruising. The facility's policy required such monitoring, which was not followed.
A facility failed to discard an expired vial of insulin lispro stored in a medication cart, which was past the 28-day usage period. A resident with diabetes mellitus had a physician's order for insulin administration, and the expired insulin posed a risk of ineffective blood glucose management. The deficiency was identified during an inspection, and the guidelines specify that opened insulin vials should be discarded after 28 days.
During a meal service, a cook failed to check the temperatures of pureed potatoes, chopped turkey, and chicken on the tray line, as required by the facility's policy. This oversight was observed and confirmed by the cook, posing a potential risk of foodborne illness to 110 medically compromised residents.
A facility failed to report an allegation of physical abuse involving a resident with COPD and respiratory failure to the State Survey Agency. The resident reported that a CNA was rough during care, causing bruises and throwing a teddy bear at them. The facility's administrator recognized this as an abuse allegation but did not report it, delaying an SSA inspection and potentially leaving other residents at risk.
The facility failed to complete Quarterly MDS assessments on time for six residents, including those with conditions like cellulitis and COPD. The assessments were not completed within the required 14-day period after the ARD, as per CMS guidelines. The delays were acknowledged by the RN, who noted potential negative impacts on residents. The DON highlighted the importance of timely assessments for effective care planning.
A resident with multiple health conditions received 13 incorrect doses of lisinopril-hydrochlorothiazide due to a transcription error by an RN. The RN used the less than symbol (<) instead of the greater than symbol (>) in the physician's order, leading to medication administration when the resident's blood pressure was below the specified threshold. The DON confirmed that the correct process involves reading back the order to the physician and avoiding the use of symbols.
Insulin Pens Improperly Stored and One Expired Pen Left in Medication Cart
Penalty
Summary
Drugs and biologicals were not stored in accordance with accepted professional principles when three unopened Humalog insulin pens were observed in the top left drawer of Medication Cart #1 instead of being kept refrigerated. During the observation, the LVN stated the pens were new and unopened because no open dates were documented, and also stated that unopened insulin pens should be stored in the refrigerator because the clear zipped bags were labeled to refrigerate until used. The DON later stated that unopened insulin pens should remain in the refrigerator until use and that removing them too early can reduce insulin efficacy. The facility also failed to discard one Humalog insulin pen that had a documented open date of 2/27/2026 and remained on Medication Cart #1 beyond the 28-day period identified by staff and the manufacturer. During the observation, the LVN stated the pen should have been discarded because opened insulin pens are good for 28 days and then must be thrown out for resident safety. The DON confirmed the pen should have been discarded after 28 days and stated staff must check medication carts at the beginning and end of each shift and discard expired medications. The manufacturer guidelines reviewed by surveyors stated the pen should be thrown out 28 days after opening and should not be used after the expiration date.
Improper Sanitizer Concentration and Missing Quat Log
Penalty
Summary
The facility failed to follow proper sanitation and food handling practices in the kitchen by not ensuring that three red sanitation buckets were at the proper concentration. During a concurrent observation and interview in the kitchen with the Dietary Supervisor, each of the three red sanitation buckets tested with a strip that did not change color, and the Dietary Supervisor stated that each bucket resulted in 0 ppm. The Dietary Supervisor also stated that the test strip should change color and that the minimum ppm should be 200 ppm, and that the sanitation solution should be changed every 2 hours and as needed if the water is cloudy. The facility also failed to implement its quaternary ammonium log policy because there was no documented evidence of a quaternary ammonium log. During interview, the Dietary Supervisor stated that the facility does not keep a log of when the sanitation solution is tested for ppm and stated that a log is important to provide proof that the testing was done. Review of the facility's Quaternary Ammonium Log Policy showed that the concentration of the sanitizer is to be tested, the solution is to be replaced when below 200 ppm, and Food and Nutrition Services staff are to record the readings three times a day to document the process was completed.
Meal Service Did Not Follow Approved Diet Spreadsheet
Penalty
Summary
The facility failed to follow the approved diet spreadsheet by serving beets instead of the chef’s vegetable of choice, carrots and zucchini, to two residents at lunch. Resident 2 was admitted with diagnoses including unspecified sequelae of cerebral infarction, cardiomyopathy, morbid obesity due to excess calories, and type 2 diabetes, and had an order for a CCHO/NAS diet. Resident 3 was admitted with chronic kidney disease, dependence on renal dialysis, morbid obesity due to excess calories, and type 2 diabetes, and had an order for a renal CCHO diet. The facility’s diet spreadsheet for Week 4, Day 26-Thursday listed lunch as savory roasted chicken, confetti rice, chef’s vegetable of choice, bread or roll with margarine, lemon pudding, and a beverage. During observation, Resident 2’s lunch tray contained chicken, rice, beets, bread, pudding, and a beverage, and Resident 3’s lunch tray contained chicken, rice, beets, bread, peaches, soup, and a beverage. The Dietary Supervisor stated Resident 2 was served beets and reviewed the spreadsheet, stating the resident should have received carrots and zucchini. The Dietary Supervisor later stated beets should not have been served for the CCHO diet and that serving beets was a mistake made by the Cook. The Cook also stated that residents on a CCHO diet should have been served carrots and zucchini and that it was a mistake that the two residents were served beets. The Registered Dietician stated the spreadsheet should have been followed to ensure residents received appropriate nutrients and calories, and noted that not following it could result in residents not receiving needed nutrition and possibly having elevated glucose levels.
Failure to Ensure CNA Competency in Colostomy Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing staff possessed and demonstrated specific competencies and skill sets necessary to provide colostomy care, as required by resident assessments and plans of care. The Director of Staff Development (DSD) stated that the facility provides care to residents with colostomies and that all nursing staff are to receive annual competencies specific to colostomy care. A facility document titled “Class Attendance Roster” for an annual skills competency day conducted by the corporate nursing consultant listed colostomy care as a course topic, along with pressure injury prevention, incontinent care, and indwelling catheter care. During interviews and concurrent record reviews, three CNAs confirmed they had not attended this colostomy care competency training and their signatures were not on the attendance roster. CNA 1 stated she did not attend the skills competency for colostomy care because she works part time at the facility. CNA 2 likewise stated she did not attend the skills competency for colostomy care and explained that she also works part time. CNA 3 stated she did not attend the skills competency training, confirmed her signature was not on the roster, and reported she was unsure if she was allowed to change a resident’s colostomy. CNA 3 further explained that she works the 3:00 p.m.–11:00 p.m. shift and that the competency trainings are conducted during the 7:00 a.m.–3:00 p.m. shift. Review of the facility’s Facility Assessment Tool dated 4/9/2025 indicated that the facility provides sufficient staff with appropriate competencies and skill sets to provide nursing and related services to assure resident safety and well-being, and that competency evaluation is checked on hire and annually thereafter. The facility’s policy and procedure titled “Competency of Nursing Staff” stated that all nursing staff must meet specific competency requirements, participate in a facility-specific, competency-based staff development and training program, and demonstrate specific competencies and skill sets necessary to care for residents’ needs as identified through assessments and plans of care. The policy also specified that facility- and resident-specific competency evaluations would be conducted upon hire and annually, including lecture with return demonstration and demonstrated ability to use tools and perform activities within the staff member’s scope of practice. Despite these stated requirements, the three sampled CNAs had not completed the annual colostomy care competency, resulting in the cited deficiency.
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The deficiency involves staff failure to honor a resident's right to dignity and respect during assistance with eating. Surveyors reviewed the admission record of Resident 3, who was readmitted with COPD with exacerbation, heart failure, and lack of coordination, and whose MDS dated 1/7/2026 documented severely impaired cognition and dependence on staff for eating, oral hygiene, toileting hygiene, and personal hygiene. During a meal observation in the resident's room, a CNA was observed assisting the resident with feeding while standing over and hovering over the resident. During a concurrent observation and interview, the facility's Infection Preventionist confirmed that the CNA was standing and hovering over the resident while assisting with feeding and stated that the CNA should be sitting and at eye level with the resident for safety and respect. In a subsequent interview, the CNA acknowledged that she had been standing while assisting with lunch and stated she knew she was supposed to sit in a chair and be at eye level with the resident to assist properly for the resident's safety and respect. Review of the facility's "Quality of Life – Dignity" policy indicated that each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality, and that residents shall be treated with dignity and respect at all times, including cognitively impaired residents.
Failure to Document Required Food Temperatures for Multiple Meals
Penalty
Summary
Surveyors identified a deficiency in the facility’s meal service related to failure to document food temperatures as required by facility policy. Review of the food temperature logs showed that for lunch on 4/11/2026, all required temperature entries were blank, including the regular entrée, mechanical soft entrée, puree entrée, vegetables, pureed vegetables, starch, pureed starch, gravy, dessert, milk, juice, and coffee. For dinner on 4/12/2026, the log again contained no documented temperatures for the entrée, mechanical soft entrée, puree entrée, vegetables, pureed vegetables, starch, pureed starch, gravy, dessert, milk, juice, and coffee. For lunch on 4/15/2026, there were no documented temperatures for the entrée, mechanical soft entrée, puree entrée, vegetables, pureed vegetables, starch, pureed starch, or gravy. During an interview and concurrent record review with the Dietary Supervisor, it was confirmed that there were no food temperatures documented for the identified meals on 4/11/2026, 4/12/2026, and 4/15/2026. The Dietary Supervisor stated that cooks are responsible for checking the temperatures of all food items prior to meal service and that all food items served should be checked and documented to ensure they are within food temperature regulations. The Dietary Supervisor further stated that food temperatures need to be checked so residents do not get sick because bacteria can start growing if food is not at the right temperatures, and that documentation is important to show proof that temperatures were actually checked. The facility’s Meal Service policy indicated that meals will be served at appropriate temperatures, that Food and Nutrition Services staff will take food temperatures prior to service with a sanitized thermometer, and that these temperatures will be recorded on the daily therapeutic menu in the designated temperature columns. The deficient practice had the potential to affect 117 of 119 in-house residents.
Failure to Administer Ordered Atorvastatin and Insulin and Notify Physician for New Admission
Penalty
Summary
The deficiency involves the facility’s failure to provide routine biologicals and pharmacy services, including administering medications as ordered, for a newly admitted resident. The resident was admitted from a general acute care hospital with diagnoses including type 2 DM, hemiplegia and hemiparesis following CVA affecting the right dominant side, and unspecified glaucoma. The resident’s MDS indicated moderately impaired cognition and dependence on staff for eating, oral hygiene, toileting hygiene, and personal hygiene. On admission, the nurse practitioner and physician were notified, and the resident’s medication orders were faxed to the pharmacy. The physician’s orders included Atorvastatin 40 mg by mouth at bedtime for hyperlipidemia and Semglee (insulin glargine) 8 units subcutaneously at bedtime for DM, both with a start date of 1/6/2026. The facility’s pharmacy delivery manifest showed that these medications were delivered the following day at 3:22 a.m. Review of the resident’s January MAR revealed that the 9:00 p.m. doses of Atorvastatin and Semglee on the admission date were not administered, and code 8 (medication not available) was documented for both medications. RN 2 stated that the facility receives pharmacy deliveries three times a day and confirmed that the medications were not given at the scheduled time because they had not yet been delivered. RN 2 further stated that the charge nurse assigned to the resident should have called the physician to inform them of the missed doses and to clarify whether additional orders were needed, but review of the progress notes for that date showed no documentation that the physician was notified. The DON confirmed that for newly admitted residents, medication orders are sent to the pharmacy and that once medications are delivered, licensed nurses administer the first dose per the physician’s orders, and that the nurse should have clarified with the physician whether medications could be initiated the following day given the late admission time. Facility policies required regular and reliable pharmaceutical services, including that new medication or admission orders be available for administration of the next dose, and required documentation of services provided and changes in the resident’s condition in the medical record to facilitate communication among the interdisciplinary team.
Failure to Complete Timely Nutritional Assessment After Readmission
Penalty
Summary
The facility failed to conduct a comprehensive nutritional assessment within seven days of readmission for one resident, as required by its own policy and procedure. The resident, who had a history of diabetes mellitus, hypertension, gastrostomy, and anemia, was initially admitted and then readmitted after a hospital stay. Upon readmission, the resident's weight was recorded as unchanged from the time of transfer to the hospital, but a comprehensive nutritional assessment was not completed until the twelfth day after readmission, exceeding the facility's seven-day requirement. Interviews with the Registered Dietitian and the Director of Nursing confirmed that the nutritional assessment was delayed and not performed within the required timeframe. The facility's policies specify that a comprehensive nutritional assessment must be completed by a dietitian within seven days of admission or readmission, especially in cases of significant weight change. Despite these requirements and the resident's medical complexity, the assessment was not completed as stipulated, resulting in a deficiency.
Failure to Maintain Privacy During Medication Administration and Care
Penalty
Summary
The facility failed to maintain resident dignity and privacy during care for three residents observed during medication pass. Resident 62 was admitted with diagnoses including muscle weakness and Type 2 DM, had intact cognitive skills for daily decision making, and was independent in activities of daily living. During a concurrent observation, an LVN entered the resident’s room while the privacy curtain was open and visible from the roommate and hallway, checked the resident’s blood sugar by fingerstick, prepared insulin, and administered the insulin injection without drawing the privacy curtain. When asked, the LVN stated the curtain should have been drawn and that not providing privacy could make the resident feel embarrassed and exposed. Resident 120 was admitted with diagnoses including acute kidney failure and adult failure to thrive. A physician progress note stated the resident could make needs known but could not make medical decisions, and the MDS indicated moderate cognitive impairment and dependence on staff for most ADLs. During a concurrent observation, an RN administered oral medications to the resident while he was in bed without pulling the privacy curtain around the bed or shutting the room door, leaving the resident visible from the hallway and inside the shared room while the medications were being given. Resident 83 was admitted and readmitted with diagnoses including epilepsy and DM. The H&P indicated the resident had capacity to understand and make decisions, and the MDS indicated the resident was cognitively intact and independent for most ADLs. During a concurrent observation, an RN checked the resident’s blood pressure and then administered oral medications and eye drops while the resident was in bed without fully pulling the privacy curtain around the bed, leaving the resident exposed to the common area at the foot of the bed in the shared room. The RN later stated the curtain should have been pulled around the residents during care and medication administration because they have a right to privacy and dignity.
Incomplete Care Plans for Communication, Medication Risk, Floor Mats, and Ambulation
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for multiple residents with identified needs. For one resident admitted with muscle weakness and unspecified dementia, the admission record and MDS showed the resident’s primary language was not English, the resident could sometimes make self-understood and sometimes understand others, and the resident was dependent on staff for ADLs. During the concurrent review, RN 3 stated there was no care plan addressing the resident’s communication needs, despite the facility policy requiring communication support for non-English speaking residents and interpreter use as needed. The same resident had an order for Seroquel 25 mg twice daily for psychotic features manifested by screaming at others. RN 3 stated there was no care plan addressing the black box warning associated with Seroquel or the risks tied to its use. The facility policy on black box warnings stated that nursing was to document the warning in the care plan when a resident is on a medication with a black box warning. The resident’s record review and staff interview showed the medication was ordered, but the related care planning was not developed. For another resident admitted with difficulty walking, muscle weakness, dysphagia, and unspecified dementia, the physician ordered bilateral floor mats for injury prevention. During observation, floor mats were present on both sides of the bed, and the MDS-RN stated they were there to help prevent injury if the resident fell. The MDS-RN also stated there should have been a physician’s order and care plan for the floor mats, but no care plan had been developed. For a third resident with multiple sclerosis and difficulty walking, the MDS showed the resident required supervision or touching assistance with walking 150 feet, and restorative nursing records showed the resident walked three times weekly with a walker. Staff interviews and record review showed the resident’s ambulation care plan had a general goal to maintain current ambulation function and an intervention to walk with the RNA, but the DON and DOR stated the goal was not specific enough and could have included more measurable detail and interventions.
Failure to Document Non-Pharmacologic Pain Interventions Before PRN Oxycodone
Penalty
Summary
The facility failed to ensure licensed nurses provided non-pharmacological interventions before administering PRN oxycodone for severe pain to a resident. Resident 147 was admitted with diagnoses including cardiomegaly and difficulty walking, and the H&P stated the resident had the capacity to understand and make decisions. The resident’s OSR included an order for non-pharmacologic pain interventions such as repositioning, back rub, relaxation techniques, fluids, redirection, music, activity, adjusting room temperature, dim light/quiet environment, toileting, breathing exercises, distraction/activities, and other interventions as noted in nurses’ notes. The MAR showed the resident received oxycodone 5 mg on three occasions for pain ratings of 9/10, 8/10, and 9/10, and no non-pharmacological interventions were documented for those administrations. During interview, RN 3 stated non-pharmacological interventions should be attempted first to see if pain can be relieved without medication, and noted that narcotic pain medication such as oxycodone can increase the risk of adverse effects such as constipation and respiratory depression. The facility policy on Pain Management stated that pain control options appropriate for the resident should be chosen and that pertinent changes, interventions, and results of pain relief interventions should be documented in the resident’s chart if indicated.
Delayed Documentation of Controlled Pain Medications and Incomplete Narcotic Count Signatures
Penalty
Summary
The facility failed to ensure that controlled pain medications were documented in the MAR immediately after administration for two residents. One resident was admitted with muscle weakness and low back pain, had intact cognitive skills for daily decision making, and was dependent on staff for toileting hygiene, dressing, and footwear. The resident had an order for Tramadol HCL 50 mg by mouth every 6 hours as needed for severe pain. During review of the medication cart, ACDR, and MAR, Tramadol was signed out on 7/29/2025 at 9:00 a.m., but the administration was not documented in the MAR. A second resident was admitted with muscle weakness and hypertension, had intact cognitive skills for daily decision making, and was dependent on staff for toileting hygiene, dressing, footwear, and personal hygiene. The resident had an order for Norco 5-325 mg, 0.5 tablet by mouth every 6 hours as needed for moderate severe pain. During the same review, Norco was signed out on 7/27/2025 at 8:00 a.m., but the administration was not documented in the MAR until 7/29/2025 at 4:09 p.m., two days later. An LVN stated she forgot to document both medications because she was distracted when another resident had a change of condition. The DON stated that after medications are administered, the nurse should document the medication administration in the ACDR and MAR, and that controlled drugs are regularly audited to ensure they are accounted for and that there are no discrepancies between the MAR and ACDR. During a separate cart inspection, the narcotic control sheet for one medication cart had a blank space for the incoming nurse’s signature for the 3 p.m. time slot. The LVN stated she did not sign the sheet when counting medications with the 7 a.m. to 3 p.m. nurse, and the DON stated the sheet should be signed by both the incoming and outgoing nurse at every shift change.
Unlabeled and Improperly Stored Medications in Medication Carts
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored and labeled in accordance with accepted professional principles in two medication carts. During observation of Medication Cart 1, Station 1, a box of Artificial Tears for Resident 98 was found labeled only with the resident’s last name. Resident 98’s record showed the resident was admitted and readmitted to the facility, had diagnoses including hypertension, and was severely impaired in cognition with dependence on staff for personal hygiene. The physician’s orders included Artificial Tears Ophthalmic Solution for dry eyes, and the care plan addressed eye irritation with medication to be applied as ordered. During observation of Medication Cart 1, Station 2, four loose pills were found inside the cart without labels or packaging: one white round pill, one green round pill, and two white oblong pills. The LVN stated the medications should not be stored that way because they could not be identified and should be disposed of in the biohazard box. The DON stated all medications should be labeled and stored correctly so staff know the type of medication and who it belongs to. The facility policy stated medications should be kept in containers that meet legal requirements and be properly labeled in accordance with current state and federal regulations.
Improper meatball portioning did not follow the menu recipe
Penalty
Summary
The facility failed to follow the menu and did not meet residents’ nutritional needs when Swedish meatballs were portioned at 4 oz instead of the planned 3 oz total portion. During review of the daily spreadsheet titled Summer Menus, residents on a regular texture diet were scheduled to receive 2 Swedish meatballs, gravy, egg noodles, vegetables, fruit, a wheat roll, margarine, raspberry parfait square, and milk. During concurrent observation of lunch trayline service, the Swedish meatballs were weighed and each of six portions measured 4 oz or 4.2 oz. The employee stated the meatballs were made from scratch using ground turkey and were portioned with a green number 16 scoop. During interview, the Dietary Supervisor stated the regular diet portion should have been 2 meatballs weighing 3 oz total and that the larger portion was not following the recipe. The supervisor also stated the green scoop was number 12 and the blue scoop was number 16, and that the wrong scoop had been used, resulting in a larger portion. The supervisor stated residents on Renal and CCHO diets would receive more protein and carbohydrates than ordered and would not follow their diets. Record review showed the facility’s Food Preparation, Menu Planning, Portion Control policies required approved recipes, menus planned to meet nutritional needs, and use of portion control equipment, including weighing meats. The standardized recipe for the meatballs specified 2 meatballs totaling 3 oz protein and directed use of number 16 scoops.
Cold Dessert Items Served Above Safe Temperature
Penalty
Summary
The facility failed to prepare food by methods that conserve temperature when a raspberry parfait for the regular texture diet was observed at 52 F and a puree raspberry parfait for the modified texture diet was observed at 59 F. During a concurrent observation and interview with the Dietary Supervisor during tray testing, the supervisor took the temperatures of both parfait items and confirmed the readings. The daily menu spreadsheet for the regular diet listed raspberry parfait square as part of the tray, and the daily menu spreadsheet for the modified texture diet listed puree raspberry parfait. During interview, the Dietary Supervisor stated the parfait temperatures were high and should have been at least 40 F. The supervisor stated the parfait and puree parfait had waited on the serving area in trayline, which caused the temperature to rise, and said the items should have been refrigerated longer or kept cold with ice in the container. The supervisor also stated residents could get sick from foodborne illnesses and could have diarrhea, stomach pain, and vomiting if they consumed food items not meeting the temperature requirement, and that residents might not eat the parfait, which could lead to dissatisfaction, complaints, and not meeting calorie needs.
Kitchen sanitation and food handling deficiencies
Penalty
Summary
Safe and sanitary food storage and preparation practices were not maintained in the kitchen. Surveyors observed dirt, dust, and food debris on multiple surfaces and pieces of equipment, including the bottom shelves of the reach-in freezer, the ice cream reach-in freezer, the bread reach-in refrigerator, refrigerator vents, the walk-in refrigerator vent, the dry storage room floor, the can opener holder, condiment containers, the kitchen hood and hood light, the mixer, the rack used for clean pan storage, and the vending machine used for residents. Ice buildup was also observed on the walk-in freezer door. The Dietary Supervisor acknowledged that the areas and equipment were not clean and stated that dust, dirt, and debris could be transferred to food or cause contamination. Surveyors also observed that the ice cream reach-in freezer did not have a thermometer inside. The Dietary Supervisor stated that thermometers were needed in refrigerators and freezers to verify temperatures and that the absence of an internal thermometer could affect whether food was held at the proper temperature. In the dry storage room, one dented can was stored with non-dented cans. The Dietary Supervisor stated dented cans should be separated and returned to the vendor because they were not acceptable for resident use and could be spoiled. Hand hygiene and utensil handling practices were also not followed. One Dietary Aide washed hands and then touched the faucet knob with bare hands before returning to work. Another Dietary Aide used the same paper towel to turn off the faucet and dry hands. A third Dietary Aide moved from the dirty dish area to the clean dish area while wearing the same gloves and handling clean dishes without washing hands or changing gloves. In addition, scoops were not fully air dried and were stored in different directions, pots and pans were stacked while wet, a strainer had amber discoloration, a plastic utensil container was divided with a cardboard box, the resident refrigerator in the activity room had rusted shelves, and the same refrigerator had cracks covered with flexi tape. The report also noted that the failures had the potential to affect 121 of 122 medically compromised residents who received food and ice from the kitchen.
Improper Dumpster Storage and Trash Area Sanitation
Penalty
Summary
Improper disposal of garbage and refuse was observed when two dumpsters were not covered while not actively being used, and there were soiled gloves and food juices on the floor of the dumpster area. During a concurrent observation and interview, one dumpster was seen overfilled with trash and not completely covered, while the other dumpster lid was open. The Dietary Supervisor stated the dumpsters were full of trash and not completely closed and covered, and also stated that flies were already going in and out of the area. During a separate observation and interview, the Maintenance Supervisor stated the dumpsters were overflowing with trash and not fully closed, and that the other dumpster had been left open by the gardener. The Maintenance Supervisor also stated the area needed to be cleaned because of the soiled gloves and food spills on the floor. Facility policy required garbage and trash cans to be inspected daily to ensure no debris was on the ground or surrounding area and that lids were closed, and the trash collection area was to be kept clean and swept and washed down on a regular basis.
Incomplete pain documentation, inaccurate orders, and medication record errors
Penalty
Summary
Pain assessments were not accurately documented for two residents when pain medication was given without a complete assessment of the pain site being recorded. One resident had diagnoses including osteoarthritis in both knees, chronic pain, and difficulty walking, and was ordered Roxicodone as needed for moderate to severe pain. The resident’s care plan directed staff to observe and assess pain location, duration, frequency, and strength. Administration notes showed multiple doses of Roxicodone were given without the pain site being documented before administration, and one nurse later stated she had added a late entry after recalling the resident’s pain location. She also stated that documenting the site later was not the correct process and that the assessment should be accurate at the time of care. A second resident, who had diagnoses including myocardial infarction, rhabdomyolysis, and generalized muscle weakness, had an order for Tylenol as needed for mild pain. The resident stated she had a headache and was waiting for Tylenol, and the administration note showed Tylenol was given without a complete pain assessment documenting the site of pain before administration. The nurse stated she had asked the resident where the pain was but did not document it. The DON reviewed the records and stated the site of pain should be included in the assessment before pain medication is administered, and that documenting the pain assessment after the fact was not best practice because the location could be forgotten and the documentation could be incomplete. The facility also failed to clarify and accurately enter a hemodialysis order for a resident with end stage renal disease, hypertension, and diabetes. The physician order stated hemodialysis Monday through Friday with a chair time, but the resident and staff stated the resident actually received dialysis only on Monday and Friday. Nurses reviewing the order stated it was not entered correctly and should have been clarified before being placed in the chart. In addition, a controlled drug count sheet was not signed by the incoming nurse at shift change and was later signed without being documented as a late entry, and another resident’s MAR showed metoprolol was documented as given even though the recorded blood pressure was below the physician’s hold parameter. The DON and nurses stated the medication should have been held when the vital signs were outside the ordered limits.
Infection Control Lapses With EBP PPE Use and Nebulizer Tubing Contamination
Penalty
Summary
Facility staff failed to follow enhanced barrier precautions for a resident with a gastrostomy tube and severe cognitive impairment. The resident was admitted with diagnoses including dysphagia and attention to a gastrostomy tube, and the MDS indicated the resident was severely impaired in cognition and dependent on staff for oral hygiene. During a concurrent observation, an LVN and a CNA entered the resident’s room to reposition the resident while wearing gloves but not an isolation gown, and the LVN later entered and exited the room multiple times while wearing the gown, including leaving the room to retrieve items from the medication cart while still in the gown. The gown also brushed against the medication cart during these movements. The LVN was observed preparing and administering G-tube medications and an injectable medication while not removing the isolation gown before exiting the room as required by the facility’s EBP practice. When questioned, the LVN stated she should have removed the gown before exiting the room but did not. The CNA stated she entered the room without a gown because she thought the LVN needed immediate help and would have had to go to a supply cart in another hallway to get one. No PPE supplies were available in the hallway outside the resident’s room. The facility also failed to keep nebulizer tubing from touching the floor for another resident receiving respiratory treatment. The resident had diagnoses including muscle weakness and acute kidney failure, and the order summary included ipratropium-albuterol solution via nebulizer as needed for shortness of breath or wheezing. During observation with the IPN, the resident’s nebulizer tubing was seen on the floor. The IPN stated the tubing should not touch the floor because the floor is dirty and germs may be present, and removed the tubing to be replaced with a new one.
Failure to Provide Ordered Fall-Prevention Device and Correct Bed Rails
Penalty
Summary
The facility failed to ensure the resident environment remained as free of accident hazards as possible for two residents. For one resident admitted with a history of falling and chronic kidney disease, the physician ordered a tab alarm while in bed to alert staff if the resident attempted to get up unassisted and to monitor placement and function. During observation, the resident was in bed without the tab alarm in place, and the RN stated the alarm should have been present and that without it staff would not be alerted if the resident got up from bed. For another resident admitted with difficulty walking, muscle weakness, dysphagia, and unspecified dementia, the physician ordered bilateral 1/4 side rails to assist with lying and repositioning in bed. The resident’s care plan and entrapment risk evaluation also documented 1/4 length side rails. During observation, the MDS RN stated the side rails in the room were much shorter 1 1/12 length rails, not the ordered 1/4 length rails, and that the resident had never been evaluated or ordered for the shorter rails. The facility’s records and policies reviewed by surveyors showed that the falls management program required a safe environment free from accident hazards as possible and that device placement and function be monitored. The bed side rail policy stated that use of bed rails should be based on assessed medical needs, clearly documented, and supported by a physician’s order. The survey findings showed the ordered fall-prevention device was not in place for one resident and the ordered side rail size did not match the equipment present for the other resident.
Medication Given Outside Ordered Blood Pressure Parameters
Penalty
Summary
The facility failed to prevent a significant medication error for one resident with end stage renal disease, hypertension, and diabetes. The resident was admitted on 1/18/2023 and readmitted on 7/20/2025. The MDS indicated the resident’s cognitive skills were intact and that the resident required maximum assistance with ADLs. A physician order dated 7/20/2025 directed hydralazine hydrochloride 25 mg by mouth every six hours for hypertension, with instructions to hold the medication for systolic blood pressure of 110 or less. On 7/30/2025 at 12:00 p.m., the MAR showed hydralazine 25 mg was administered when the recorded blood pressure was 100/65 mmHg. During interviews and record review, an LVN, an RN, and the administering RN stated the dose should have been held because the systolic blood pressure was below the ordered parameter. The facility’s policy on medication administration stated medications are to be administered in a safe and effective manner, with contraindications noted prior to administration and the medication label read before giving the medication.
Failure to Document Room Temperature Checks
Penalty
Summary
The facility failed to implement its policy on maintaining a homelike environment by not providing documented evidence of daily room temperature checks for residents from January 26 to January 28, 2025. The Maintenance/Housekeeping Director (MHD) stated that the facility is supposed to check and document room temperatures three times a day, with the first check by 9:00 a.m. However, during a review of the facility's Air Temperature Monitor Log, it was found that there was no documentation of temperature checks for the specified three days. Maintenance Assistant 1 (MA 1), who was responsible for checking the room temperatures, admitted to not performing the checks during this period because they forgot and were busy. The MHD emphasized the importance of daily temperature checks for residents' comfort and the necessity of documenting these checks to provide proof of compliance with the facility's policy. The facility's policy, dated May 2024, requires staff to ensure a safe, clean, comfortable, and homelike environment by maintaining comfortable room temperatures.
Unlabeled Medications Found in Medication Cart
Penalty
Summary
The facility failed to adhere to proper medication labeling and storage protocols, as evidenced by the discovery of two unidentified and unlabeled medication tablets in one of the medication carts at Nursing Station 1. During an observation and interview with the Infection Prevention Nurse (IPN), it was noted that the medication cart contained one pink and one white tablet, both unlabeled. The IPN confirmed that all medications should be labeled with the resident's name, medication name, dose, and expiration date. This oversight was acknowledged by Licensed Vocational Nurse 1 (LVN1), who admitted forgetting to discard the unlabeled medications, which should have been removed immediately to prevent medication errors. The Director of Nursing (DON) reiterated the importance of storing medications according to the facility's policy and manufacturer's recommendations to maintain their effectiveness. A review of the facility's medication storage policy, last revised in August 2020, indicated that any outdated, contaminated, or deteriorated medications, as well as those in compromised containers, should be promptly removed and disposed of according to the established procedure. The failure to remove the unidentified tablets from the medication cart represents a breach of these protocols, potentially compromising the efficacy of medications administered to residents.
Medication Management and Fall Prevention Deficiencies
Penalty
Summary
The facility failed to ensure the safety of residents by not properly managing medication administration and fall prevention measures. For Resident 163 and Resident 164, medications were left unattended at their bedsides without a completed self-administration assessment. Resident 164, who was alert and oriented, had a Tylenol pill left at the bedside by a nurse, which was not in accordance with the facility's policy as the self-administration assessment was conducted after the incident. Similarly, Resident 163, who was severely impaired in cognition, had multiple pills left at the bedside without a prior self-administration assessment or physician's order, posing a risk of medication misuse. Additionally, the facility did not adhere to the care plan for Resident 29, who was at high risk for falls due to severe cognitive impairment and a history of falls. The care plan specified the use of bilateral floor mats to prevent injury from falls, but during an observation, no floor mats were found next to Resident 29's bed. This oversight increased the risk of injury for Resident 29, who had previously attempted to get out of bed unassisted. The facility's policies on self-administration of medications and fall prevention were not followed, leading to potential safety hazards for the residents involved. The Director of Nursing confirmed the lapses in procedure, acknowledging the importance of assessments and appropriate interventions to ensure resident safety. The failure to conduct timely assessments and implement care plan interventions contributed to the deficiencies observed.
Failure to Implement Non-Pharmacological Interventions Before Opioid Use
Penalty
Summary
The facility failed to ensure that licensed nurses provided non-pharmacological interventions before administering PRN opioid medication to two residents, which could increase the risk of adverse side effects from opioid use. Resident 11, admitted with diagnoses including encephalopathy, migraine headaches, and osteoarthritis, had a care plan that included non-pharmacological interventions such as maintaining proper body alignment, engaging in conversation, and using relaxation techniques. However, there was no documented evidence that these interventions were attempted before administering hydrocodone-acetaminophen on multiple occasions. Similarly, Resident 83, who was readmitted with cellulitis and had intact cognition, also had a care plan that required non-pharmacological interventions for pain management. Despite this, there was no documentation of such interventions being attempted before administering hydrocodone-acetaminophen on several occasions. Interviews with RN 4 and the DON confirmed the lack of documentation and emphasized the importance of non-pharmacological interventions to potentially avoid unnecessary opioid use. The facility's policy on pain management, last reviewed in May 2024, mandates following the resident's care plan for pain management. The DON acknowledged that non-pharmacological interventions should be attempted first, as they might suffice in managing the resident's pain without medication. The absence of documented attempts at these interventions before administering opioids represents a deficiency in the facility's adherence to its pain management policy.
Infection Control Deficiencies in Visitor Screening and Resident Care
Penalty
Summary
The facility failed to implement its infection control policy and procedures in several instances, leading to potential risks of infection among residents. Two visitors were not screened for COVID-19 symptoms or exposure on two separate days, contrary to the facility's policy requiring passive visitor screening. This oversight was acknowledged by the Director of Nursing, who emphasized the importance of screening to protect residents from potential illness. In the kitchen, a dietary aide did not wash their hands after touching a trash can lid before putting on gloves, which could lead to cross-contamination and foodborne illness. The dietary aide admitted to usually washing hands after touching contaminated surfaces, and the Dietary Supervisor confirmed that handwashing is required in such situations. The facility's handwashing policy underscores the importance of washing hands after handling soiled items to prevent infection spread. Additionally, several issues were noted with resident care items. A resident's oxygen nasal cannula was not labeled with the date it was last changed, which is necessary to prevent bacterial growth and respiratory infections. Another resident's urinal was not labeled with an identifier, increasing the risk of cross-contamination. Furthermore, a resident's oxygen tubing was observed touching the floor, which should be avoided to prevent infection. These observations were verified by staff, who acknowledged the lapses in following infection control protocols.
Failure to Respect Resident's Privacy and Dignity
Penalty
Summary
The facility failed to ensure that staff knocked and asked permission before entering a resident's room, violating the resident's rights to respect and dignity. This incident involved a resident admitted with diagnoses including muscle weakness, a history of falling, and chronic kidney disease. The resident had the capacity to understand and make decisions. During an observation, a registered nurse entered the resident's room without knocking and admitted to forgetting to do so, acknowledging that knocking is a sign of respect for the resident's personal space. The facility's policy on dignity, last reviewed in May 2024, requires staff to knock and request permission before entering residents' rooms.
Privacy Violation During Resident Care
Penalty
Summary
The facility failed to ensure the privacy of a resident during personal care, which resulted in a violation of the resident's right to privacy. The incident involved a Certified Nursing Assistant (CNA 1) who did not fully close the privacy curtain while assisting a resident, identified as Resident 96, with dressing. This oversight was observed during a survey when Resident 96 was found fully undressed and sitting on the edge of the bed with the privacy curtain open at the foot of the bed. Resident 96 had been admitted to the facility with diagnoses including difficulty in walking, generalized muscle weakness, and glaucoma. The resident's records indicated intact cognition and the ability to understand and make decisions, requiring supervision or assistance for most activities of daily living. During an interview, CNA 1 acknowledged the failure to close the privacy curtain, and the Director of Nursing confirmed the expectation for staff to provide full privacy during personal care. The facility's policy on dignity and privacy emphasized the importance of maintaining resident privacy during personal care and treatment procedures.
Room Temperature Exceeds Acceptable Range
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for residents in Room A, as the room's temperature exceeded the acceptable range of 71 to 81 degrees Fahrenheit. This deficiency was identified through observations, interviews, and record reviews involving four residents: Resident 100, Resident 167, Resident 168, and Resident 363. The temperatures recorded in Room A were 87.1 F, 84.9 F, 83.3 F, and 82.7 F during the first measurement, and 81.3 F, 79.3 F, and 84.1 F during the second measurement. All four residents expressed discomfort due to the warm room conditions. Resident 100 was admitted with end-stage renal disease and required dialysis, while Resident 167 and Resident 168 had anemia, and Resident 363 had a urinary tract infection. The Minimum Data Set (MDS) assessments indicated varying levels of cognitive impairment among the residents, with some requiring assistance with eating. The Maintenance Supervisor and the Director of Nursing confirmed the importance of maintaining room temperatures within the specified range to prevent discomfort and potential dehydration. The facility's policy, last reviewed in May 2024, mandates daily temperature checks in multiple rooms to ensure compliance with the temperature guidelines.
Failure to Adhere to Fluid Restriction for a Resident
Penalty
Summary
The facility failed to adhere to a physician's order for a strict fluid restriction for Resident 317, who was diagnosed with conditions including hypo-osmolality, hyponatremia, hypokalemia, kidney failure, and muscle weakness. Despite the resident's care plan specifying no water pitcher at the bedside and a fluid restriction of 1200 milliliters per day, a water pitcher and additional cups were observed at the resident's bedside. This oversight occurred even though a sign above the resident's bed indicated that water pitchers should not be left at the bedside. The deficiency was identified during an observation on August 19, 2024, when the Director of Staff Development confirmed the presence of the water pitcher and acknowledged the risk of fluid overload for the resident. The Director of Nursing also emphasized the importance of following the physician's orders to prevent electrolyte imbalance and potential hospitalization. The facility's policy on fluid restriction guidelines, reviewed in May 2024, requires nursing to notify dietary services once a fluid restriction order is prescribed, ensuring the appropriate amount of fluid is managed by the nursing department.
Failure to Implement Scheduled Toileting Plan
Penalty
Summary
The facility failed to provide a scheduled toileting plan for a resident who was admitted with diagnoses including adult failure to thrive and extrarenal uremia. The resident was assessed as cognitively intact and required substantial assistance with walking. The Minimum Data Set (MDS) indicated that the resident was continent of bladder and incontinent of bowel. Despite this assessment, the facility did not implement a scheduled toileting plan as outlined in the resident's care plan, which included offering a bedpan or urinal at regular intervals and assisting the resident to the bathroom. During the review, it was found that the facility's policy required a voiding diary to be maintained and communicated among staff, but there was no documentation of scheduled bowel elimination for the resident. Interviews with the Minimum Data Set Nurse and the Director of Nurses confirmed the lack of adherence to the facility's policy. The Director of Nurses acknowledged the importance of maintaining continence or identifying reasons for incontinence to potentially place the resident on a bowel training program.
Failure to Complete Post-Dialysis Assessment
Penalty
Summary
The facility failed to complete a post-dialysis assessment for Resident 102, who was admitted with end-stage renal disease and required dialysis. The resident's care plan specified the need to assess the dialysis access site for complications such as bleeding, and to check for bruit and thrill. However, the Dialysis Assessment Form dated 8/20/2024 was not filled out, and there was no documentation of vital signs or an assessment in the resident's electronic chart after returning from dialysis. Licensed Vocational Nurse 3 confirmed that the post-dialysis assessment section was not completed and admitted to forgetting to fill out the form or write an assessment note. The Director of Nursing stated that licensed nurses are responsible for completing the post-dialysis assessment to ensure the resident's stability and absence of complications. The facility's policy on end-stage renal disease care requires licensed nurses to look for signs of infection and complications, but this was not adhered to in this instance.
Failure to Remove Lidocaine Patch as Ordered
Penalty
Summary
The facility failed to adhere to professional standards of quality care by not ensuring the timely removal of a lidocaine patch as per the physician's order for a resident. The resident, who was admitted with diagnoses including muscle weakness, a history of falling, and chronic kidney disease, had a physician's order for a lidocaine patch to be applied to both knees for pain management, with instructions to keep the patch on for 12 hours and then remove it for 12 hours. However, during a medication administration observation, it was noted that the patch applied the previous day was not removed after 12 hours, as it was still attached to the resident's knees when the new patch was being applied. The Registered Nurse (RN) acknowledged that the patches should have been removed the previous day according to the physician's order. The Director of Nursing (DON) confirmed that the failure to remove the patch could lead to excessive dosing and potential adverse effects, as indicated in the medication's package insert. The DON agreed that the patch should have been removed after 12 hours to prevent discomfort and potential adverse side effects due to increased absorption of lidocaine.
Failure to Monitor Anticoagulant Side Effects
Penalty
Summary
The facility failed to ensure that licensed nurses monitored for side effects in residents receiving anticoagulant medications, specifically affecting two residents. Resident 73, who was readmitted with a diagnosis of atherosclerotic heart disease, was on apixaban for DVT prophylaxis. Despite the care plan indicating the need to monitor for bleeding or bruising, there was no documentation found to confirm that nurses were monitoring for these side effects. The Director of Nursing acknowledged the importance of monitoring for side effects due to the increased risk of bleeding associated with anticoagulants. Similarly, Resident 364, admitted with chronic obstructive pulmonary disease and other conditions, was on heparin for DVT prophylaxis. The care plan required monitoring for bleeding, bruising, and blood in the urine or stool. However, there was no documentation of such monitoring in the resident's medical record. The Licensed Vocational Nurse confirmed that side effects are usually documented on the MAR, but this was not done for Resident 364. The facility's policy on anticoagulation required monitoring for complications, which was not adhered to in these cases.
Expired Insulin Storage Deficiency
Penalty
Summary
The facility failed to ensure that a vial of insulin lispro, which was past its discard date, was not stored in one of the medication carts. This deficiency was identified during an inspection of Medication Cart A, where a vial of insulin lispro belonging to a resident with diabetes mellitus was found. The insulin vial had an open date that exceeded the 28-day usage period recommended by the manufacturer. Licensed Vocational Nurse 2 confirmed that the insulin should have been discarded after 28 days from opening, as it would lose its efficacy beyond this period. The resident involved had been admitted with a diagnosis of diabetes mellitus and required assistance for self-care. The physician's order for the resident included administering insulin lispro before meals and at bedtime. The manufacturer's guidelines and FDA recommendations specify that opened vials of insulin lispro should be discarded after 28 days, whether stored at room temperature or refrigerated. The failure to adhere to these guidelines resulted in the potential for expired insulin to be administered, which could lead to ineffective blood glucose management for the resident.
Failure to Check Food Temperatures During Meal Service
Penalty
Summary
The facility staff, specifically Cook 1, failed to check the temperature of all food items on the tray line during a mealtime service. This incident occurred on 8/21/2024 at approximately 12 p.m. when Cook 1 did not measure the temperatures of pureed potatoes, chopped turkey, and chicken. This oversight was observed during a kitchen tray line observation and later confirmed in an interview with Cook 1, who acknowledged missing the temperature checks for these specific food items. The facility's policy and procedure, titled 'Meal Service' and last reviewed on 5/22/2024, mandates that food and nutrition services staff must take food temperatures prior to meal service using a thermometer. The failure to adhere to this policy had the potential to result in harmful bacteria growth and cross-contamination, posing a risk of foodborne illness to 110 of the 114 medically compromised residents who received food from the kitchen.
Failure to Report Alleged Abuse to State Survey Agency
Penalty
Summary
The facility failed to develop and implement policies and procedures for reporting a reasonable suspicion of a crime, specifically an allegation of physical abuse, in accordance with section 1150B of the Act. This deficiency was identified when the facility did not report an allegation of physical abuse involving a resident, who was admitted with chronic obstructive pulmonary disease and respiratory failure, to the State Survey Agency (SSA). The resident, who had the capacity to understand and make decisions, reported to a family member that a Certified Nursing Assistant (CNA) was rough while assisting them to a wheelchair, resulting in bruises on the arm and the CNA throwing the resident's teddy bear at them. The incident was documented in a grievance report, and the facility's administrator acknowledged that the rough handling should be considered an allegation of abuse. However, the facility did not report this allegation to the SSA, as required by their own Abuse Prevention Program policy. This failure resulted in a delay of an onsite inspection by the SSA to ensure the safety of other residents and had the potential to result in unidentified abuse.
Delayed MDS Assessments in LTC Facility
Penalty
Summary
The facility failed to ensure that the Quarterly Minimum Data Sets (MDS) assessments for six residents were completed within the required timeframe. The residents affected included those with various medical conditions such as cellulitis, metabolic encephalopathy, chronic obstructive pulmonary disease (COPD), acute embolism, and hypothyroidism. The assessments were not completed within the 14-day period following the Assessment Reference Date (ARD), as mandated by the Centers for Medicare and Medicaid Services (CMS) guidelines. During interviews and record reviews, it was revealed that the MDS assessments for these residents were completed late, ranging from several days to weeks past the deadline. For instance, Resident 83's assessment was due by July 27, 2024, but was not completed until August 12, 2024. Similarly, Resident 42's assessment was due by July 29, 2024, but was also completed on August 12, 2024. These delays were acknowledged by the Registered Nurse (RN) involved, who stated that such delays could negatively impact the residents by failing to identify significant changes in their conditions in a timely manner. The Director of Nursing (DON) emphasized the importance of timely MDS assessments to ensure that residents' specific needs are addressed promptly and that care planning is influenced by the most current assessment data. The facility's policy, last reviewed in May 2024, outlined the responsibility of the MDS Nurse/Coordinator to maintain a master schedule for MDS assessment completion and to ensure regular review by the Interdisciplinary Team (IDT). Despite these policies, the facility did not adhere to the required timelines, resulting in the identified deficiencies.
Medication Transcription Error Leads to Incorrect Doses
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) accurately transcribed a physician's order and administered the correct dose of lisinopril-hydrochlorothiazide for a resident. The resident, who had a history of cerebral infarction, acute respiratory failure, hypertension, depression, and dementia, was given 13 incorrect doses of the medication over a period of time. The physician's order specified that the medication should only be administered if the resident's systolic blood pressure (SBP) was greater than 140/80 mmHg. However, the RN mistakenly transcribed the order using the less than symbol (<) instead of the greater than symbol (>), leading to the administration of the medication when the resident's blood pressure was below the specified threshold. The resident's Medication Administration Record (MAR) showed that the medication was administered on multiple occasions when the resident's blood pressure was below 140/80 mmHg. Specific instances included blood pressure readings such as 130/60, 129/66, and 106/74, among others. During an interview, the RN admitted to the transcription error and acknowledged that she should have used the greater than symbol as per the physician's order. The Director of Nursing (DON) confirmed that the correct process for receiving telephone orders involves reading back the order to the physician to ensure accuracy and that symbols should not be used in such orders. The facility's policy on physician's orders requires complete and accurate transcription of orders, including the resident's full name, date of the order, medication name, dosage, administration information, route of administration, and the physician's signature. The policy also mandates that staff verify the order with the physician for accuracy. The failure to follow these procedures resulted in the resident receiving incorrect doses of medication, placing them at risk for serious health complications.
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What surveyors actually found near you
We read the 4,557 citations issued within 25 miles in the last 12 months — including the 28 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Van Nuys
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| California Healthcare And Rehabilitation Center | 0.1 mi | ★★★★★ | 43 | 0 |
| Terrace Post Acute | 1.1 mi | ★★★★★ | 26 | 0 |
| Lake Balboa Care Center | 1.7 mi | ★★★★★ | 17 | 0 |
| The Care Center On Hazeltine, Llc | 1.7 mi | ★★★★★ | 12 | 0 |
| The Meadows Post Acute | 2.2 mi | ★★★★★ | 23 | 1 |
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