Average — CMS composite of the measures below.
The next survey window likely opens around November 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 Brentwood Health Care Center during CMS and state inspections, most recent first.
A high fall-risk male resident with multiple comorbidities, impaired cognition, and total dependence for transfers had a physician order for a tab alarm in bed and wheelchair, with placement and function to be monitored each shift. During observation, a tab alarm was found attached only to the wheelchair, not to the resident, and without batteries. An LVN confirmed the alarm was not connected to the resident and was nonfunctional, while the DSD later stated only the bed pad alarm had been checked that morning and not the wheelchair tab alarm, contrary to facility policy requiring secure attachment, testing, and shift-by-shift maintenance of alarms.
A resident with Parkinson’s disease, encephalopathy, mild cognitive impairment, and multiple stage 4 PUs did not receive care consistent with physician orders and facility policy. Care plans for impaired skin integrity were generic, using non-specific language such as “treatment as ordered” without detailing wound staging or individualized interventions, and were not updated when new DTIs developed. Turning and repositioning ordered q2h was poorly documented over many days, and a CNA reported finding the resident in the same position for up to four hours. The LAL mattress was not set according to the resident’s weight, effectively placing the resident on a hardened surface. New PUs, including DTIs on the right shoulder and left shin, were not promptly addressed with SBARs or timely assessments, and wound treatments were missed or delayed due to unclear assignment and follow-through by the treatment nurse and an LVN. These actions and omissions led to worsening existing PUs and the development of facility-acquired PUs.
A resident with Parkinson’s disease, encephalopathy, cognitive communication deficit, and multiple stage 4 PUs was dependent on staff for ADLs and had orders for specific wound care and q2h turning. Care plans for impaired skin integrity used generic language such as “treatment as ordered” without specifying treatments or individualized interventions, and CNA documentation showed many missed or undocumented repositioning times. Nursing staff failed to perform and document thorough head-to-toe skin assessments, did not promptly complete SBARs or notify the physician and family when new PUs developed on the shoulder and left shin, and the treatment nurse was unable to accurately describe the new wounds or DTPI. The resident’s LAL mattress was set at a default 400 lbs rather than near the resident’s actual weight, contrary to staff and wound care specialist statements that settings must be weight-based. These failures delayed treatment of a new unstageable PU on the shin and did not follow the facility’s own pressure ulcer assessment policy, which the report notes could have led to further deterioration, infection, sepsis, organ failure, and death.
Improper Food Date Marking and Unsafe Meat Storage: Dietary staff failed to properly date-mark and store refrigerated foods. Opened cheese packages had handwritten expiration dates that were covered by pre-printed labels with later dates, and beef patties were found soaking in a dark reddish liquid in a container. The DSS stated the cheese needed to be discarded because the handwritten expiration dates had already expired and said the meat was not safe to cook and serve because it was discolored.
Failure to Provide Appropriate Meal Alternatives: A resident with intact cognition, colon cancer history, and multiple food allergies and intolerances reported difficulty obtaining food she could eat and said she was only given limited alternatives such as bread, cheese, and noodles. During lunch observation, the tray served did not match the meal ticket, and staff acknowledged the resident often refused the kitchen food, the tray was not appetizing, and the kitchen could not consistently accommodate her alternative meal needs.
Inaccurate PASRR Level I Screening: A resident with diagnoses including dementia, anxiety, and paranoid schizophrenia had a PASRR Level I that did not identify schizophrenia, even though the record showed the diagnosis and use of Sertraline for depression. The resident also had no care plan focus, goals, or interventions related to PASRR Level I or Level II. The DON stated the PASRR was not accurately completed and that the resident needed a correct PASRR.
A resident with intact cognition and the ability to make ADL decisions was receiving bed baths instead of showers despite stating a preference for showers and reporting no shower since admission. Staff said showers were not provided because the resident could not bear weight and they believed transfers after bathing were unsafe, even though the facility had a bariatric shower chair rated for 500 lbs and a functional Hoyer lift. The facility’s bathing policy stated residents are offered baths and showers with additional bathing based on preference.
Failure to honor a resident's food preferences: A resident with impaired cognition and multiple chronic conditions reported being served eggs despite stating he does not eat eggs and having told the DS after admission. The meal ticket for breakfast listed an omelet, while the DS said resident food dislikes and preferences are normally listed on meal tickets but could not explain why the egg dislike was not documented.
A resident's orthopedic appointment was unnecessarily rescheduled due to the facility's failure to arrange transportation and communicate with the resident's representative. The oversight by the social service assistant led to confusion and distress, as the representative was not informed of the rescheduling despite having previously provided the appointment details.
The facility failed to ensure safe food storage by keeping expired canned food, including corned beef hash, with non-expired items in the kitchen storage area. This was confirmed by the Dietary Supervisor, who noted that expired food should be separated to prevent serving it to residents, especially given their age and medical conditions. The facility's policies require proper inspection and storage of food, but these were not followed, risking foodborne illness for 57 residents.
Two residents were not provided a dignified dining experience as CNAs stood over them while feeding, contrary to facility policy. One resident with dementia and dysphagia and another with multiple health issues were affected. The DON confirmed that feeding should occur at eye level to maintain dignity.
The facility failed to provide ongoing activities for 57 residents, as a CNA, covering for the vacationing Activities Director, was untrained in conducting activities. The DON acknowledged the importance of activities for residents' mental well-being but was unaware of the location of activity logs.
The facility failed to create comprehensive care plans for two residents, leading to deficiencies in their care. One resident, with dementia and psychotic disturbance, was prescribed psychotropic medications without a care plan addressing their use or targeted behaviors. Another resident, with major depressive disorder and atrial fibrillation, was receiving anticoagulant medication without a care plan. The absence of these care plans was confirmed by nursing staff and highlighted the facility's failure to adhere to its policies for person-centered care planning.
Two residents in the facility were not properly monitored for the effects of anticoagulants and antidepressants, leading to potential health risks. One resident on Eliquis was not monitored for bleeding, as required by their care plan, due to an oversight in carrying over orders upon readmission. Another resident on Apixaban and antidepressants lacked monitoring orders, resulting in no documentation of potential side effects or effectiveness. The facility's protocols for medication monitoring were not adhered to, as confirmed by the DON and nursing staff.
The facility failed to properly execute informed consent forms for psychotropic medications for two residents. One resident, with dementia and anxiety, received multiple medications without individual consent forms for each. Another resident, with major depressive disorder, also had medications listed on a single form. The facility's policy requires separate consent forms for each medication, specifying dosage and clinical indications.
A resident with intact cognition reported ants in their room, confirmed by observations. The facility had recently treated exterior ant activity but failed to address interior infestations promptly. The Maintenance Supervisor had to spray the room himself due to a delay in fumigation services. The DON acknowledged the facility's responsibility to ensure a pest-free environment.
A resident was found with an unlabeled medication cup containing a white powder, identified as antifungal powder, without a physician's order or assessment for self-administration capability. The resident, with intact cognition but requiring assistance for some daily activities, was not assessed for safe self-administration, and the medication was not stored securely as per facility policy. Staff were unaware of the medication's presence, and no physician order was found for its use.
The facility failed to record advanced directives for two residents, despite their intact cognitive skills and the facility's policy requiring acknowledgment forms to be signed and dated. Both residents reported that the facility did not discuss advanced directive information with them, and interviews with staff confirmed the importance of these forms in ensuring care aligns with residents' wishes.
A facility failed to accurately document a resident's use of an anticoagulant in their MDS assessment. The resident, admitted with conditions including atrial fibrillation, was prescribed Apixaban, but this was not reflected in the MDS. Interviews with staff revealed the omission was an oversight, highlighting the need for accurate assessments to coordinate care. Facility policies and CMS guidelines require comprehensive assessments, which were not followed in this instance.
A CNA was assigned to cover for the Activities Director without proper training or qualifications, affecting the well-being of 57 residents. The CNA was observed monitoring residents watching TV and admitted to being untrained. Interviews with the DSD and DON confirmed the lack of training, and the DON could not locate activity logs. The facility's job description required specific qualifications that the CNA did not meet.
A facility failed to create a care plan with measurable goals for a resident with dementia, despite the resident's severe cognitive impairment and use of medications for psychosis and anxiety. Observations and interviews confirmed the absence of a tailored care plan, contrary to the facility's policy on dementia management.
A resident was found applying antifungal powder without a physician's order, and the medication was stored improperly in an unlabeled cup at the bedside. Staff were unaware of the medication's presence, and facility policy on self-administration and secure storage was not followed.
The facility failed to document an accurate fall risk assessment for a resident with multiple diagnoses and a recent fall history, incorrectly identifying her as low risk for falls. The LVN did not review the resident's history and physical, which would have indicated a higher fall risk score. The DON confirmed that all documentation should be included in fall risk assessments.
Failure to Properly Apply and Test Tab Alarm for High Fall-Risk Resident
Penalty
Summary
The facility failed to ensure a tab alarm was properly applied and tested for a high fall-risk resident, as ordered and required by facility policy. The resident was an older male with multiple diagnoses including type 2 DM, atherosclerotic heart disease, chronic kidney disease, dysphagia, cognitive communication deficit, a stage 3 sacral pressure ulcer, BPH, anemia, hypothyroidism, PVD, and a prosthetic heart valve. His MDS dated 3/27/26 showed impaired cognition and total dependence on staff for toileting, personal hygiene, and transfers. A fall risk assessment identified him as high risk for falls, and a physician’s order dated 3/28/26 required a tab alarm while in bed and in the wheelchair to alert staff when he attempted to get up without assistance, with monitoring of tab alarm placement and functionality every shift. On observation in the resident’s room, the resident was seated in a wheelchair with a tab alarm attached to the wheelchair but not attached to the resident, and the alarm had no batteries. The LVN present confirmed the alarm was not connected to the resident and that it lacked batteries, and stated the DSD rounds daily to check alarms. The DON stated it was everyone’s responsibility to check alarms and that the DSD checks placement and functionality during morning rounds, with replacement if alarms are broken or not working. The DSD reported that the resident’s pad alarm was checked that morning while the resident was in bed, but the wheelchair tab alarm was not checked. The facility’s written policy required that tab alarms be attached securely, tested, and maintained by testing each shift and checking batteries and cords, which was not done for this resident’s wheelchair tab alarm.
Failure to Individualize Pressure Ulcer Care and Properly Use Support Surfaces
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate pressure ulcer care and to prevent the deterioration and development of pressure injuries for a resident with multiple existing pressure ulcers. The resident had diagnoses including Parkinson’s disease, encephalopathy, cognitive communication deficit, and multiple stage 4 pressure ulcers to the sacral region and both hips. An MDS indicated mild cognitive impairment, dependence on staff for ADLs, and the presence of three stage 4 pressure ulcers with risk for additional ulcers. Physician orders included use of a pressure-relieving mattress and turning and repositioning every two hours, with refusals to be documented. However, the facility did not consistently implement and document these interventions. Care plans initiated for impaired skin integrity related to pressure injuries on the right buttocks and sacrum contained generic interventions such as “treatment as ordered” and did not specify individualized treatments, staging details, or clearly defined interventions beyond broad statements like monitoring skin and turning and repositioning. The treatment nurse stated that care plans for wounds and treatments were not updated with specific orders when wounds were reclassified or when new SBARs were generated, and that it was considered redundant to place actual treatment orders on the care plan. The treatment nurse also acknowledged that the same generic verbiage (“treatment as ordered”) was used for residents with various treatments ordered, and admitted that no SBAR was completed when a new right shoulder deep tissue injury (DTI) was discovered. A left shin DTI was discovered later, and the treatment nurse confirmed that a head-to-toe assessment could have identified this pressure ulcer earlier and prompted SBAR completion and physician and representative notification. Documentation of turning and repositioning was incomplete over multiple days, with numerous time slots lacking evidence that the resident was repositioned every two hours as ordered. A CNA reported doing her best to reposition the resident but stated there were instances when the resident was found in the same position four hours later. The CNA also reported that the resident had pressure ulcers on the buttocks, right upper arm, and a more recent ulcer on the left lower leg. The wound care specialist explained that the low air loss (LAL) mattress is weight-based and must be set close to the resident’s weight, and that setting it to 400 lbs for a resident weighing 139 lbs would be like placing the resident on a table, potentially worsening current wounds or contributing to new pressure ulcers. The medical director stated that staff must notify a physician as soon as possible for changes in condition, urgently for new pressure ulcers, and that care plans must include clear, individualized goals, and also confirmed that placing a resident on a hardened surface for a prolonged period could worsen and cause more pressure ulcers. The facility’s own policies required comprehensive, individualized care plans and detailed assessment and documentation of pressure sores, including support surfaces, which were not fully followed in this case. Additional interviews and record reviews further highlighted lapses in wound care delivery and communication. The treatment nurse initially stated he had not performed the resident’s wound care on a specific date, then later recalled that he had completed the treatments but was unable to describe the shin pressure injury and could not clearly describe what a DTI looked like. He also confirmed that lack of treatment to the left shin could result in wound deterioration, infection, sepsis, organ failure, and death. An LVN who covered as treatment nurse on one of the dates stated she had not completed the resident’s treatment because she was assigned to a different station, which was supposed to be covered by the treatment nurse. The facility’s policies on care planning and pressure ulcer/skin breakdown required comprehensive care plans prepared by the IDT and detailed assessment and documentation of pressure sores, including current treatments and support surfaces, but the practices described in the report did not align with these requirements, contributing to worsening existing pressure ulcers and the development of facility-acquired pressure ulcers for this resident.
Failure to Competently Assess and Report New Pressure Ulcers and Manage Support Surfaces
Penalty
Summary
The deficiency involves the facility’s failure to ensure that licensed nurses had the competencies and skills to adequately assess, describe, and report a new pressure ulcer for a resident with multiple existing pressure injuries and significant comorbidities. The resident had Parkinson’s disease, encephalopathy, a cognitive communication deficit, and multiple stage 4 pressure ulcers to the sacrum and both hips, and was mostly dependent on staff for ADLs. Care plans initiated for impaired skin integrity included generic interventions such as “treatment as ordered” and did not specify the actual wound treatments, staging details, or individualized interventions beyond broad statements. The resident’s MDS documented three stage 4 pressure ulcers and risk for additional PUs, and physician orders included specific wound care treatments and turning/repositioning every two hours, but these details were not clearly integrated into individualized care plans. Surveyors’ review of CNA documentation for turning and repositioning showed numerous time slots over multiple days with no documented evidence that the resident was repositioned as ordered. A CNA reported that she tried to reposition the resident but sometimes found the resident in the same position four hours later. The resident was observed with adhesive dressings on the right upper arm and left shin; the CNA stated the resident had pressure ulcers to the buttocks, right upper arm, and a more recent one to the left lower leg. The treatment nurse later stated the resident was being treated for four pressure ulcers (sacrum, left posterior trochanter, right buttocks, and right shoulder DTPI) but was initially unable to state what was under the dressings to the right upper arm and left shin, incorrectly believing those areas had healed PUs. The treatment nurse also acknowledged that head-to-toe skin assessments are supposed to be done and that SBARs and care plans must be updated for new or reclassified wounds, but admitted that treatments on care plans were documented only as “treatment as ordered” and that this same generic wording was used for multiple residents. An SBAR note dated 1/23/2026 documented a pressure injury to the left shin and right shoulder, with concern for an unstageable pressure injury on the shin and a DTPI/UTI-type injury on the shoulder, and indicated the development of pressure injury due to pillow placement. During wound care observation, the room had a foul odor, and the right upper arm ulcer was covered in black-brown jelly-like eschar, while the left shin ulcer measured approximately 7 cm by 3 cm with hard yellow-grey slough and a red halo, with no drainage. The family member reported they only learned of the left shin pressure ulcer a few days earlier during a visit and that the facility had not informed them of this new wound. The treatment nurse admitted that no SBAR had been completed when the right shoulder DTPI was discovered and that the left shin DTI had just been discovered that morning, acknowledging that a head-to-toe assessment could have identified it earlier and prompted SBAR completion and physician and representative notification. The treatment nurse initially stated he had not done the resident’s wound care on 1/21/2026, later recalled that he had, and was still unable to accurately describe the shin wound or what a DTPI looked like. Additional findings showed that the resident’s low air loss (LAL) mattress was not set according to the resident’s weight. The resident weighed 139 lbs, but the mattress was set over the maximum of 400 lbs. The DON stated that mattresses were usually set at 400 lbs to ensure tubes were inflated and should not be set lower than 152 lbs, but could not explain why, while the wound care specialist and an LVN stated that LAL mattresses are weight-based and must be set as close to the resident’s weight as possible, and that incorrect settings could lead to more or worsening pressure injuries. The facility’s pressure ulcer/skin breakdown policy required nurses to perform and document a full assessment of pressure sores, including location, stage, measurements, exudate or necrotic tissue, pain, mobility status, current treatments including support surfaces, and all active diagnoses. The survey findings showed that licensed nursing staff did not consistently perform or document comprehensive assessments, did not accurately describe and stage new wounds, did not promptly complete SBARs or notify the physician and resident representative of new pressure injuries, and did not ensure that support surfaces such as the LAL mattress were properly set, all contributing to a delay in treatment for the resident’s new unstageable pressure injury to the left shin, which the report states could have resulted in further deterioration, infection, sepsis, organ failure, and/or death.
Improper Food Date Marking and Unsafe Meat Storage
Penalty
Summary
Dietary staff failed to ensure refrigerated foods were properly date-marked and stored within the facility’s required timeframes. During a concurrent observation and interview with the Dietary Services Supervisor, grated parmesan cheese was found in the refrigerator in its original package, opened and stored inside a plastic bag with a handwritten open date of 11/16/2025 and an expiration date of 11/21/2025. A yellow and white pre-printed label with an expiration date of 1/16/2026 was placed over the handwritten expiration date. Smoked cheese was also found in the refrigerator in its original package with a handwritten date of 11/14/2025 and an expiration date of 11/21/2025, and a pre-printed label for American Cheese with an expiration date of 2/22/2026 was placed over the handwritten expiration date. Five beef patties were found in the refrigerator in their original package, opened and stored inside a round plastic container with a handwritten open date of 11/30/2025 and a used-by date of 12/02/2025. The patties were observed soaking in a dark reddish liquid. The Dietary Services Supervisor stated the liquid was not normal, that the meat should be discarded, and that the beef patties were not safe to cook and serve because the meat was discolored. The facility policy titled Labeling/Date Marking and Safe Storage of Refrigerated and Frozen Foods stated commercially processed foods are good for seven days or until the expiration date on the label if that date comes before the seventh day, and that ground meat/patties should be stored for 1 to 2 days from package opening.
Failure to Provide Appropriate Meal Alternatives
Penalty
Summary
The facility failed to ensure that Resident 34 was provided with alternative meals that were appealing, nutritional, and appetizing. Resident 34 was admitted with diagnoses including malignant neoplasm of the colon, anemia, and muscle weakness. Her MDS dated 7/1/2025 indicated intact cognition, and her H&P dated 6/30/2025 stated she could make decisions for activities of daily living. During interview, Resident 34 stated she needed a vegetarian diet, was allergic to gluten, oats, and corn, and did not like peas, lentils, fish, eggs, or milk because those foods made her nauseous and caused swelling in her legs, feet, and ankles. She stated she was only getting bread and cheese as alternatives and noodles several days per week, and that she was trying to pursue a vegetarian lifestyle to improve her health after cancer remission. During lunch observation and record review, Resident 34 was served a tray with noodles and red sauce and no other food items on the plate, while the meal ticket listed lemon baked chicken, GF spaghetti, buttered spinach, GF garlic bread, sherbet, water, and butter. The CNA stated Resident 34 often had difficulty with the food served and would usually have her own food or an alternative plate, and the kitchen would sometimes give her something special. The RSD stated the Administrator had approved ordering food from a restaurant for Resident 34 because the kitchen staff could not accommodate her need for an alternative lunch choice. The DS reviewed a picture of the lunch tray and stated Resident 34 refused the food provided by the kitchen, said she would throw up if she ate it, and that the food did not look appetizing and was not the same as what was described on the meal ticket. The DON stated the lunch ticket or card describing what was being delivered was not accurate and that the food on the tray should match the meal ticket.
Inaccurate PASRR Level I Screening
Penalty
Summary
The facility failed to ensure that Resident 9’s PASRR Level I screening was accurately completed. Resident 9 was admitted with diagnoses including unspecified dementia with mood disturbance and anxiety, and paranoid schizophrenia. The resident’s MDS dated 11/21/2024 indicated moderately impaired cognition with poor decision-making and a need for cues and supervision. However, the PASRR Level I screening dated 5/21/2025 did not identify any serious mental disorder diagnoses such as schizophrenia, despite the resident’s documented diagnosis of paranoid schizophrenia. Resident 9’s record also showed ongoing mental health concerns. The care plan did not include focus, goals, or interventions related to PASRR Level I and Level II. A care plan dated 6/15/2025 addressed antidepressant use related to depression, with goals related to avoiding discomfort or adverse reactions and decreasing signs and symptoms of depression, and interventions to monitor, document, and report adverse reactions to antidepressant therapy. Psychiatry follow-up documentation dated 10/8/25 noted a history of depression, feelings of depression and hopelessness, trouble with memory recall, and use of Sertraline for depression. Physician progress notes dated 11/24/2025 documented diagnoses of unspecified dementia with behavioral disturbance, anxiety disorder, and schizophrenia, along with memory loss and lack of capacity to make medical decisions. During interview, the DON stated the PASRR Level I form was not accurately completed because the resident had schizophrenia and depression and was taking Sertraline for depression. The DON also stated the facility was responsible for obtaining a correct PASRR if the one received from the hospital was incorrect, and that the resident did not have a care plan related to PASRR Level I and/or Level II because PASRR was not done correctly.
Failure to Honor Resident Bathing Preference
Penalty
Summary
The facility failed to provide reasonable accommodation for a resident’s preferences and choices for bathing. Resident 21 was admitted with diagnoses including COPD, anemia, morbid obesity, abnormality of gait and mobility, and muscle weakness. The resident’s MDS dated 9/2/2025 indicated cognition was intact, and the H&P dated 9/2/2025 stated the resident could make decisions for ADLs. During interview, the resident stated a preference to take showers but had only been receiving bed baths since admission because the facility did not have a bariatric shower chair, and the resident reported not having had a shower since admission. Staff interviews reflected that showers were not being provided because the resident was unable to bear weight on the lower extremities and staff believed transferring the resident back to bed after a shower was not safe for the resident and staff. The facility was observed to have a bariatric shower chair that could accommodate up to 500 lbs and a functional Hoyer lift, and the resident weighed 369 lbs. The resident’s order summary later indicated a bed bath only order for safety. The facility’s shower and bathing policy stated residents are offered two baths and showers per week, with additional bathing based on resident preference, and that bathing assistance promotes independence, dignity, privacy, and choice.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to consistently honor food preferences for one resident out of 18 sampled, identified as Resident 51. Resident 51 was admitted with diagnoses including diverticulosis, liver transplant status, pulmonary fibrosis, chronic kidney disease, abnormalities of gait and mobility, and depression. The MDS dated 11/10/2025 indicated moderately impaired cognition, and the resident required supervision or touching assistance with eating, oral hygiene, and personal hygiene. The order summary dated 12/4/2025 showed a vegetarian, no added salt diet of regular texture with thin liquids, and no food likes or dislikes were listed. During an initial tour on 12/1/2025, Resident 51 stated that staff gave him eggs for breakfast even though he does not eat eggs and said he had told the Dietary Supervisor after admission that he does not eat eggs. The breakfast meal ticket for 12/1/2025 listed an omelet as one of the items served for the resident's vegetarian breakfast. During interview, the Dietary Supervisor stated she usually visits newly admitted residents and that residents' food dislikes and preferences are listed on meal tickets, but she could not explain why Resident 51's dislike for eggs was not listed. The facility policy titled Food Procedure, Food Preparation stated the facility must provide each resident a nourishing, palatable, well-balanced diet that meets daily nutritional and special dietary needs, taking into consideration each resident's preferences.
Failure to Arrange Transportation for Resident's Appointment
Penalty
Summary
The facility failed to arrange and confirm transportation for a resident's orthopedic appointment, leading to an unnecessary change in the appointment schedule. The resident, who had multiple diagnoses including diabetes, dementia, and an artificial knee joint, required assistance with daily activities and had a surrogate decision maker. The resident's appointment was initially scheduled for the morning, but due to a lack of communication and oversight by the social service assistant (SSA), the appointment was rescheduled without notifying the resident's representative. On the day of the appointment, the certified nursing assistant (CNA) discovered the oversight and informed the SSA, who then attempted to reschedule the appointment for later in the day. The resident's representative, who had arrived to take the resident to the appointment, was not informed of the rescheduling and was upset by the lack of communication. The representative had previously informed the facility of the appointment details, but the SSA failed to document and arrange transportation as per the facility's policy. The director of nursing (DON) acknowledged the oversight but did not investigate further, assuming the issue was resolved since the resident eventually attended the appointment. The facility's policy requires the social service staff to assist residents in accessing transportation, but this was not adhered to in this instance, leading to confusion and distress for the resident's representative.
Expired Food Storage in Kitchen
Penalty
Summary
The facility failed to ensure safe food storage practices in the kitchen by storing expired canned food, specifically corned beef hash, alongside non-expired food in the food storage area. This was confirmed during an interview and observation with the Dietary Supervisor, who acknowledged that expired canned food should be separated from non-expired food to prevent serving it to residents. Additionally, some dented cans were observed, which further indicated a lapse in proper food storage practices. The Dietary Supervisor emphasized that expired food should not be served to residents, particularly because they are elderly and have medical conditions that could be exacerbated by consuming expired food. The facility's policy and procedures for food storage and handling were reviewed, revealing that all foods delivered require inspection, and damaged goods should be placed in a specified area labeled 'Return to Vendor Do Not Use.' The policy also mandates that food should be stored properly, with labels visible and arranged to permit rotation of supplies so that the oldest items are used first. Despite these guidelines, the facility did not adhere to its own procedures, as evidenced by the presence of expired and dented canned food in the storage area, posing a risk of foodborne illness to the 57 residents receiving food from the kitchen.
Failure to Maintain Dignified Dining Experience
Penalty
Summary
The facility failed to ensure a dignified dining experience for two residents, Resident 4 and Resident 58, by not maintaining eye-level contact during feeding. Observations revealed that Certified Nursing Assistants (CNAs) stood over the residents while feeding them, which is against the facility's policy that emphasizes the importance of feeding residents at eye level to maintain their dignity. This practice was confirmed by interviews with the CNAs and the Director of Nursing (DON), who acknowledged that feeding residents while standing diminishes their dignity. Resident 58, who was admitted with diagnoses including dementia, dysphagia, and muscle weakness, was observed being fed by CNA 1 while the CNA stood over the resident. The resident's care plan required assistance with feeding due to chewing difficulties, and the facility's policy mandated a dignified dining experience. Despite this, the CNA did not adhere to the policy, as confirmed by the CNA's own admission and the DON's statement. Similarly, Resident 4, who had diagnoses including hypertension, major depressive disorder, and congestive heart failure, was also fed by a CNA who stood over them. The resident's care plan indicated a need for assistance with feeding due to limited physical mobility. The Director of Staff Development and the DON both stated that CNAs should be seated at eye level with residents during feeding to ensure dignity, which was not followed in this case.
Deficiency in Resident Activities Due to Untrained Staff
Penalty
Summary
The facility failed to provide ongoing activities tailored to the comprehensive assessment and preferences of all 57 residents, which is essential for supporting their physical, mental, and psychosocial well-being. This deficiency was observed when a Certified Nursing Assistant (CNA 6) was found monitoring residents in the communal dining area while they watched television, instead of engaging them in activities. CNA 6 was covering for the Activities Director (AD), who was on vacation, and admitted to not having received training on conducting activities, despite being handed a guide on which activities to conduct. Further interviews revealed that the Director of Staff Development (DSD) confirmed CNA 6's lack of training in conducting activities. The Director of Nursing (DON) acknowledged the importance of activities in preventing residents' mental decline and admitted to being unaware of the location of activity logs. The facility's undated AD job description outlined the AD's responsibility for planning and directing activities to meet residents' needs, requiring specific qualifications and experience, which were not met during the AD's absence.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, leading to deficiencies in their care. Resident 58, who was admitted with diagnoses including dementia with psychotic disturbance and anxiety disorder, was prescribed psychotropic medications Risperidone and Seroquel to manage visual hallucinations. However, the facility did not create individualized care plans addressing the use of these medications or the targeted behavior of visual hallucinations. This oversight was confirmed during interviews with the Registered Nurse Supervisor and the Director of Nursing, who acknowledged the absence of necessary care plans and the potential for untreated behaviors or side effects. Similarly, Resident 164, admitted with conditions such as major depressive disorder and atrial fibrillation, was receiving Apixaban for deep vein thrombosis prophylaxis. Despite this, there was no care plan in place for the anticoagulant medication or the resident's activities. The lack of a care plan was noted during a review of the resident's chart and confirmed by the Registered Nurse Supervisor and the Director of Nursing. The absence of a care plan was recognized as a barrier to providing individualized and appropriate care. The facility's policies and procedures, revised in March 2023, emphasize the importance of comprehensive, person-centered care plans that include measurable objectives and timeframes. These care plans are intended to ensure that residents receive services to maintain their highest practicable physical, mental, and psychosocial well-being. The failure to adhere to these policies resulted in increased risk for suboptimal care for Residents 58 and 164, as their specific medical needs were not adequately addressed through individualized care planning.
Failure to Monitor Anticoagulant and Antidepressant Use
Penalty
Summary
The facility failed to appropriately monitor the drug regimens of two residents, leading to potential complications. Resident 6, who was readmitted with diagnoses including atrial fibrillation and transient ischemic attack, was prescribed Eliquis, an anticoagulant. Despite a care plan indicating the need for monitoring for signs of bleeding, there was no documented evidence of such monitoring in the medication administration records. The MDS Nurse confirmed that the order for monitoring was not carried over upon readmission, and the Director of Nursing acknowledged that the staff should have documented monitoring for bleeding and bruising. Resident 164, admitted with major depressive disorder and atrial fibrillation, was prescribed Apixaban, another anticoagulant, and antidepressants Mirtazapine and Escitalopram. The facility's protocol required monitoring for signs of bleeding, but there was no order for such monitoring, and consequently, no documentation on the MAR. The Registered Nurse Supervisor noted that monitoring for bleeding should have been automatically ordered with the anticoagulant prescription. Additionally, there was a lack of monitoring for the effectiveness and side effects of the antidepressants, which was necessary to adjust dosing appropriately. The facility's policies and procedures for anticoagulation and antipsychotic medication use were not followed, as evidenced by the lack of monitoring and documentation for both residents. The Director of Nursing confirmed the necessity of monitoring and documenting findings for residents on anticoagulants and antidepressants to prevent unnoticed bleeding and ensure appropriate medication adjustments.
Inadequate Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that the Facility Verification of Informed Consent forms were fully completed and properly executed for psychotropic medications for two residents. Resident 58, who was admitted with diagnoses including dementia with psychotic disturbance and anxiety disorder, was receiving multiple psychotropic medications such as Risperidone, Seroquel, and Ativan. However, the informed consent form for these medications was not completed correctly, as it listed all three medications on one form instead of having individual forms for each medication. The Registered Nurse Supervisor confirmed the error, stating that each medication should have its own form with the dosage and frequency clearly written. Similarly, Resident 164, who was admitted with major depressive disorder and other health issues, was prescribed Mirtazapine and Escitalopram for depression. The informed consent form for these medications was also not accurately completed, as it included both medications on one form instead of separate forms for each. The Director of Nursing confirmed that each medication should have its own consent form, including the dose, diagnosis, and behaviors to be treated. The facility's policy and procedures require that informed consent be obtained for each psychotropic medication, specifying the dosage and clinical indications. The deficient practice of not properly executing informed consent forms had the potential to leave residents unaware of the risks and benefits of the psychotropic medications they were receiving. This oversight could lead to medication errors and residents not being fully informed about their treatment, as highlighted by the facility's policy and procedures on informed consent for psychotherapeutic medications.
Failure to Maintain Pest-Free Environment
Penalty
Summary
The facility failed to maintain a pest-free environment, resulting in a deficiency related to providing a homelike environment. Resident 214, who was admitted with diagnoses including anxiety disorder and muscle weakness, was affected by this deficiency. The resident, whose cognition was intact and could make decisions for medical care, reported seeing ants on the wall and floor near the sliding glass door in their room. Observations confirmed the presence of ants in the resident's room, indicating a failure to ensure a pest-free environment. The facility had recently engaged fumigation services to address heavy ant activity outside the building, treating four ant colonies found in trees by the sidewalk. However, the fumigation company had not sprayed inside the building, and ants were discovered inside the facility, including in Resident 214's room. The Maintenance Supervisor confirmed the presence of ants and had to spray the resident's room himself, as the fumigation company would take at least 24 hours to return. The Director of Nursing acknowledged the responsibility of the facility to provide a pest-free environment for residents, as outlined in the facility's policy and procedures for maintaining a homelike environment.
Failure to Ensure Safe Self-Administration of Medication
Penalty
Summary
The facility's interdisciplinary team failed to ensure that a resident did not keep medications at the bedside without a physician's order and without being assessed for the capability to self-administer medications. This deficiency was identified when a resident was found with an unlabeled medication dispensing cup containing a white powder-like substance, which the resident identified as antifungal powder used for self-application under the breasts. The resident had been admitted with diagnoses including acute respiratory failure, congestive heart failure, major depressive disorder, muscle weakness, and dysphagia, and was assessed to have intact cognition but required assistance with certain activities of daily living. During observations and interviews, it was revealed that neither the Certified Nursing Assistant nor the Treatment Nurse was aware of the contents of the medication cup. The Director of Nursing confirmed that residents are only allowed to have medications at the bedside if they have been assessed as cognitively intact, have demonstrated the ability to self-administer safely, and have a physician's approval. The facility's policy requires that self-administered medications be stored securely, which was not adhered to in this case. A review of the physician orders showed no approval for the resident to apply antifungal powder, indicating a lapse in following the facility's procedures for self-administration of medication.
Failure to Record Advanced Directives for Two Residents
Penalty
Summary
The facility failed to ensure that the residents' right to formulate an advanced directive was recorded for two residents. Resident 23 was admitted with diagnoses including hyperlipidemia, hypertension, and generalized muscle weakness. Despite having intact cognitive skills, the advanced directive acknowledgment form for Resident 23 was marked as verbal, and the resident stated that the facility did not discuss advanced directive information with him. Similarly, Resident 26, who was admitted with hyperlipidemia, hypertensive chronic kidney disease, and generalized muscle weakness, also had intact cognitive skills. However, the advanced directive acknowledgment form for Resident 26 was left blank, and the resident confirmed that the facility did not discuss advanced directive information with him. Interviews with the Social Services Director (SSD), Director of Nursing (DON), and Facility Administrator (FA) revealed that the facility's policy requires the advanced directive acknowledgment form to be signed and dated by the resident to be complete and accurate. The SSD and FA acknowledged that the lack of a completed form could lead to care that does not align with the residents' wishes. The facility's policy emphasizes the importance of informing residents about their rights to formulate an advanced directive upon admission, but this was not adhered to in the cases of Residents 23 and 26.
Inaccurate Documentation of Anticoagulant Use
Penalty
Summary
The facility failed to ensure that the medical records of Resident 164 accurately documented the use of an anticoagulant medication. Resident 164 was admitted with diagnoses including major depressive disorder, atrial fibrillation, and dysphagia. The Minimum Data Set (MDS) assessment for Resident 164, dated shortly after admission, indicated cognitive impairment and dependence on staff for various activities. However, the MDS did not reflect the resident's use of Apixaban, an anticoagulant prescribed for deep vein thrombosis prophylaxis, despite this being documented in the physician's orders. Interviews with the MDS nurse and the Director of Nursing revealed that the omission of Apixaban from the MDS was an oversight. The MDS nurse acknowledged that the medication should have been included to ensure the assessment accurately reflected the care being provided. The Director of Nursing emphasized the importance of complete and accurate MDS assessments for determining the resident's level of care and coordinating a resident-specific care plan. The facility's policy and procedures, as well as CMS guidelines, require comprehensive and timely resident assessments, which were not adhered to in this case.
Unqualified Staff Assigned to Activities Program
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistant 6 (CNA 6) was trained and qualified to serve as a therapeutic recreation specialist or activities professional, impacting the well-being of all 57 residents. During an observation, CNA 6 was seen monitoring residents in the communal dining area while they watched television. CNA 6 admitted to covering for the Activities Director (AD), who was on vacation, and stated it was their first day in this role. CNA 6 mentioned receiving a guide on activities but had not been trained on conducting activities with residents. Interviews with the Director of Staff Development (DSD) and the Director of Nursing (DON) confirmed that CNA 6 had not received proper training for conducting activities. The DON acknowledged the importance of activities in maintaining residents' mental engagement and preventing decline. However, the DON was unable to locate the activity logs and could not provide specific dates when CNA 6 had worked with the AD. The facility's job description for the AD outlined the need for a qualified professional with specific educational and experiential qualifications, which CNA 6 did not meet.
Lack of Dementia Care Plan for Resident
Penalty
Summary
The facility failed to develop a care plan with measurable goals and interventions for a resident diagnosed with dementia, which is a deficiency in providing appropriate care. The resident, admitted on 9/26/2024, had a history of dementia with psychotic disturbance, anxiety disorder, and cognitive communication deficit. Despite being on medications such as Risperidone and Seroquel for psychosis and Ativan for anxiety, there was no individualized care plan addressing the resident's dementia and cognitive skills. Observations noted the resident had a flat affect and limited communication, indicating a need for a tailored care approach. The Minimum Data Set (MDS) indicated the resident had severely impaired cognition and was dependent on others, yet the facility did not have a documented care plan to address these needs. Interviews with the Registered Nurse Supervisor and the Director of Nursing confirmed the absence of a dementia care plan, which should have included behavioral interventions. The facility's policy on dementia management required appropriate interventions based on clinical symptoms, but this was not implemented for the resident, leading to a deficiency in care delivery.
Failure to Obtain Physician's Order for Antifungal Powder
Penalty
Summary
The facility failed to obtain a physician's order and clinical indication for the application of antifungal powder for one resident. This deficiency was identified during an observation where an unlabeled medication dispensing cup containing a white powder was found in the resident's bedside drawer. The resident confirmed that the powder was an antifungal medication applied under her breasts. However, there was no physician's order or clinical indication documented for this medication in the resident's records. Interviews with facility staff, including a CNA and the Treatment Nurse, revealed that they were unaware of the contents of the medication cup and acknowledged that it should not have been left unlabeled and accessible. The Director of Nursing stated that residents are only allowed to have medications at their bedside if they have been assessed as cognitively intact and have physician approval, which was not the case here. The facility's policy requires that self-administered medications be stored securely, which was not adhered to in this instance.
Inaccurate Fall Risk Assessment
Penalty
Summary
The facility failed to document an accurate fall risk assessment for a resident, which had the potential to place the resident at risk for falls causing injuries or even death. The resident, a [AGE] year old female, was admitted with multiple diagnoses including osteoporosis with a current pathological fracture, atherosclerotic heart disease, chronic kidney disease stage 4, sick sinus syndrome, presence of a cardiac pacemaker, hyperlipidemia, essential tremor, hearing loss, and a history of malignant neoplasms. The resident's history and physical indicated she was admitted after a fall that resulted in a T10 hyperextension fracture. Despite this, the fall risk assessment completed by the LVN did not account for the resident's fall history, incorrectly identifying her as low risk for falls. The LVN admitted to not reviewing the resident's history and physical, which would have indicated a higher fall risk score. The Director of Nursing confirmed that fall risk assessments should include all facility documentation and the physician's history and physical to determine fall risk accurately. The facility's policy and procedures for fall risk assessment were not followed, leading to the inaccurate assessment of the resident's fall risk.
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What surveyors actually found near you
We read the 5,652 citations issued within 25 miles in the last 12 months — including the 36 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.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Santa Monica
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Westwood Post Acute Care | 0.6 mi | ★★★★★ | 5 | 0 |
| Berkley East Healthcare Center | 0.8 mi | ★★★★★ | 14 | 0 |
| Santa Monica Health Care Center | 0.8 mi | ★★★★★ | 6 | 0 |
| Santa Monica Rehabilitation Center | 0.9 mi | ★★★★★ | 21 | 0 |
| Berkley West Healthcare Center | 1 mi | ★★★★★ | 13 | 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.