Above 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 Bonnie Brae Skilled Nursing during CMS and state inspections, most recent first.
Failure to Address Aggressive Behavior and Refusals of Care: A resident with schizoaffective disorder bipolar type had repeated verbal aggression, agitation, and refusals of care and meetings, yet the facility did not develop effective individualized behavioral interventions. Records and staff interviews showed ongoing yelling, abusive behavior, and refusal of psychiatric evaluation, treatment, activities, and services. The resident later became involved in a verbal and physical altercation with another resident near the nursing station, after staff described a pattern of aggressive episodes and inability to manage his behaviors.
Two residents at risk for pressure injuries had LALM orders that did not include specific settings. One resident had severe cognitive impairment, was bed bound, and was observed on a LAL mattress set near 120 lbs even though the order only said the mattress may be used and the resident weighed 91 lbs. The other resident had DM, stroke-related deficits, moderate cognitive impairment, and dependence for many ADLs; the order also lacked parameters, the mattress was observed set to 180 lbs, and staff noted there was no current weight in the chart to guide the setting.
Failure to provide dignified meal assistance: A resident with dysphagia, dementia, COPD, DM2, and weakness was observed being assisted with lunch by a CNA who stood over him instead of sitting at eye level. The resident required substantial/maximal help with eating and was receiving OT for ADL retraining. The LVN, ADON, and DON all stated the CNA should have been at the resident’s eye level to preserve dignity, and facility policy specifically says residents should not be stood over during meal assistance.
A resident with dementia, psychotic disturbance, mood disturbance, and anxiety received Seroquel 25 mg BID via G-tube without timely informed consent from the resident or RP. Records showed the antipsychotic was continued after return from GACH, behavior documentation was inconsistent, no GDR was attempted, and the DON, RN, MD, and pharmacist confirmed the medication was being used without proper consent and without clear documentation of the indication.
A resident with schizoaffective disorder, MDD, and anxiety alleged that a CNA took $500.00 from the resident. The ADM was informed of the allegation but did not promptly notify law enforcement and did not immediately remove the accused CNA from resident contact, while staff also reported that required monitoring had not begun and the facility’s response to abuse allegations was inconsistent with its policy.
Inaccurate MDS Assessment and BIMS Scoring: The facility failed to complete an accurate MDS for a resident with CHF, COPD, DM, dementia, Alzheimer’s disease, and other diagnoses. The MDS LVN stated she asked the resident the BIMS recall words but pressed override instead of recording the responses, which changed the recall items to not assessed and resulted in an incorrect BIMS score of 99. RN and the DON confirmed the assessment was inaccurate, and the DON noted the MDS is used to develop, review, and revise the resident’s care plan.
A resident with dementia, metabolic encephalopathy, blindness, hearing loss, and severe functional dependence was found to lack capacity to make medical decisions, yet the facility did not obtain a public guardian or other legally recognized decisionmaker. Staff documented that the resident had no family, no AD, and could not communicate, and the POLST was updated with only one physician signature. The SW and RN confirmed the ombudsman was not included, and the DON stated the facility did not follow its POLST P&P.
Resident rooms failed to meet the required 80 square feet per resident in multiple rooms. The facility requested room variances for 11 of 18 rooms, and the waiver listed several rooms as below the minimum square footage per bed. During observation, the MS measured two rooms at 62 and 12 square feet, while nursing staff and the OT stated there was sufficient space to provide care. Residents interviewed said the rooms were big enough and that care had not been compromised.
A facility failed to maintain an effective pest control program, as evidenced by the observation of a cockroach at the nurses' station and daily sightings reported by a resident with multiple chronic conditions. Staff acknowledged the issue as related to cleanliness and infection control, and facility policies required ongoing pest control, but cockroaches remained present despite regular pest control visits.
The facility failed to protect residents from abuse, as a resident with known behavioral issues was not provided with necessary psychiatric evaluations, leading to a verbal and physical altercation with another resident. Despite being aware of the resident's disruptive behavior, the facility did not take appropriate action to prevent the incident, resulting in physical injury.
The facility failed to complete annual competency and performance evaluations for two CNAs, three LVNs, and an RN, as required by policy. The evaluations were either outdated or missing, potentially compromising resident care. The Administrator confirmed the oversight, which was the responsibility of the Director of Staff Development.
The facility failed to properly label, store, or discard medications, including insulin, Aplisol, and Pneumovax 23, according to professional standards. Insulin vials were found without proper labeling, and expired medications were not removed from storage. An expired emergency medication kit was also not replaced, posing a risk to resident safety.
The facility failed to document discussions and provide written information about advance directives for two residents with severe cognitive impairments. Both residents' acknowledgment forms lacked signatures from responsible parties, confirming receipt of information. The Social Services Director confirmed the oversight, violating residents' rights to be informed about advance directive options.
Two residents in an LTC facility had inaccurate MDS assessments, leading to potential delays in care. One resident's COPD diagnosis was omitted, while another's psychiatric diagnoses were not continued after hospital readmission, despite receiving related medications. The facility's policies on accurate MDS completion and psychotropic medication management were not followed, contributing to these deficiencies.
A resident with limited ROM did not receive required quarterly joint mobility assessments, increasing the risk of contractures. Despite an initial assessment showing limitations, no follow-up assessments were documented. The DON and PT acknowledged the oversight, citing high demands and lack of specific policy on assessment timing.
The facility failed to label and date oxygen humidifier bottles for two residents with COPD, as confirmed by an LVN and the DON. This oversight increased the risk of infection control issues, potentially leading to resident discomfort or infection.
The facility did not complete annual performance evaluations for two CNAs, as required by its policy. CNA 1 and CNA 2, hired in 2016 and 2020 respectively, lacked documented evaluations in their files. The Administrator confirmed that the Director of Staff Development was responsible for ensuring these evaluations were completed. This oversight increased the risk of not identifying staff weaknesses, potentially affecting resident care.
Two residents experienced medication errors, resulting in a 12% error rate. A resident was not instructed to properly use their Qvar inhaler, leading to improper dosage. Another resident received a crushed ferrous sulfate tablet instead of the prescribed liquid form and pantoprazole at the wrong time. The errors were acknowledged by the LVN and confirmed by the DON, highlighting a failure to follow physician orders and facility policies.
A resident with Type II diabetes mellitus received insulin injections at the same site repeatedly, contrary to facility policy and manufacturer guidelines. This practice, confirmed by the RN and DON, increased the risk of adverse effects such as lipodystrophy. The facility's policies emphasized the importance of rotating injection sites to minimize adverse consequences.
A facility failed to coordinate hospice care for a resident with severe cognitive impairment and schizophrenia, as there were no documented visits from hospice staff and no hospice care plan. Interviews with staff confirmed the absence of necessary documentation and coordination, which is required by the facility's hospice policy.
A resident's oxygen nasal cannula was found on the floor, posing an infection risk. The resident, with COPD, had a physician's order for oxygen via nasal cannula. An LVN confirmed the cannula should not be on the floor, and the DON stated it should be covered in a plastic bag when not in use. The facility's policy also required this practice.
The facility failed to meet the required square footage per resident in 10 rooms and two single rooms, as observed by the Maintenance Supervisor. Despite some residents and a CNA reporting no issues with room size, the facility's policy mandates specific space requirements, which were not met, resulting in a deficiency.
Failure to Address Aggressive Behavior and Refusals of Care
Penalty
Summary
The facility failed to ensure necessary behavioral health care and services were provided for a resident with schizoaffective disorder, bipolar type, by not addressing episodes of aggressive behavior and not creating individualized interventions for refusals of care. The resident was admitted with a diagnosis of schizoaffective disorder bipolar type and had documented episodes of verbal aggression toward staff and other residents, including an SBAR note on 11/20/2025 describing verbal aggression and a social services note the same day describing agitation, verbal abuse, purposeful spilling of coffee, and knocking hard on another resident’s door after a prior argument. A care conference was held on 11/24/2025 to discuss the resident’s behavior, but the resident refused to attend. The resident’s H&P dated 1/3/2026 indicated he had the capacity to understand and make decisions. The resident’s psychosocial care plan, developed on 1/3/2026, identified schizophrenic behaviors, manipulative tendencies, and schizoaffective disorder bipolar type, with a goal of fewer daily episodes and interventions including psychiatric consult, assessment of negative emotions, emotional support, encouragement to express feelings, and education for residents and staff about special care needs. The MDS dated 1/27/2026 indicated intact cognition, symptoms of depression, little interest in activities, no hallucinations, no physical behavior symptoms toward others, and use of antipsychotic medication. Facility staff stated the resident refused to participate in planned activities, care meetings, psychiatric evaluation and treatment, and daily services, and the social services director and DON stated the resident refused all interventions and the facility had run out of ideas for new interventions. On 4/4/2026 at 4:57 PM, the resident was verbally abusive to a charge nurse and other residents near the nursing station, and another resident attempted to calm him, leading to a verbal and physical altercation in which the other resident pushed him on the stomach. The progress note stated the resident said the other resident hit and spit at him. Interviews with staff and the administrator confirmed the resident had ongoing aggressive episodes, refused services and meetings, and was not a good fit for the facility, while the facility’s behavioral health policy stated residents would receive behavioral health services as needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being.
LAL Mattress Orders Lacked Specific Settings for Two Residents
Penalty
Summary
The facility failed to provide skin and pressure ulcer care consistent with professional standards and physician orders for two residents who were using low air loss mattresses (LALM). For one resident, the admission record showed diagnoses including respiratory failure with hypoxia, muscle weakness, and osteoporosis. The care plan identified the resident as at risk for pressure sores and noted use of pressure relieving devices as needed. The MDS showed memory problems, severe impairment in decision making, and risk for pressure injuries with a pressure-reducing bed device in place. During observation and record review, that resident was lying on a LAL mattress that was set at a little under 120 lbs on normal pressure, while the physician order stated only that the resident may use a low air loss mattress and did not include a specific setting. The resident’s weight was documented as 91 lbs. In interview, the LVN stated the mattress was set between 80 and 120 lbs and confirmed the order did not give instructions for the setting. The DON also stated the order should have included specific instructions and that the facility should have followed its weight-setting policy. For the second resident, the record showed diagnoses including type 2 DM with hyperglycemia, hypertensive disease with heart failure, partial intestinal obstruction, generalized muscle weakness, cerebral infarction, cerebrovascular disease, hemiplegia, and hemiparesis. The MDS showed moderate cognitive impairment, risk for pressure injuries, and dependence on staff for multiple activities of daily living. The order summary listed LALM with no specific parameters, and the resident was observed in bed with the LALM set to 180 lbs. The DON and an LVN stated the mattress needed specific instructions and was usually set based on weight, but no weight was recorded in the chart for December 2025 or January 2026, and staff did not have a specific order to guide the setting.
Failure to Provide Dignified Meal Assistance
Penalty
Summary
The facility failed to honor Resident 17’s right to dignity when CNA 1 stood over the resident while assisting with lunch on 1/5/2026. Resident 17 was admitted on 6/10/2019 and readmitted on 11/24/2025 with diagnoses including pneumonitis due to inhalation of food and vomit, COPD, diabetes mellitus type II, muscle weakness, dysphagia, major depressive disorder, and dementia. The MDS dated 12/31/2025 indicated the resident sometimes could understand others and sometimes could make himself understood, and required substantial/maximal assistance for eating. Resident 17’s care plan for self-care deficits, dated 11/25/2025, identified a need for moderate assistance with eating and included the intervention to encourage the resident to do as much as possible for himself to increase independence. The order summary dated 12/31/2025 showed a regular diet with pureed food and moderately thick liquids. PT/OT notes dated 1/5/2026 indicated the resident was receiving OT for ADL retraining. During a concurrent observation and interview, CNA 1 was seen standing over Resident 17 while assisting with the meal. CNA 1 stated he was standing because the OT told him to assist Resident 17 with eating/feeding himself. LVN 1 stated CNA 1 should have been sitting while helping Resident 17 with the meal and not standing over him to provide dignity. The ADON and DON both stated CNAs should be at the same eye level as residents when assisting with meals to provide dignity, and the DON stated standing over Resident 17 could have made the resident feel overpowered. The facility’s Assistance with Meals and Dignity policies stated residents should be fed with attention to safety, comfort, and dignity and should not be stood over while being assisted.
Psychotropic Medication Used Without Informed Consent
Penalty
Summary
The facility failed to ensure that one sampled resident was free from chemical restraint use by not obtaining informed consent for Seroquel and not documenting the indication for its use with the resident or the resident’s responsible party. The resident had diagnoses including unspecified dementia, psychotic disturbance, mood disturbance, and anxiety disorder, and the record showed the resident lacked capacity to understand and make decisions. The resident’s order summary included Seroquel 25 mg via G-tube twice daily, and the facility’s informed consent form indicated that no informed consent had been received for the medication at the time it was reviewed. The resident’s records also showed that the medication was being monitored for behaviors such as unconsolable screaming and yelling, but the monthly behavioral summary was left blank and the nursing administration reports showed no such behaviors during some reviewed periods and only one episode during another period. The care plan identified agitation manifested by yelling and screaming and directed staff to administer medication per physician order. The pharmacist questioned the use of the antipsychotic for dementia-related behaviors and noted that the medication was not FDA approved for that use, while the psychiatrist later disagreed and signed the review form stating the resident had episodes of agitation. Interviews with RN, DON, MD, pharmacist, and MDIR confirmed that Seroquel had been continued after the resident returned from the acute care hospital, that informed consent had not been obtained from the resident or a representative at the time the medication was started, and that the physician signed the informed consent form much later. The DON and RN acknowledged the resident was receiving psychotropic medication without informed consent. The record also showed that no gradual dose reduction had been attempted, and the psychiatrist note did not indicate that dose reduction was clinically contraindicated or that the current dose was the lowest effective dose. The resident was observed lying in bed with both bed rails up and opened eyes when voice prompted.
Failure to Timely Report and Remove Staff After Financial Abuse Allegation
Penalty
Summary
The facility failed to follow its policy and procedures for Abuse, Neglect, Exploitation, or Misappropriation - Reporting and Investigating for one sampled resident who alleged that a CNA took $500.00 from the resident. The resident had diagnoses including schizoaffective disorder, bipolar type, major depressive disorder, and anxiety disorder. The resident’s MDS indicated good recall but not orientation to the day of the week. During an interview, the resident stated the CNA owed the resident $500.00 and that the CNA’s wife, who worked at the facility, gave the CNA the money. The resident said the money was given in December. The ADM was informed of the allegation on 1/5/2026, but the ADM did not report the allegation to local police until 1/6/2026 and did not suspend the CNA until 1/6/2026. The ADM stated the facility had not reported similar allegations in the past because of the resident’s mental capacity. The Social Services note documented that the resident reported to a surveyor that a facility staff member took the resident’s $500.00 and that the facility started an investigation on 1/5/2026. The SW stated that 72-hour monitoring had not begun after the allegation was reported. During interviews, the ADM and RN stated the facility’s response to abuse allegations varied and that police involvement was not always considered unless there was an altercation, physical injury, or the resident requested it. RN stated the police were not notified, and the CNA remained working in the facility until the later suspension. The ADM also stated the facility did not schedule an IDT meeting for the allegation and was unsure whether a psychological consult had been arranged. The facility’s policy dated 7/2025 stated the administrator immediately reports suspicion to state licensing/certification, the local ombudsman, and law enforcement officials, and that any employee accused of resident abuse would be placed on leave with no resident contact until the investigation was completed.
Inaccurate MDS Assessment and BIMS Scoring
Penalty
Summary
The facility failed to provide an accurate MDS assessment for one sampled resident. The resident was admitted on 4/1/2022 and readmitted on 12/2/2025 with diagnoses including CHF, COPD, type 2 DM, muscle weakness, HTN, atherosclerotic heart disease, schizoaffective disorder bipolar type, functional quadriplegia, dementia, and Alzheimer’s disease. A history and physical dated 11/26/2025 stated the resident had the capacity to understand and make decisions. During a concurrent interview and record review on 1/6/2026, the MDS LVN reviewed the resident’s MDS and stated the BIMS score of 99 was not correct because she had completed the BIMS assessment. The MDS showed C0100 as yes for conducting the BIMS, C0200 as none, and C0300 and C0400 responses that reflected the recall items as not assessed. The MDS LVN stated she asked the resident to recall the words sock, blue, and bed, but the resident was not able to recall them. She stated she pressed override instead of answering the recall questions correctly, and that this caused the recall items to change automatically to not assessed. The MDS LVN stated the resident’s BIMS score should have been 0, not 99, and that the MDS assessment was not accurate. RN1 also stated the MDS was not accurate and needed to be accurate for staff to know how to appropriately care for the resident. The DON reviewed the MDS and stated the MDS LVN should not have pressed override on the recall questions because it defaulted the answers to not assessed, rendering the assessment inaccurate. The DON also reviewed the facility policy titled Resident Assessments, which states resident assessments are used to develop, review, and revise the comprehensive care plan.
Failure to Obtain Legal Decisionmaker and Follow POLST Process
Penalty
Summary
The facility failed to provide medically related social services for Resident 5 by not obtaining a public guardian when the resident was assessed as lacking capacity to understand and make medical decisions. Resident 5 was admitted and later readmitted with multiple diagnoses including gastrostomy, COPD, persistent atrial fibrillation, ventricular tachycardia, bilateral blindness, metabolic encephalopathy, bilateral hearing loss, adult failure to thrive, unspecified dementia, and anxiety disorder. The H&P documented that the resident did not have capacity to understand and make decisions, and the MDS showed the resident was rarely or never understood, had short-term and long-term memory problems, had no recall ability, and was dependent on staff for multiple activities of daily living. During observation, Resident 5 was lying in bed with both side rails up, opened eyes when spoken to, and did not respond verbally. The resident’s care conference record showed an interdisciplinary meeting related to a change in condition, with the resident not attending because of cognitive impairment. The record also indicated the resident was on hospice and not to receive CPR, but the agent/responsible person section was blank. Staff interviews showed the resident had no family members, no advanced directive, and could not communicate. The SW stated a referral would be needed if a resident did not have an advanced directive, and later stated that if a resident was incapacitated, the SSD had to find a public guardian. The facility also failed to follow its POLST policy and procedures when Resident 5’s POLST was updated. The SW reviewed the POLST and stated it was not the same as an advanced directive, that the resident was unable to sign because of cognitive impairment, and that only one physician signed the form even though the SW stated two doctors were supposed to sign if the resident could not sign. RN 1 confirmed there was only one physician signature and stated the resident had no family, no advanced directive, and could not communicate. RN 1 also stated the ombudsman should have been included in the decision to change the POLST, and the DON stated the facility should have tried to obtain a public guardian or conservatorship and should have invited the ombudsman to the care conference. The facility policy stated that if the resident lacked decision-making capacity, the initial POLST review was to be conducted with the legally recognized healthcare decisionmaker, identified as the ombudsman or public guardian's office.
Resident Rooms Did Not Meet Required Square Footage
Penalty
Summary
The facility failed to ensure that 10 of 18 resident rooms met the required 80 square feet per resident in multiple resident rooms. During review of the facility’s room waiver letter dated 1/5/2026, the letter showed the facility was requesting a room variance for 11 of 18 resident rooms, including rooms [ROOM NUMBER], 3, 4, 5, 6, 9, 12, 15, 18, 23, and 24. The waiver letter listed several rooms as having less than 80 square feet per bed, with floor areas and capacities documented for the affected rooms. During observation on 1/8/2026, the Maintenance Supervisor measured rooms [ROOM NUMBER] and [ROOM NUMBER], and the rooms measured 62 and 12 square feet, respectively. During multiple observations of nursing care in the waived rooms, nursing staff were observed with adequate space to provide care, and residents had privacy curtains, working call lights, storage, and bedside tables with personal belongings stored in each resident’s chosen location. The Occupational Therapist stated there was sufficient space in the waived rooms to provide care and complete the residents’ plan of care. Resident 90 stated the room was big enough to accommodate him and his wife and that the room size had never stopped care from being completed. Resident 10 stated the room was big enough and that nursing care had never been compromised. The facility policy stated resident bedrooms must be designed and equipped for adequate nursing care, comfort, and privacy and must measure at least 80 square feet per resident in multiple resident bedrooms.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of cockroaches within the building. During an observation at the nurses' station, a large cockroach was seen crawling on the floor. A registered nurse confirmed the insect was a cockroach and acknowledged that its presence was related to cleanliness and posed a pest control and infection control issue. A resident reported seeing cockroaches daily and expressed concern about the cleanliness of the environment, stating that the situation was not right and could lead to illness. The interim Director of Nursing also stated that cockroaches in the facility could cause residents to become ill, particularly those with weakened immune systems. A review of the facility's pest control policy indicated that the facility was supposed to maintain an ongoing pest control program to keep the building free of insects. The administrator stated that the pest control company visited the facility monthly and as needed, with the most recent visit occurring earlier in the month. Despite these measures, the continued presence of cockroaches was observed and reported by both staff and a resident. The facility's infection prevention and control policy also referenced pest control as part of maintaining a safe and sanitary environment.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from abuse, specifically resident-to-resident verbal and physical abuse, involving two residents. Resident 1 exhibited behavioral symptoms, such as entering other residents' rooms without permission and shouting at them. Despite these behaviors, the facility did not provide necessary behavioral health assessments or refer Resident 1 for psychiatric or psychological evaluations as required by the care plan. This lack of intervention allowed Resident 1's disruptive behavior to continue unchecked. On a specific day, Resident 1 engaged in verbal abuse towards Resident 2, leading to a physical altercation. Resident 1 was yelling and irritating Resident 2, who then struck Resident 1 with a cellphone, causing physical injury. Resident 1 sustained redness and bruising on the right side of the face and complained of blurry vision. The facility's failure to address Resident 1's behavioral issues and provide timely psychiatric consultation contributed to the escalation of the situation. Interviews with staff and residents revealed that Resident 1 was known to be loud and disruptive, often going into other residents' rooms and causing disturbances. Despite these known behaviors, the facility did not perceive Resident 1 as a threat and did not take appropriate action to prevent the altercation. The facility's policies and procedures for resident assessment and abuse prevention were not effectively implemented, resulting in a failure to protect residents from abuse.
Failure to Complete Annual Competency and Performance Evaluations
Penalty
Summary
The facility failed to ensure that two Certified Nursing Assistants (CNAs), three Licensed Vocational Nurses (LVNs), and one Registered Nurse (RN) had completed their annual competency and performance evaluations. This deficiency was identified through interviews and record reviews, revealing that the evaluations were either outdated or missing entirely. Specifically, CNA 1's last competency evaluation was completed in August 2023, while CNA 2's was last done in October 2021. LVN 3 had no records of competency or performance evaluations, LVN 4 had a recent performance evaluation but no competency evaluation, and LVN 5's last competency evaluation was in April 2021. RN 2 also lacked both competency and performance evaluations. The Administrator confirmed that the Director of Staff Development was responsible for ensuring timely completion and updating of these evaluations in employee files. The facility's policy mandates that job performance and competency evaluations be conducted annually. The failure to adhere to these policies potentially compromised the quality of care provided to residents, as acknowledged by the Administrator during the interview.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that medications were labeled, stored, or discarded according to current professional standards. During an observation, it was found that insulin Humulin R vials for two residents were improperly stored at room temperature without appropriate labeling of the open date. One vial was found without any date indicating when it was opened, while another vial was labeled with an expired date. This oversight led to the potential risk of administering expired insulin, which could be ineffective in managing blood sugar levels. Additionally, in the medication room, two Aplisol multi-dose vials were found stored in the refrigerator with labels indicating they were opened beyond the manufacturer's recommended 30-day usage period. An unopened Pneumovax 23 syringe was also found stored at room temperature, contrary to the manufacturer's requirement for refrigeration. Furthermore, an expired emergency medication kit was not removed or replaced, increasing the risk of using ineffective medications in emergencies. Interviews with the LVN and the DON revealed a lack of adherence to the facility's policies and procedures regarding medication labeling and storage. The DON acknowledged that the emergency medication kit and expired medications should have been removed and replaced. The facility's failure to follow its own policies and the manufacturer's guidelines resulted in the presence of expired and improperly stored medications, posing a risk to resident safety.
Failure to Document Advance Directive Discussions
Penalty
Summary
The facility failed to ensure that residents' medical records were updated to reflect discussions and provision of written information regarding advance directives for two residents. Resident 2, who was admitted with diagnoses including dementia, dysphagia, and gastrostomy, was found to have severe cognitive impairment and was unable to make decisions. The Advance Directive Acknowledgment form for Resident 2, dated January 30, 2024, indicated the resident's incapacity to sign, and there was no signature from the responsible party acknowledging receipt of information about the resident's right to formulate an advance directive. Similarly, Resident 4, admitted with diagnoses of senile degeneration of the brain and schizophrenia, also had severe cognitive impairment and was unable to make decisions. The Advance Directive Acknowledgment form for Resident 4, dated February 1, 2021, similarly lacked a signature from the responsible party. During an interview and record review, the Social Services Director confirmed that written information regarding the right to formulate an advance directive was not provided to the responsible parties for both residents. This oversight violated the residents' rights to be fully informed about their options for advance directives.
Inaccurate Resident Assessments Lead to Care Deficiencies
Penalty
Summary
The facility failed to ensure accurate assessments for two residents, leading to deficiencies in their care. Resident 18's Minimum Data Set (MDS) did not include a diagnosis of chronic obstructive pulmonary disease (COPD), despite the resident's history and physical records indicating this condition. The MDS Nurse acknowledged the omission and emphasized the importance of including all diagnoses to prevent delayed treatment. The Director of Nursing (DON) also confirmed that all active diagnoses should be reflected in the MDS to avoid missing critical information that could delay care. Resident 25's MDS failed to list psychiatric diagnoses such as depression, bipolar disorder, and schizophrenia, despite the resident receiving medications for these conditions. The MDS Nurse noted that these diagnoses were not continued upon the resident's return from the General Acute Care Hospital (GACH), leading to a potential delay in care continuity. The Licensed Vocational Nurse (LVN) confirmed the importance of matching diagnoses with medications to ensure proper treatment. The DON explained that the admitting nurse should verify all diagnoses during re-admission, but this process was not followed, resulting in the omission. The facility's policies and procedures require accurate completion and signing of the MDS assessment form, as well as proper management of psychotropic medications, including monitoring for efficacy and adverse effects. However, these protocols were not adhered to, leading to the deficiencies observed in the residents' care. The failure to accurately document and continue diagnoses upon re-admission contributed to the potential for delayed treatment and improper medication management.
Failure to Conduct Quarterly Joint Mobility Assessments
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion (ROM) received quarterly joint mobility assessments, as required. Resident 11, who was admitted with a diagnosis of muscle weakness, had an initial joint mobility assessment indicating limitations, but no subsequent assessments were documented. This lack of follow-up assessments increased the risk of contractures and hindered the ability to monitor and maintain the resident's mobility. Interviews with the Director of Nursing (DON) and the Physical Therapist (PT) revealed that the facility lacked a specific policy on the timing of joint mobility assessments, although a general policy on resident mobility and ROM existed. The DON acknowledged that quarterly assessments should occur every three months, but no recent assessments were found for Resident 11. The PT admitted that despite a low workload, the demands were high, and many residents, including Resident 11, had not been reassessed, leaving no measurement of progress.
Failure to Label Respiratory Equipment in COPD Residents
Penalty
Summary
The facility failed to provide necessary respiratory care services for two residents diagnosed with chronic obstructive pulmonary disease (COPD). Both residents, identified as Resident 18 and Resident 34, had oxygen humidifier bottles that were not labeled or dated, which is a requirement according to the facility's policy. This oversight was confirmed during observations and interviews with Licensed Vocational Nurse 1 (LVN 1) and the Director of Nursing (DON). The lack of labeling on the oxygen humidifier bottles increased the risk of infection control issues, potentially leading to resident discomfort or infection. Resident 18 was admitted with a diagnosis of COPD and had a physician's order for oxygen at two liters per minute via nasal cannula as needed. The resident's care plan indicated a risk for respiratory distress, yet the oxygen humidifier bottle was not labeled or dated. Similarly, Resident 34, also diagnosed with COPD, had a physician's order for oxygen administration under specific conditions. During an observation, it was noted that both the oxygen humidifier bottle and nasal cannula were not labeled or dated. The DON confirmed the importance of labeling respiratory equipment to ensure timely changes and prevent potential health risks.
Failure to Complete Annual Performance Evaluations for CNAs
Penalty
Summary
The facility failed to ensure that two Certified Nursing Assistants (CNAs) had completed annual performance evaluations, which is a requirement according to the facility's policy and procedure. CNA 1, hired on April 23, 2016, and CNA 2, hired on August 13, 2020, both lacked documented performance evaluations in their employee files. During an interview and record review with the Administrator, it was confirmed that the Director of Staff Development was responsible for ensuring these evaluations were completed and updated in the files. The absence of these evaluations was acknowledged by the Administrator, who noted the potential risk to the quality of care provided to residents due to this oversight. The facility's policy, revised in 2024, mandates that employee job performance be reviewed and evaluated at least annually. The failure to adhere to this policy resulted in an increased risk of not identifying areas of weakness in staff performance, potentially affecting the services provided to residents.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate of 5% or lower, resulting in a 12% error rate during a survey. This was due to three medication errors observed among 35 opportunities for two residents. Resident 34 was not instructed to properly use their Qvar inhaler, leading to medication escaping and not being fully inhaled. This was contrary to the manufacturer's instructions, which require a full seal around the mouthpiece to ensure proper dosage. Resident 36 experienced two medication errors. The resident was administered a crushed ferrous sulfate tablet instead of the prescribed liquid form, and the pantoprazole oral packet was given at an incorrect time. The Licensed Vocational Nurse (LVN) acknowledged these errors, noting that the administration did not follow the physician's orders or the facility's policy, which allows a 60-minute window for medication administration. The Director of Nursing confirmed these errors, emphasizing the importance of following physician orders and manufacturer instructions to prevent potential harm. The facility's policies on medication administration and error prevention were not adhered to, contributing to the observed deficiencies.
Failure to Rotate Insulin Injection Sites
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors related to insulin administration. Specifically, the facility did not rotate the subcutaneous injection sites for insulin administration for a resident with Type II diabetes mellitus. The resident was prescribed Humulin 70/30 insulin to be administered subcutaneously once a day in the morning and in the evening. However, the Medication Administration Record (MAR) for November 2024 showed that the insulin was repeatedly administered in the same site, the right arm, by several licensed nurses over multiple days. Interviews with a Registered Nurse (RN) and the Director of Nursing (DON) confirmed that the failure to rotate injection sites was against facility policy, standard practice, and manufacturer guidelines. This practice increased the risk of adverse effects such as lipodystrophy and cutaneous amyloidosis. The facility's policies and procedures emphasized the importance of rotating injection sites to minimize adverse consequences, as outlined in the manufacturer's guide for Humulin 70/30.
Lack of Coordination in Hospice Care for Resident
Penalty
Summary
The facility failed to ensure consistent coordination of care for a resident receiving hospice services, leading to a deficiency in the provision of necessary care. Resident 4, who was admitted with diagnoses including senile degeneration of the brain and schizophrenia, was supposed to receive hospice care as per the physician's orders. However, a review of the hospice records revealed that there were no signatures from a skilled nurse or home health aide on the sign-in sheets, indicating a lack of documented visits. Additionally, there was no hospice care plan in place for Resident 4, which is crucial for addressing the specific needs of the resident. Interviews with facility staff, including a Registered Nurse and the Director of Nursing, confirmed the absence of documented hospice visits and a care plan. The RN acknowledged the importance of ensuring hospice staff visits and having a care plan, while the DON emphasized the need for hospice staff to sign in and maintain a care plan to prevent compromising the resident's care. The facility's policy on hospice care mandates coordination with hospice representatives to meet the resident's needs, which was not adhered to in this case.
Infection Control Deficiency: Oxygen Cannula on Floor
Penalty
Summary
The facility failed to provide a safe and sanitary environment for a resident, identified as Resident 34, when the resident's oxygen nasal cannula was observed on the floor. This incident was noted during an observation and interview with an LVN, who confirmed that the nasal cannula should not be on the floor due to infection control concerns. The resident, who was admitted with chronic obstructive pulmonary disease (COPD), had a physician's order for oxygen administration via nasal cannula as needed for shortness of breath and low oxygen saturation levels. The Director of Nursing (DON) confirmed that the nasal cannula should be covered in a plastic bag when not in use to prevent infection, as the floor is considered a dirty surface. The facility's policy on infection prevention for respiratory therapy also indicated that oxygen cannulae and tubing should be kept in a plastic bag when not in use. Despite these guidelines, the nasal cannula was found on the floor, posing a risk of contamination and infection to the resident.
Deficiency in Room Size Requirements
Penalty
Summary
The facility failed to ensure that 10 out of 22 rooms met the required 80 square feet per resident in multiple occupancy rooms and failed to ensure that two rooms met the required 100 square feet for single occupancy. This deficiency was identified during an observation and interview process. The Maintenance Supervisor measured several rooms, and it was found that Rooms 1, 3, 4, 5, 6, 12, 15, 18, 13, and 24 did not meet the required space per resident. Additionally, two single rooms did not meet the 100 square feet requirement. The measurements were consistent with a client accommodation analysis conducted earlier. Interviews with residents and staff revealed that some residents, such as Resident 3 and Resident 12, did not express concerns about the room sizes, indicating they were able to move around without issues. A Certified Nurse Assistant also reported no concerns with the room size while providing care. Despite these individual experiences, the facility's policy requires specific square footage per resident, which was not met, leading to the deficiency.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Los Angeles
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Angels Nursing Health Center | 0.1 mi | ★★★★★ | 0 | 0 |
| Westlake Convalescent Hospital | 0.1 mi | ★★★★★ | 8 | 0 |
| The Rehabilitation Center Of Los Angeles | 0.1 mi | ★★★★★ | 0 | 0 |
| Mid-wilshire Health Care Cntr | 0.3 mi | ★★★★★ | 35 | 0 |
| Pih Health Good Samaritan Hospital D/p Snf | 0.5 mi | ★★★★★ | 3 | 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.