Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Brighton Care Center during CMS and state inspections, most recent first.
A resident with a history of cerebral infarction, right-sided hemiplegia/hemiparesis, and speech impairment, who required substantial/maximal assistance for toileting and was assessed as high fall risk, was placed on a wheeled shower chair over the toilet by a CNA. The CNA locked only the front wheels, did not verify that all wheel locks were latched, and left the resident alone despite the resident’s high assistance needs. The resident leaned forward to clean himself, the chair moved, and he fell forward, striking his head, and was later found lying on his side with the shower chair on his legs. Maintenance records showed routine checks of shower chair brakes, and the DON confirmed there was an expectation, but no specific written policy, that staff check wheel locks before use and that this resident should not have been left unattended during toileting.
Oxygen therapy was not provided as ordered for two residents. One resident with COPD, chronic respiratory failure, and dyspnea was receiving O2 with an empty humidifier bottle, and the DON confirmed the humidifier should have contained water. Another resident with COPD and emphysema was ordered O2 at 2 L/min via NC, but was observed receiving 3 L/min; the DON stated the flow rate did not match the physician's order, and staff confirmed oxygen flow rates should be checked against orders.
Medication Administration and Controlled Substance Documentation Failures: Multiple residents received scheduled meds outside the facility’s required time frame, including meds for DM, HTN, dementia, depression, COPD, and other conditions. An LPN administered several meds late, stated staff interruptions and misunderstanding of the policy contributed, and two residents’ PRN opioid doses were not properly documented on the narcotic sheet, with tablet counts not matching the record.
Medication administration timing errors caused the facility’s error rate to exceed the allowed threshold. An LVN gave several morning meds late for multiple residents, including DM, HTN, depression, dementia, and respiratory conditions, with doses such as metformin, potassium chloride, metoprolol, aspirin, docusate sodium, venlafaxine, memantine, vitamin D3, and prednisone administered outside the required 1-hour window. The DON stated the nurses did not follow the facility’s med administration policy.
Medication administration times were not followed for several residents. An LPN gave scheduled DM, HTN, CVA prophylaxis, dementia, depression, vitamin D, and COPD medications outside the required time window, including doses that were more than an hour late. The DON stated the facility’s policy allowed meds to be given only within one hour before or after the scheduled time, but the nurses administered them later than that and cited being new, interruptions, and being busy with another resident.
Unlabeled resident food and staff food were found in the refrigerator designated for residents’ use. Three unopened Ensure drinks lacked resident identifiers, one opened apple juice bottle lacked a use-by date, and a staff fruit plate plus an unlabeled food container were stored with resident items. An activity staff member admitted placing her own food in the refrigerator despite knowing it was for residents only.
Infection control measures were not followed during multiple resident care activities. An RN failed to perform hand hygiene after removing a soiled wound dressing for a resident with a pressure ulcer and immunodeficiency, and also failed to clean hands after touching a bedside table in one EBP room before preparing treatment for another resident. A laundry staff member handled trash and then clean linen without hand hygiene. The RN also moved from one wound site to another on a resident with a stage 3 pressure ulcer and ESBL without hand hygiene between sites, and an LVN did not disinfect a blood glucose monitor before and after checking a resident’s blood sugar.
Failure to Complete Antibiotic Surveillance Forms: The facility did not complete antibiotic surveillance data collection forms for two residents receiving antibiotics for cellulitis. One resident had an order for meropenem IV for bilateral lower extremity cellulitis, and another had an order for Bactrim DS PO for cellulitis. The IPN stated the surveillance forms were not completed, despite the facility policy requiring antibiotic usage and outcome data to be documented on the approved tracking form.
A cognitively intact resident with psychiatric and medical diagnoses reported to a surveyor that someone had hit him hard on the ribs while he was sitting on his bed, stating he only saw a shadow and not the assailant. The allegation was documented in the resident’s care plan and SBAR, and nursing staff notified the DON, who acknowledged that such an allegation of striking constitutes physical abuse and should trigger completion of an SOC 341 and reporting to CDPH, the Ombudsman, and law enforcement. However, the DON and ADM did not report the allegation to external agencies within the two-hour timeframe required by the facility’s abuse reporting policy, instead attributing the report to the resident’s mentation and behavior, resulting in a failure to follow the facility’s abuse reporting procedures.
SNF ABN Not Provided to A Resident: The facility failed to provide a resident with the SNF Beneficiary Notification form when Medicare Part A skilled coverage ended. The resident had schizophrenia, bipolar disorder, and cellulitis, and the MDS showed intact decision-making skills with assistance needed for several ADLs. The BOM stated she did not know the notice was required, and the facility policy required staff to prepare, review, obtain signature, and provide the ABN when Medicare payment may be denied.
Unattended Computer Displayed Resident Wound Treatment Information: A resident with a right lower extremity skin issue had wound treatment information left visible on an unlocked computer screen at the nurse’s station while unattended. The ADM, LVN, and DON stated staff should have logged off or locked the screen to protect the resident’s confidential medical information, and the DON stated the facility’s privacy and confidentiality policy was not followed.
Failure to Coordinate Level II PASRR After Positive Level I Screening: A resident with Huntington's disease, dementia, schizoaffective disorder, and anxiety disorder had a positive PASRR Level I for serious mental illness, but the facility did not ensure Level II coordination within 24 hours. The resident's record showed severe cognitive impairment, psych/ mood disorder, and use of antipsychotic and antianxiety medications. The SSA and DON acknowledged the need for Level II review when Level I is positive, and the facility policy required timely coordination with the Level II contractor.
The facility failed to ensure care was provided for two residents with untreated skin and nail conditions. One resident with DM and a fracture was observed scratching an itchy arm with peeling, discolored skin, and staff stated no treatment order was in place. Another resident with dementia, dysphagia, and weakness was observed with thick, brittle, yellow-brown nails, and staff stated the condition should have been assessed and reported because it could indicate a fungal infection.
A resident with an indwelling catheter, UTI history, BPH, and ESBL had repeated catheter care issues, including the drainage bag touching the floor and urine changes such as sediment, cloudiness, and pink-tinged urine. Staff did not consistently document the ordered urine assessments, and an LVN reported seeing sediment and hematuria but only flushed the catheter without notifying the physician. The DON confirmed the bag should not touch the floor and that abnormal urine findings were not documented or reported as required.
Unlabeled GT Formula Bag During Tube Feeding: A resident with Huntington’s disease, dementia, schizoaffective disorder, and gastrostomy status had a GT feeding running at the ordered rate, but the formula bag was not labeled with the required initials, date, time, or order information. The LVN and DON both stated the bag should be labeled and checked against the physician’s order to ensure the feeding is administered correctly.
A resident with ESRD, DM2, HF, and dialysis had a physician-ordered 1200 ml/day fluid restriction, but staff documented intake in separate records without totaling it to verify compliance. CNA staff were unaware of the restriction, licensed nurses did not complete weekly fluid intake assessments, and the dialysis care plan only addressed pre- and post-dialysis vital signs without individualized interventions for the fluid restriction. The DON confirmed the care plan was not comprehensive and that the facility did not follow its fluid restriction policy.
An unopened Humalog insulin vial for a resident with HTN, CKD, type 2 DM, and cerebral infarction was found in the medication cart instead of the refrigerator. An LVN and the DON both stated unopened insulin should be refrigerated because improper storage can affect potency, and the facility policy required refrigerated storage for unopened insulin.
A resident with dependence on supplemental O2, palliative care, and metabolic encephalopathy had a hospice order for O2 2 LPM continuously for SOB, but the facility’s order summary listed O2 2 LPM via NC PRN to keep O2 sat at 92% or above. The DON confirmed the orders did not match and stated the hospice order had not been transcribed correctly into the facility record, even though staff were giving the resident O2 continuously.
A resident with a documented gluten allergy, identified in the admission record, assessment, diet order, and care plan, was served a breakfast tray that included sourdough toast containing gluten. The care plan specified honoring food preferences and offering substitutes as needed, and the resident was cognitively intact and able to communicate needs. A CNA reported that the resident stated they were allergic to gluten and could not eat the toast, demonstrating that the meal service did not align with the documented allergy and dietary requirements.
A resident with moderate cognitive impairment and multiple chronic conditions was found to have her call light tied to a bed rail and hanging below the bed, making it inaccessible. The resident was unaware of the call device's location and expressed fear of falling if she tried to reach it. Staff interviews confirmed the call light should have been within easy reach, in accordance with facility policy.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A resident with dementia, anxiety, depression, and peripheral vascular disease repeatedly wrapped a bed remote cord around his arms, resulting in skin discolorations. Despite staff observations and documentation of this behavior, no individualized care plan with measurable objectives or interventions was created to address the issue, contrary to facility policy.
A resident with a history of falls and moderate cognitive impairment experienced an unwitnessed fall resulting in a nasal fracture. Although internal notifications and medical care were provided, the facility failed to report the incident to state authorities as required by policy and regulations, leading to a delay in external investigation.
A resident with a colostomy did not have a care plan developed or implemented to address their specific needs, despite having physician orders for colostomy care and requiring moderate assistance with daily activities. Staff interviews confirmed the absence of a care plan, and facility policy requires comprehensive, person-centered care plans for all residents.
A resident with a colostomy did not receive physician-ordered colostomy care, as staff only emptied the colostomy bag without cleansing the site or changing the bag as required. The nurse did not document any refusal of care or notify the physician, despite instructions from the resident's family member, and the medical record lacked evidence of proper documentation or care as per facility policy.
A resident with a colostomy and cancer diagnosis did not receive or have accurately documented the ordered daily colostomy care. Nursing staff either failed to provide the required cleansing and bag change or documented the care as completed without actually performing it, contrary to facility policy requiring accurate and complete treatment records.
Two residents in an LTC facility experienced falls and injuries due to inadequate supervision. One resident, requiring increased assistance, was left unsupervised during breakfast, resulting in rib fractures. Another resident, with poor sitting balance, was left alone during dinner, leading to a femur fracture. The facility failed to update care plans and ensure staff followed supervision protocols, contributing to these incidents.
A resident at high risk for falls experienced multiple unwitnessed falls due to the facility's failure to revise the care plan to include increased assistance and supervision as recommended by a Physical Therapy Recertification note. Despite the resident's diagnoses of dizziness, muscle wasting, and difficulty walking, the care plan was not updated to address these needs, leading to continued fall risks.
A resident with severe cognitive impairment and multiple health issues was left unattended despite their call light being on and calls for help. An LVN did not respond, citing not being the charge nurse, contrary to facility policy requiring prompt response to call lights. This delay in addressing the resident's needs highlights a deficiency in the facility's care practices.
A resident dependent on assistance for ADLs was found with long, jagged, and dirty fingernails and toenails, despite facility policies requiring regular nail care. The resident's care plan indicated a need for assistance with personal hygiene, but this was not adequately provided, leading to the deficiency.
The facility failed to update the Direct Care Service Hours Per Patient Day (DHPPD) as per its policy, leading to potential misinformation about staffing levels. Observations revealed that the DHPPD had not been updated for several days, and interviews with staff confirmed the lapse. The facility's policy requires daily posting of staffing data, including the number of nursing personnel and resident census, which was not adhered to.
A resident's Santyl ointment was found unlabeled, lacking necessary information such as the resident's name and administration instructions, posing a risk of improper medication administration. Additionally, a medication cart was left unlocked and unattended, risking unauthorized access. The facility's policies require proper labeling and secure locking of medication carts.
The facility failed to maintain dignity and respect for two residents. One resident, with muscle wasting and dementia, was left with food-stained clothes and linens, despite needing assistance with daily activities. Another resident, with metabolic encephalopathy and multiple sclerosis, was fed by a CNA standing up, rather than at eye level, which the DON acknowledged could make the resident feel disrespected. The facility's policy on resident rights was not followed in these instances.
The facility failed to develop comprehensive care plans for several residents, leading to potential delays in necessary care. A resident with oxygen needs, another requiring RNA services, and a third refusing RNA services lacked appropriate care plans. Additionally, a resident using a Low Air Loss mattress and another with an indwelling catheter did not have care plans, which are crucial for guiding staff interventions and ensuring continuity of care.
Two residents in a facility were found to have their low air loss (LAL) mattresses set incorrectly, contrary to physician orders and facility policy. One resident, weighing 107 pounds, had a mattress set for 210 pounds, while another, weighing 93 pounds, had a mattress set for 130-180 pounds. This failure to adjust settings according to weight could lead to discomfort and ineffective pressure ulcer management.
A long-term care facility failed to provide appropriate catheter care for two residents, leading to deficiencies in monitoring and documenting signs of urinary tract infections (UTIs). One resident with a history of kidney issues had sediment in the catheter tubing, which was not documented or reported to a physician. Another resident with Parkinson's disease and schizophrenia had catheter tubing touching the floor, posing an infection risk, and sediment was observed but not documented. Staff interviews revealed non-adherence to facility policies, contributing to the deficiency.
The facility failed to provide necessary respiratory care services for four residents, leading to deficiencies in their care. A resident's nasal cannula was improperly placed, and nebulizer equipment was not changed or stored properly. Another resident was not provided with a new humidifier when needed. A third resident received oxygen therapy without a physician's order, and a fourth resident's oxygen tubing was not stored or changed as required, increasing the risk of infection.
Two residents in the facility experienced medication administration deficiencies. One resident did not receive aspirin with food as required, risking stomach irritation, while another received eye drops outside the prescribed time frame. The LVN acknowledged these errors, and the DON emphasized the importance of following physician orders and facility policy to prevent adverse reactions.
A long-term care facility was found to have a medication error rate of eight percent during a survey. Errors included administering aspirin without food and late administration of Simbrinza Ophthalmic Suspension. The LVN involved acknowledged the mistakes, and the DON emphasized the importance of following physician orders and facility policies to prevent adverse reactions.
The facility failed to follow proper food handling practices, as observed by surveyors. Food items in the kitchen were not labeled with names and 'use by' dates, and expired items were not discarded. The Dietary Supervisor confirmed these deficiencies, which violated the facility's policies and the FDA Food Code.
The facility failed to follow infection control protocols, including not changing N95 masks after leaving isolation rooms, allowing a resident to take linen from carts, and not wearing masks during a COVID outbreak. Additionally, a nasal cannula was reused after being on the floor, suction equipment was not cleaned, and PPE was not worn in a droplet isolation room, increasing the risk of infection spread.
The facility failed to provide accessible call light systems for two residents, leading to deficiencies in care. One resident with dementia and depression was unable to reach their call light, while another with functional quadriplegia was given an inappropriate call light for their condition. The facility's policy required alternative communication means for residents with disabilities, which was not followed.
A facility failed to coordinate hospice care for a resident with quadriplegia, metabolic encephalopathy, and multiple sclerosis. Despite the responsible party signing a hospice consent and the administrator signing an agreement, there was no physician order for hospice services, and the facility did not collaborate with Hospice 1. The DON acknowledged the lack of an IDT meeting and follow-up on the hospice request, resulting in a delay in hospice care delivery.
A resident with multiple diagnoses, including contracture of the right hand, did not receive physician-ordered Restorative Nursing Services for passive range of motion (PROM) on the upper extremities. Despite orders for PROM exercises five times per week, the facility's Restorative Orders for November and December 2024 did not include these services. Interviews and record reviews confirmed the absence of RNA services and documentation, leading to a deficiency in maintaining the resident's range of motion and preventing further decline.
A facility failed to ensure proper pharmaceutical services by not labeling an open Humalog insulin vial with an open date and improperly storing two unopened Humulin N KwikPens in a medication cart instead of a refrigerator. The resident involved had chronic kidney disease and type 2 diabetes mellitus. The RN acknowledged the oversight, and the DON explained the importance of dating opened insulin and refrigerating unopened insulin to maintain efficacy.
A resident with diabetes and GERD expressed dissatisfaction with the taste of meals provided, noting that the food was bland and unappealing. A test tray sampling confirmed that the mashed potatoes and carrots lacked flavor, which was acknowledged by the Dietary Supervisor. The facility's policy requires food to be palatable, which was not met in this case.
A resident and their responsible party were not informed of the resident's rights and services upon readmission to the facility. Despite the facility's policy requiring an admission packet to be signed within 48 to 72 hours, the packet was not provided until nearly three years later. Interviews with staff confirmed the oversight, indicating a deficiency in the facility's admission process.
A resident with a history of hemiplegia and alcohol abuse eloped from an LTC facility through a sliding door and an emergency exit with a malfunctioning alarm. The alarm had been non-functional for a year, and maintenance staff failed to report it. The resident was found the next day outside the facility, highlighting a breach in the supervision system.
The facility failed to post and maintain accurate NHPPD forms, omitting actual nursing hours and resident census data on multiple occasions. The forms were not displayed in accessible locations, and many were missing, violating the facility's policy. The DON confirmed the absence of a Director of Staff Development contributed to this issue.
A resident with dementia was transferred to another facility without completing necessary documentation, including a Transfer Assessment form, Discharge Summary, and Physician's order. The resident was not informed of the transfer destination, and the facility failed to follow its own transfer/discharge policy.
Failure to Lock Shower Chair Wheels and Provide Adequate Supervision During Toileting
Penalty
Summary
The deficiency involves the facility’s failure to prevent accidents by ensuring that a shower chair’s wheels were locked and that adequate supervision was provided while a resident used the toilet. The resident had been admitted with diagnoses including cerebral infarction, right-sided hemiplegia/hemiparesis, dysarthria, and anarthria, and the MDS showed intact cognition but substantial/maximal assistance needs for toileting and dependence for showering/bathing. The resident was assessed as high risk for falls. On the date of the incident, a CNA assisted the resident onto a wheeled shower chair over the toilet but did not ensure that all wheels were locked or verify that the locks were latched before leaving the resident alone in the bathroom. According to the SBAR and staff interviews, the CNA reported assisting the resident to the toilet and placing the resident on the shower chair, locking only the front wheels and not recalling whether the back wheels were locked. The CNA also stated she did not double-check that the wheel locks were securely latched and did not remember reporting any possible malfunction of the shower chair brakes to maintenance. The resident later fell while attempting to clean himself, reporting that he leaned forward, felt the chair move, and then fell forward, striking his head, with the shower chair ending up on his legs. The SBAR documented that the resident was found lying on his right side with the shower chair on top of his legs. Maintenance records showed that routine environmental and safety checks included visual checks of shower and wheelchair brakes, seats, sharp objects, and wheels, and maintenance staff stated that a properly locked shower chair should not move, and any movement when locked would indicate a problem that should be reported. The DON stated that the facility’s ADL and fall management policies required appropriate support and assistance with toileting and recognized conditions such as lower extremity weakness and functional impairments as fall risks. The DON further stated that the resident, given the need for substantial to maximal assistance with toileting and high fall risk, should not have been left alone in the toilet, and that there was no specific written policy for checking shower chair wheels before use, although it was an expectation that staff would do so to ensure resident safety.
Oxygen Therapy Not Provided as Ordered
Penalty
Summary
Safe and appropriate respiratory care was not provided for two residents receiving oxygen therapy. Resident 102 had diagnoses including dependence on supplemental oxygen, chronic respiratory failure with hypoxia, dyspnea, and COPD. The physician ordered oxygen at 3 liters per minute via nasal cannula for shortness of breath to maintain oxygen saturation at 92% and above, with instructions to call the physician if saturation was less than 92%. During observation, Resident 102 was in bed receiving oxygen via nasal cannula and stated her throat felt dry. The oxygen concentrator had an empty humidifier bottle beside the bed. The DON later confirmed the humidifier bottle was empty and stated it should contain water so the oxygen would not be dry. The facility policy for oxygen administration stated the humidifying jar should contain water and be rechecked periodically. Resident 13 had diagnoses including COPD and emphysema and was identified as being at risk for shortness of breath and ineffective airway exchange/chest congestion. The care plan and order summary directed continuous oxygen therapy at 2 liters per minute via nasal cannula, but during observation the resident was receiving oxygen at 3 liters per minute. The DON stated the flow rate was not according to the physician's orders, and LVN 5 stated oxygen flow rates should be checked every shift and verified against physician orders. The facility policy stated oxygen therapy shall only be administered with a valid physician order specifying flow rate, delivery method, frequency, and whether humidification is required.
Medication Administration and Controlled Substance Documentation Failures
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with its policy and procedure by administering several scheduled medications outside the required time frame for multiple residents. Resident 95, who had diagnoses including paroxysmal atrial fibrillation, nonrheumatic mitral valve insufficiency, and type 2 DM, was scheduled to receive metformin 1000 mg and potassium chloride 20 mEq at 7:15 AM, but both medications were administered at 8:55 AM. Resident 64, who had diagnoses including essential HTN, hyperlipidemia, and depression, was scheduled to receive metoprolol tartrate 12.5 mg at 7:15 AM, but it was administered at 9:12 AM. Resident 24, who had diagnoses including unspecified dementia, major depressive disorder, and essential HTN, was scheduled to receive aspirin 81 mg, docusate sodium 200 mg, venlafaxine XR 75 mg, memantine 5 mg, and vitamin D3 2000 IU at 9:00 AM, but these medications were administered at 10:24 AM. Resident 82, who had diagnoses including pneumonia, chronic respiratory failure with hypoxia, and emphysema, was scheduled to receive prednisone 10 mg at 7:15 AM, but the medication was not given at the scheduled time. During interviews, LVNs stated they believed medications could be given within a broader time window than the facility policy allowed, and one LVN stated the delay occurred because he was new to the facility and was interrupted during medication administration. The report also identified failures involving controlled substances for Resident 15 and Resident 109. Resident 15, who had diagnoses including injury of the right hip, varicose veins, cellulitis of the right lower limb, and spinal stenosis, received tramadol 50 mg at 8:16 AM, but the narcotic sheet was not signed and the tablet count did not match the sheet. Resident 109, who had diagnoses including fractures of the left humerus and left femur and spinal stenosis, received oxycodone HCl 5 mg at 8:31 AM, but the narcotic sheet was not signed and the tablet count did not match the sheet. The DON stated the narcotic sheet needed to be signed to prevent missing or misused opioids and to avoid over- or underdosing residents.
Medication Administration Timing Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to keep its medication error rate below 5 percent during an observed medication pass, with 8 medication errors out of 29 opportunities for error, resulting in a 27.59% error rate for four sampled residents. The errors involved medications that were not administered within 60 minutes of the scheduled time for residents receiving morning medications. The report identified that the facility’s policy required medications to be administered within one hour of the prescribed time unless otherwise specified. For one resident with diagnoses including paroxysmal atrial fibrillation, mitral valve insufficiency, and type 2 DM, metformin 1000 mg and potassium chloride 20 mEq were scheduled for 7:15 AM but were administered at 8:55 AM. For another resident with diagnoses including HTN, hyperlipidemia, and depression, metoprolol tartrate 12.5 mg was scheduled for 7:15 AM but was administered at 9:12 AM. The LVN stated the facility allowed medications to be given two hours before and two hours after the scheduled time, although the DON later stated the facility allowed only one hour before and one hour after the scheduled time. For a third resident with diagnoses including dementia, major depressive disorder, and HTN, aspirin 81 mg, docusate sodium 200 mg, venlafaxine XR 75 mg, memantine 5 mg, and vitamin D3 2000 IU were scheduled for 9:00 AM but were administered at 10:24 AM. During interview, the LVN stated these medications were not given within 60 minutes of the scheduled time and said the delay was due to being new to the facility and being interrupted by staff during medication administration. For a fourth resident with pneumonia, chronic respiratory failure with hypoxia, and emphysema, prednisone 10 mg was scheduled for 7:15 AM but was not administered within 60 minutes of the scheduled time; the LVN stated the resident was asleep and she did not return before the 8:15 AM cutoff she believed applied. The DON stated the nurses did not follow the facility’s policy to administer medications on time.
Medication Administration Not Given Within Required Time Frame
Penalty
Summary
The facility failed to ensure that four sampled residents received medications within 60 minutes of their scheduled administration times. During observation and record review, a nurse administered metformin HCl 1000 mg and potassium chloride 20 mEq to one resident at 8:55 AM even though both medications were scheduled for 7:15 AM. That resident’s record showed diagnoses including paroxysmal atrial fibrillation, nonrheumatic mitral valve insufficiency, and type 2 DM, and the MDS indicated moderately impaired memory and cognitive skills for daily decision making. A second resident with diagnoses including essential HTN, hyperlipidemia, and depression was scheduled to receive metoprolol tartrate 12.5 mg at 7:15 AM, but the medication was administered at 9:12 AM. The nurse stated the facility staff were allowed to administer medications two hours before and two hours after the scheduled time. A third resident with diagnoses including unspecified dementia, major depressive disorder, and essential HTN was scheduled to receive aspirin, docusate sodium, venlafaxine, memantine, and vitamin D3 at 9:00 AM, but these medications were administered at 10:24 AM. The nurse later stated these medications were not administered within 60 minutes of their scheduled time. A fourth resident with diagnoses including pneumonia, chronic respiratory failure with hypoxia, and emphysema was ordered prednisone 10 mg daily for COPD and was scheduled to receive it at 7:15 AM, but the nurse did not administer it at that time because the resident was asleep. The nurse stated she had until 8:15 AM to give the medication and did not return before that time because she was busy with another resident. The DON stated facility staff were allowed to administer medications one hour before and one hour after the scheduled time, and that the nurses did not follow the facility’s policy to administer medications on time.
Unlabeled resident food and staff food stored in residents’ refrigerator
Penalty
Summary
The facility failed to provide safe and sanitary storage and handling of food brought in by family or other visitors in accordance with its policy titled Food Brought in by Family/Visitors. During a concurrent observation and interview in the activity room, the refrigerator designated for residents’ use was found to contain three unopened Ensure drinks without the resident’s name and one opened apple juice bottle without a use-by date. The Activity Director and LVN confirmed these items were not labeled as required, and also identified one fruit plate dated 1/28 that belonged to staff and one unlabeled container with food in the same refrigerator. During an interview, an activity staff member stated she had placed her own food in the residents’ refrigerator even though she knew it was only for residents’ use. The Administrator reviewed the facility’s policy and stated that food brought in for residents, including bottled juice and protein supplement drinks such as Ensure, should be labeled with the resident’s name, room number, and use-by date if opened, and that staff food should not be stored in the residents’ refrigerator. The Administrator also stated that unlabeled food items or staff food in that refrigerator could be mistaken for resident food and may pose a risk of cross contamination.
Infection control failures during wound care, room care, laundry handling, and blood glucose monitoring
Penalty
Summary
The facility failed to observe infection control measures during wound care for Resident 5, who had a stage 2 pressure ulcer, immunodeficiency, and type 2 DM. During wound care, Treatment Nurse 1 removed the resident’s soiled dressing and changed gloves without performing hand hygiene before continuing care. The nurse later stated hand hygiene should have been performed after removing the dirty dressing and before putting on clean gloves. The DON and Infection Preventionist Nurse also stated gloves do not replace hand hygiene and that hand hygiene should have been performed after handling the soiled dressing and before proceeding. The facility also failed to follow hand hygiene expectations when Treatment Nurse 1 moved from Resident 49’s room, which was on enhanced barrier precautions, to prepare treatment for Resident 105, whose room was also on enhanced barrier precautions. After entering Resident 49’s room and touching the bedside table, the nurse left the room and prepared treatment supplies for Resident 105 without performing hand hygiene. The nurse stated he did not perform hand hygiene after coming out of the room and before touching the treatment cart, and the DON stated hand hygiene was required before entering and after exiting the resident’s room, especially after contact with the resident’s immediate vicinity, and before preparing treatment supplies. In the laundry room, Laundry Staff was observed picking up trash from the floor, opening the trash can lid to discard it, and then handling clean linen without performing hand hygiene. The IPN stated hand hygiene should have been performed before handling the clean linen, and the DON stated hand hygiene should have been performed after handling the trash and before continuing with the clean laundry. The facility’s laundry policy was reviewed and indicated laundry should be kept clean to prevent spread of infection. The facility further failed to perform hand hygiene between two wound sites on Resident 9, who had a stage 3 sacral pressure ulcer, ESBL resistance, metabolic encephalopathy, and severe cognitive impairment. During wound treatment, Treatment Nurse 1 completed care to one wound, changed gloves, and proceeded to the second wound without performing hand hygiene. The nurse stated changing gloves alone was what he did and that hand hygiene was not performed before putting on another glove. The DON stated the policy required staff to change gloves and wash hands before moving from one wound to another, and the written hand hygiene policy stated alcohol-based hand rub or soap and water should be used before moving from a contaminated body site to a clean body site and after handling used dressings. Finally, Licensed Vocational Nurse 1 failed to clean and disinfect the blood glucose monitor before and after checking Resident 95’s blood sugar. Resident 95 had type 2 DM and was ordered to have Accuchek testing twice daily. LVN 1 prepared the meter and supplies, checked the resident’s blood sugar, returned the meter and used supplies to the tray, and then placed the meter back in the medication cart drawer without sanitizing it before or after use. LVN 1 stated the meter was not sanitized and that it was important to disinfect it for infection control because the check involved the resident’s blood. The DON stated licensed nurses were required to sanitize the blood glucose monitor before and after resident use, and the facility’s blood sampling policy required reusable blood glucose meters to be cleaned and disinfected between resident uses.
Failure to Complete Antibiotic Surveillance Forms
Penalty
Summary
The facility failed to complete antibiotic surveillance data collection forms for two sampled residents receiving antibiotics. One resident was admitted and readmitted with diagnoses including cellulitis of both lower extremities and a left lower leg ulcer, and had a physician order for meropenem 2 grams IV every 8 hours for cellulitis of the bilateral lower extremities until 2/6/2026. During interview, the Infection Preventionist Nurse stated that an antibiotic surveillance data collection form was not completed for this resident’s meropenem use, and stated the form should have been completed to ensure the resident met criteria for antibiotic use and received the correct antibiotic. A second resident was admitted with diagnoses including cellulitis of the left lower limb, DM, and pressure ulcers of the sacral region and left heel. The resident’s physician order included Bactrim DS 800-160 mg by mouth twice daily for cellulitis for 10 days. During interview, the Infection Preventionist Nurse stated that an antibiotic surveillance data collection form was not completed for this resident’s Bactrim use, and stated the form should have been completed to ensure the resident met criteria for an antibiotic and received the correct antibiotic. The facility policy stated antibiotic usage and outcome data would be collected and documented using the facility-approved antibiotic surveillance tracking form.
Failure to Timely Report Resident’s Allegation of Physical Abuse to Required Agencies
Penalty
Summary
The facility failed to follow its abuse reporting policy and regulatory requirements when an allegation of physical abuse was made by a resident and was not reported to the California Department of Public Health (CDPH), local law enforcement, or the Ombudsman within two hours. Resident 8, who had diagnoses including schizophrenia, bipolar disorder, and cellulitis of the left lower limb, was cognitively intact per the MDS dated 11/12/2025 and required only supervision or touching assistance for several ADLs. During an interview with a surveyor on 1/26/2026, the resident stated that about a month earlier, while sitting on his bed and reading, someone hit him very hard on his right ribs, cracking them, and that he did not see who hit him but only saw a shadow. The allegation was documented in the resident’s records. The care plan dated 1/27/2026 noted that the resident had alleged being struck by a shadow a month prior, and interventions included close monitoring of the resident’s whereabouts, room visits every two hours and as needed, and following the abuse prohibition protocol. An SBAR dated 1/26/2026 recorded that the resident told the surveyor that someone had struck him on his rib and that he only saw a shadow. Nursing staff, including a RN supervisor, reported that the DON was notified of the resident’s statement that he had been struck on his right side by a shadow. Despite this, the allegation was not reported to external agencies as required by facility policy. The DON acknowledged that an allegation of abuse involving a staff member hitting a resident should be reported to the Administrator, who serves as the abuse coordinator, and that an SOC 341 form should be completed and sent to CDPH, the Ombudsman, and the police. The DON and Administrator both confirmed that the allegation was not reported when they were informed, and the DON stated she did not report it because she attributed the resident’s statement to his mentation and behavior related to his mental illness. Review of the facility’s abuse reporting and investigating policy, revised September 2022, showed that all reports of resident abuse must be immediately reported—defined as within two hours—to the state licensing/certification agency, Ombudsman, and law enforcement, which did not occur in this case.
SNF ABN Not Provided to Resident
Penalty
Summary
The facility failed to ensure that one sampled resident, admitted with diagnoses including schizophrenia, bipolar disorder, and cellulitis of the left lower limb, was provided the Skilled Nursing Facility (SNF) Beneficiary Notification form. The resident’s MDS dated 11/12/2025 indicated intact cognitive skills for daily decision making and need for supervision or touching assistance with toileting hygiene, showering/bathing, sitting to standing, and walking ten feet. A review of the SNF Beneficiary Notification Review form completed on 1/28/2026 showed that the resident’s Medicare Part A skilled services episode began on 9/30/2025 and the last covered day of Part A services ended on 12/3/2025, and that the SNF ABN form was not provided to the resident. During interview, the BOM stated she did not know she needed to notify the resident of the SNF ABN and stated it was important to inform and give the form so the resident could understand the benefits covered and when coverage would end. The facility’s policy stated that designated staff were responsible for completing the ABN when needed and for reviewing it with the resident or authorized representative, obtaining signature and date, providing a copy, and filing the original.
Unattended Computer Displayed Resident Wound Treatment Information
Penalty
Summary
Facility staff failed to secure and maintain confidentiality of Resident 85’s medical record information when the resident’s wound treatment order was left visible on Computer 1’s screen in Nurse’s Station 1 while the computer was unattended and unlocked. Resident 85 was admitted with diagnoses including a displaced supracondylar fracture with intracondylar extension of the lower end of the right femur, aftercare following joint replacement surgery, and difficulty walking. The resident’s MDS dated 1/15/2026 indicated impaired cognitive skills for daily decision making and that the resident required supervision or touching assistance with eating, oral hygiene, and personal hygiene, as well as partial/moderate assistance with toileting hygiene, upper and lower body dressing, rolling, sit to stand, sit to lying, and walking 10 feet. The physician order dated 1/27/2026 included treatment for skin discoloration on the right lower extremity with monitoring for skin integrity every shift for 14 days. During observation and interview at 9:29 AM on 1/27/2026, the Administrator observed Computer 1 unattended with Resident 85’s wound treatment information displayed on the screen and stated the screen should not have been left open or unattended and should have been locked when staff walked away. LVN 4 later stated staff need to log off before walking away to protect residents’ information and that leaving the computer on and unattended with the resident’s wound treatment information exposed was unacceptable. The DON stated residents have a right to privacy, that staff, visitors, laboratory technicians, and vendors could have accessed the information, and that the facility’s privacy and confidentiality policy was not followed.
Failure to Coordinate Level II PASRR After Positive Level I Screening
Penalty
Summary
The facility failed to ensure coordination for a Level II PASRR assessment within 24 hours for a resident whose Level I PASRR was positive for serious mental illness. Resident 60 was admitted and readmitted to the facility with diagnoses including Huntington's disease, dementia, schizoaffective disorder, and anxiety disorder. The resident's PASRR Level I screening dated 8/6/2025 was positive for serious mental illness, and the record also showed a care plan addressing mental illness/psychosis with behaviors such as disorganized behavior, inappropriate laughing or shouting, strange voices or faces, and repetitive purposeless body movements. Record review further showed the resident had severely impaired cognitive skills for daily decision making on the MDS dated 12/1/2025 and was receiving antipsychotic and antianxiety medications, including clonazepam and haloperidol. During interview, the SSA stated the latest PASRR was completed on 8/6/2025 and that the facility should have coordinated the Level II with the Contractor within 24 hours after the positive Level I. The DON stated a Level II PASRR was needed when the Level I was positive to determine whether the facility was the proper placement based on the resident's medical diagnosis. The facility policy stated that if the Level I screen is positive, the individual is referred for Level II evaluation and the facility participates in the process within 24 hours of submitting the completed Level I screening or upon request of the Level II Contractor.
Failure to Address Resident Skin and Nail Conditions
Penalty
Summary
The facility failed to ensure treatment and care were provided according to orders, resident preferences, and goals for two residents. One resident with diagnoses including a right fibula fracture and diabetes mellitus was observed scratching her left arm, which had skin discoloration, scars, and peeling skin. The resident stated her arm was itchy and that nurses were not applying anything to relieve the itch. The same resident was later observed again scratching her arm, and staff interviews indicated the condition had been present since admission. A treatment nurse stated that if the resident’s arm was itchy, a change of condition form would need to be completed and the physician informed so the resident could receive treatment. The nurse also stated there was no current physician order for the arm itching and that a treatment should be in place to prevent scratching and possible infection. The DON stated the CNA should report the skin condition to the licensed nurse, who would then call the doctor for a treatment order and monitor for skin breakdown. The facility’s skin-related policies indicated staff should report skin changes and obtain a physician’s order. The second resident, who had diagnoses including dementia, dysphagia, and muscle weakness, was observed with nails that were yellow and brown, thick, and brittle. Staff stated they had not noticed the nails because the resident usually kept her hands closed, but they confirmed the nails were thick, brittle, and discolored when observed during restorative nursing services. The DON and other staff stated the nail condition should have been assessed and reported to the physician because it could indicate a fungal infection. The facility’s nail care policy stated unusual observations should be reported to the licensed nurse for follow-up.
Failure to Monitor and Document Indwelling Catheter Findings
Penalty
Summary
The facility failed to provide appropriate care and services for a resident with an indwelling catheter by not consistently assessing, monitoring, and documenting signs and symptoms of UTI as ordered and care planned, and by allowing the catheter bag to touch the floor. The resident had a history that included UTI, obstructive and reflux uropathy, BPH, and ESBL, and the MDS indicated severely impaired cognitive skills for daily decision making, substantial/maximal assistance with toileting hygiene, and use of an indwelling catheter. The physician orders required monitoring urine every shift for sediments, cloudiness, hematuria, and clear urine, and the care plan directed staff to monitor for UTI signs such as hematuria, cloudy urine, burning, foul odor, flank pain, elevated temperature, weakness, and sudden change in consciousness. During observations, the catheter bag was seen touching the floor on multiple occasions, and later the catheter tubing showed sediment, cloudy urine, and pink-tinged urine. The RN supervisor stated the urine was very dark, concentrated, and had particles with a tinge of pink. Record review showed documentation gaps in the TAR and nurses' notes, including no documentation of urine assessment on 1/27/2026 and the morning shift of 1/28/2026, and no documentation of hematuria, sediments, or catheter flushing interventions. An LVN stated she observed moderate white sediments and scant hematuria in the catheter tubing and flushed it, but did not report the findings to the physician. The DON confirmed the catheter bag should not touch the floor, that abnormal urine findings should be monitored and reported, and that the medical record did not show the physician was notified of the sediment in the catheter.
Unlabeled GT Formula Bag During Tube Feeding
Penalty
Summary
The facility failed to ensure appropriate treatment and services for a resident with a gastrostomy tube by not properly labeling the resident’s GT formula bag with the licensed nurse’s initials, date, and time the formula was hung and administered, as required by facility policy. Resident 60 had diagnoses including Huntington’s disease, dementia, schizoaffective disorder, and gastrostomy status, and the MDS indicated the resident’s cognitive skills for daily decision making were severely impaired, eating was not attempted due to medical conditions or safety concerns, and the resident received more than 51% of total calories through tube feeding. Resident 60’s physician orders directed Nutren 2.0 to run at 45 ml/hour for 20 hours via Kangaroo Pump with water flushes of 50 ml/hour for 20 hours per day, starting at 1 PM and stopping at 9 AM or when the total volume was completed. During observation, the resident was in bed with the GT connected to a pump and the formula running at 45 ml/hour, but the GT formula bag was not labeled with the patient’s name, patient ID, date/time started, or tube feeding order. LVN 1 stated the bag should have been labeled with the time, date, feeding rate, and licensed nurse’s initials, and the DON stated licensed nurses are required to label the formula bag to ensure the feeding is administered according to the physician’s order.
Failure to Monitor Fluid Restriction and Care Plan for Dialysis Resident
Penalty
Summary
The facility failed to provide safe, appropriate dialysis-related care for one sampled resident who had end stage renal disease, type 2 DM, and heart failure and was receiving dialysis. The resident’s physician ordered a 1200 ml per day fluid restriction, with amounts divided across nursing and dietary shifts. Record review showed fluid intake was documented separately on the MAR and Nutrition-Fluids form, but the licensed nurses did not total the documented intake to determine whether the resident remained within the ordered daily limit. The DON stated the facility did not assess the resident’s weekly fluid intake and that the documented amounts were not added up to ensure the resident did not exceed 1200 ml per day. The resident’s dialysis care plan, dated 9/22/2025, was reviewed and found to address hemodialysis but not the resident’s fluid restriction in a comprehensive and individualized way. The only intervention identified on the care plan was to take vital signs before and after dialysis days. LVN 4 stated the care plan did not include interventions addressing the fluid restriction, and the DON stated it was not comprehensive because it did not include interventions to prevent fluid overload. The DON also stated the care plan policy was not followed. Facility staff interviews confirmed gaps in communication and monitoring. CNA 4 stated he did not know the resident was on fluid restriction or how much fluid was allowed during his shift. LVN 4 stated the resident’s fluid intake was documented in two separate places, but she did not know whether the totals were added at the end of the day. The facility’s policies required licensed nurses to make a care plan entry for fluid restriction, place the resident on intake and output monitoring, complete weekly fluid intake assessments, and monitor compliance with dialysis diets including fluid restrictions.
Unopened insulin stored in medication cart instead of refrigerator
Penalty
Summary
The facility failed to ensure safe pharmaceutical storage when one unopened Humalog insulin vial for a resident was observed inside the medication cart instead of being refrigerated. The resident was admitted with diagnoses including HTN, chronic kidney disease, type 2 DM, and cerebral infarction, and the H&P described the resident as awake, alert, and oriented times 1. The physician order dated 1/28/2026 directed Humalog insulin injection solution 100 units/ml to be given per sliding scale before meals and at bedtime for type 2 DM. During an observation and interview on 1/29/2026 at 11:40 AM, LVN 2 confirmed the unopened insulin vial should have been refrigerated because storage at room temperature could affect the potency of the insulin, and stated the vial would need to be discarded and replaced. During an interview with the DON, the facility’s policy was reviewed and the DON stated unopened insulin should be stored in the refrigerator until opened because it may not be effective for the resident. The facility policy on storage of medications stated medications requiring refrigeration are stored in a refrigerator in the drug room or other secured location, and the insulin storage policy stated unopened insulin shall be stored in a medication refrigerator maintained at 36 degrees Fahrenheit to 46 degrees Fahrenheit.
Inaccurate transcription of hospice oxygen order
Penalty
Summary
The facility failed to provide accurate documentation of treatment for one sampled resident by not transcribing the hospice oxygen order into the facility’s physician order record. Resident 9 was admitted with diagnoses including dependence on supplemental oxygen, palliative care, and metabolic encephalopathy. The hospice medication list showed oxygen 2 LPM continuously for shortness of breath, while the facility’s Order Summary Report listed oxygen 2 LPM via nasal cannula as needed to maintain oxygen saturation at 92% and above. During observation, Resident 9 was seen in the room receiving oxygen via nasal cannula at 2 LPM. The DON reviewed the hospice orders and the facility order summary and stated the orders were not the same because the facility order was entered as needed rather than continuously. The DON stated the order had not been transcribed correctly from the hospice order, and that licensed nurses had been giving the resident oxygen continuously even though the facility physician order was entered incorrectly as PRN. The facility policy on charting and documentation stated medical record documentation will be objective, complete, and accurate.
Failure to Provide Gluten-Free Meal to Resident With Documented Allergy
Penalty
Summary
The facility failed to ensure a resident with a documented gluten allergy received a breakfast tray free of gluten-containing food. The resident’s admission record, admission assessment, diet order and communication, and care plan all identified gluten as a food allergy. The care plan also included interventions to honor the resident’s reasonable food preferences and to offer substitutes for meals as needed. The resident’s MDS indicated the resident was cognitively intact and required only supervision, setup, or clean-up assistance for mobility, dressing, personal hygiene, and eating. Despite these documented allergies and care plan interventions, on 12/22/2025 the resident was served a breakfast tray that included sourdough toast, which contains gluten, along with eggs. A CNA reported that the resident informed him at that time that they were allergic to gluten and could not eat the sourdough toast on the tray. The facility’s failure to prevent the inclusion of gluten-containing food on the resident’s tray had the potential to result in an allergic reaction such as anaphylaxis, as noted in the report.
Call Light Inaccessibility for Resident Needing Assistance
Penalty
Summary
A deficiency was identified when a resident's call light was not within easy reach, as observed during a survey. The call device was found tied to the right-side rail and hanging below the bed frame, making it inaccessible to the resident. During an interview, the resident stated she did not know where her call device was and preferred to stay in bed rather than attempt to reach for it, expressing fear of falling. The resident required partial to moderate assistance with several activities of daily living and had moderate cognitive impairment but was able to make her own decisions and follow commands. Her medical history included type II diabetes mellitus, rheumatoid arthritis, and lumbar spinal stenosis without neurogenic claudication. Staff interviews confirmed that the call light was supposed to be within the resident's reach to ensure timely care and safety. Both a CNA and the Registered Nurse Supervisor stated that the call device should be accessible near the resident's hands, and the Director of Nurses reiterated that the call light is intended to ensure timely responses to resident needs and for safety monitoring. A review of the facility's policy on answering call lights also indicated that the call light should be accessible to residents in various locations, including in bed.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Develop Individualized Care Plan for Resident's Harmful Behavior
Penalty
Summary
The facility failed to develop an individualized, resident-centered care plan with measurable objectives, timeframes, and interventions for a resident who exhibited the behavior of wrapping the bed remote cord around his arms. Despite multiple observations and staff interviews confirming that the resident had been engaging in this behavior since early May, and that it resulted in skin discolorations on both arms, there was no care plan in place to address this specific issue. The resident had a history of dementia, anxiety, depression, and peripheral vascular disease, and required varying levels of assistance with daily activities. The absence of a care plan was confirmed during a review of the resident's records with the Director of Nursing, who acknowledged that a care plan should have been created when the behavior was first noted. Staff, including a Licensed Vocational Nurse and a Certified Nursing Assistant, reported observing the resident wrapping the cord around his arms, and a Treatment Nurse documented multiple areas of skin discoloration on both forearms. The facility's policy and procedure required that identified problem areas and risk factors be incorporated into the care planning process, but this was not done for the resident's cord-wrapping behavior. As a result, necessary care and services were delayed, leading to the development of skin discolorations on the resident's arms.
Failure to Report Resident Fall to State Authorities
Penalty
Summary
The facility failed to report a fall incident involving a resident in accordance with its own policy and regulatory requirements. The resident, who had a history of falls, chronic obstructive pulmonary disease (COPD), and type II diabetes, experienced an unwitnessed fall resulting in a nasal fracture. The resident required moderate assistance with daily activities and had moderate cognitive impairment. After the fall, the nurse on duty notified the physician, obtained an x-ray order, informed the conservator, and followed the internal chain of command by notifying the Director of Nursing (DON) and the administrator. The resident was subsequently transferred to the hospital for further care. Despite these internal notifications, the facility did not report the fall to the California Department of Public Health (CDPH) or other appropriate agencies as required by both facility policy and state regulations. Interviews with staff, including the Registered Nurse Supervisor, Director of Staff Development, and the administrator, revealed a lack of understanding or misinterpretation of the reporting requirements. The facility's policy clearly states that unusual occurrences affecting resident welfare must be reported to appropriate agencies within specified timeframes, but this protocol was not followed, resulting in a delay in external investigation and potential interventions.
Failure to Develop Colostomy Care Plan
Penalty
Summary
The facility failed to develop and implement a care plan for a resident with a colostomy, as required by facility policy. The resident was admitted and readmitted with diagnoses including colostomy status, malignant neoplasm of the colon, and intestinal abscess. Documentation showed the resident required partial to moderate assistance with activities such as toileting hygiene, bathing, and personal hygiene, and had a colostomy site on the abdomen. Physician orders were in place for colostomy care, including cleansing the site and applying a colostomy bag, but there was no corresponding care plan in the resident's medical record. Interviews with facility staff, including a treatment nurse, registered nurse supervisor, and the DON, confirmed that a care plan addressing the resident's colostomy was not developed. Staff acknowledged that a care plan should have been created to guide nursing interventions, monitor the stoma site, and ensure continuity of care. Review of facility policy indicated that comprehensive, person-centered care plans with measurable objectives and timetables are required for each resident, but this was not followed for the resident in question.
Failure to Provide Ordered Colostomy Care and Document Refusal
Penalty
Summary
A deficiency occurred when a resident with a colostomy did not receive colostomy care as ordered by the physician. The resident's medical record indicated a diagnosis of colostomy status, malignant neoplasm of the colon, and abscess of the intestine. The physician's order required the colostomy site to be cleansed with normal saline, patted dry, and a colostomy bag applied every dayshift. However, during observation, the treatment nurse only emptied the colostomy bag and did not perform the required cleansing or bag change. The nurse stated that she followed instructions from the resident's family member to only empty the bag and admitted to not documenting any refusal of care or notifying the physician, as required. Further review of the resident's medical chart showed no documentation of refusal of colostomy care or physician notification regarding any treatment refusal. The Director of Nursing confirmed that the physician's order was not followed and emphasized the importance of providing treatments as ordered. The facility's policy also required proper colostomy care and documentation of any concerns or refusals, which was not adhered to in this case.
Failure to Accurately Document and Provide Ordered Colostomy Care
Penalty
Summary
The facility failed to ensure accurate and complete documentation of colostomy care for one resident with a history of colostomy status, malignant neoplasm of the colon, and abscess of the intestine. The resident required partial to moderate assistance with toileting hygiene and had a physician's order for daily cleansing of the colostomy site with normal saline, patting dry, and applying a colostomy bag every dayshift. Review of the Treatment Administration Record (TAR) for the relevant period showed that the required colostomy care was documented as completed, but direct observation and staff interviews revealed that the care was not actually provided as ordered on at least one occasion. During observation, a nurse was seen only emptying the colostomy bag without performing the required cleansing or bag replacement. Interviews with two treatment nurses confirmed that one did not provide or document the care, while the other documented the care as completed despite not having performed or witnessed it. The Registered Nurse Supervisor and Director of Nursing both confirmed that facility policy requires accurate, complete, and timely documentation by the staff who actually provide the care. Review of the facility's documentation policy further emphasized the need for objective, complete, and accurate records of all treatments and services provided.
Inadequate Supervision Leads to Resident Falls and Injuries
Penalty
Summary
The facility failed to ensure adequate supervision and safety measures for two residents, leading to falls and injuries. Resident 1, who was assessed to require increased assistance and supervision to prevent falls, was left unsupervised by CNA 2 while sitting in a wheelchair during breakfast. This lack of supervision resulted in Resident 1 falling and sustaining acute hairline fractures in the ribs. The care plan for Resident 1 was not updated to reflect the need for increased assistance and supervision, despite previous falls and recommendations from physical therapy. Similarly, Resident 2, who had poor static sitting balance and required supervision, was left unsupervised by LVN 1 while sitting on the side of the bed during dinner. This resulted in Resident 2 falling and suffering a mildly displaced fracture of the right femur. The care plan for Resident 2 was not resident-centered and did not include necessary interventions for supervision, despite the resident's cognitive impairments and recommendations from physical therapy. The facility's policies and procedures on safety and supervision were not adequately followed, as both residents were left without necessary supervision, leading to preventable accidents. The facility's failure to revise care plans and ensure staff adherence to supervision requirements contributed to the incidents, highlighting deficiencies in the facility's approach to resident safety and fall prevention.
Failure to Revise Care Plan for High Fall Risk Resident
Penalty
Summary
The facility failed to revise the care plan for a resident at high risk for falls, which was not updated to reflect the recommendations from a Physical Therapy Recertification note. The resident, who was admitted with diagnoses of dizziness, muscle wasting, and difficulty walking, was assessed as being at high risk for falls. Despite having multiple falls, the care plan was not updated to include increased assistance and supervision as recommended by the Physical Therapy Recertification note dated 3/4/2025. The resident experienced three unwitnessed falls within the facility, with the second and third falls occurring after the Physical Therapy Recertification note was issued. The care plan, initiated on 2/28/2025, did not incorporate the necessary changes to address the resident's need for increased assistance and supervision to mitigate fall risks. The Director of Nursing acknowledged that the care plan should have been revised to reflect these needs, particularly after the third fall when the resident was left unsupervised during breakfast. The facility's policies and procedures for managing falls and developing comprehensive, person-centered care plans were not adhered to, as the care plan did not include measurable objectives and interventions based on the comprehensive assessment. The failure to revise the care plan as per the Physical Therapy Recertification note contributed to the resident's continued risk of falls.
Failure to Address Resident's Call Light Promptly
Penalty
Summary
The facility failed to ensure that a resident's call light was addressed in a timely manner, which is a critical communication tool linking nursing home staff to the needs of residents. This deficiency was observed in the case of a resident who was admitted with diagnoses including dysphagia, muscle weakness, and hypothyroidism, and who had severely impaired cognitive skills for daily decision-making. The resident was dependent on staff for various personal care activities. During an observation, the resident's call light was on, and the resident was heard calling for help, indicating a need for assistance. Despite the call light being on and the resident calling for help, a Licensed Vocational Nurse (LVN) present at the nursing station did not respond, stating that she was not the charge nurse for the resident. Interviews with other staff, including another LVN and the Director of Nursing (DON), highlighted the importance of addressing call lights promptly to prevent residents from feeling helpless and to avoid potential accidents. The facility's policy requires that calls for assistance be answered as soon as possible, but not later than five minutes, with urgent requests addressed immediately. This policy was not adhered to in this instance, leading to a delay in care and services for the resident.
Failure to Provide Adequate Grooming Services
Penalty
Summary
The facility failed to provide adequate grooming services to a resident who was dependent on assistance for activities of daily living (ADLs). The resident, who was admitted with diagnoses including sepsis, dysphagia, and depression, was observed to have long, jagged, and dirty fingernails and toenails. This condition was noted during an observation and interview with a treatment nurse, who confirmed the poor state of the resident's nails. The resident's Minimum Data Set (MDS) indicated that their cognitive skills for daily decision-making were intact, but they were dependent on personal hygiene assistance. The facility's policies and procedures for ADLs and nail care, which were reviewed, stated that residents unable to perform ADLs independently should receive services to maintain grooming and personal hygiene. The policy specifically outlined the need for daily cleaning and regular maintenance of nails to prevent infections. Despite these guidelines, the resident's care plan, which required assistance with all ADLs, was not adequately followed, resulting in the resident's unkempt nails. This deficiency was identified as a failure to adhere to the facility's established procedures, potentially leading to skin injury, infection, and scarring.
Failure to Update Daily Staffing Information
Penalty
Summary
The facility failed to ensure that the Direct Care Service Hours Per Patient Day (DHPPD) was updated in accordance with its policy and procedure titled Posting Direct Care Daily Staffing Numbers. During an observation and interview with a licensed vocational nurse (LVN 1), it was noted that the DHPPD had not been updated since 3/4/25, despite the observation taking place on 3/7/25. This lapse in updating the DHPPD was confirmed by LVN 2, who stated that the nursing hours should be posted in every station to reflect the number of Registered Nurses (RN), LVNs, and Certified Nursing Assistants on each shift, based on the resident census. The failure to update the DHPPD could lead to residents and staff receiving incorrect information. Further investigation with the Director of Nursing (DON) revealed that the facility's policy and procedure, dated 1/2021, required the posting of nurse staffing data on a daily basis for each shift. This data should include the number of nursing personnel responsible for providing direct care to residents and should be posted within two hours of the beginning of each shift in a prominent location. The information should also include the facility's name, the current date, the resident census at the beginning of the shift, and the 24-hour shift schedule. The DON acknowledged that the DHPPD was not updated as per the policy, which could potentially misinform residents and visitors about the facility's census and staffing.
Medication Labeling and Security Deficiencies
Penalty
Summary
The facility failed to ensure that a resident's Santyl ointment was properly labeled according to the facility's policy and procedure. The ointment, used for treating pressure injuries, lacked a label indicating the resident's name, route of administration, medication dose, and frequency of administration. This was observed during a medication preparation by a treatment nurse, who acknowledged that the label had fallen off. The absence of a label posed a risk of the resident not receiving the medication as ordered or directed. Additionally, the facility did not secure medication cart 1, which was found unlocked and unattended. This was confirmed during an observation and interview with a licensed vocational nurse, who admitted the cart was supposed to be locked to prevent unauthorized access. The Director of Nursing reiterated the importance of keeping medication carts locked to prevent unauthorized individuals from accessing medications. The facility's policies and procedures clearly state that medication carts must be securely locked at all times when out of the nurse's view.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure that two residents were treated with dignity and respect. Resident 22, who has diagnoses of muscle wasting and dementia, was observed with food stains on his shirt and bed linens on two separate occasions. Despite being cognitively independent, Resident 22 required assistance with activities of daily living, including dressing and hygiene. Interviews with staff revealed that the resident was not offered a change of clothes or linens, which the Director of Nursing (DON) acknowledged as a dignity issue. The facility's policy on resident rights emphasizes treating residents with kindness, respect, and dignity, which was not adhered to in this case. Additionally, Resident 1, who has metabolic encephalopathy, multiple sclerosis, and contracture of the right hand, was not assisted with feeding at eye level. The resident required partial assistance with eating, and during an observation, a Certified Nursing Assistant (CNA) was seen standing while feeding the resident, which the DON stated could make the resident feel disrespected and uncomfortable. The facility's policy also requires staff to treat residents with dignity, which was not followed in this instance, as feeding should be done at eye level to ensure comfort and respect for the resident.
Lack of Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive, resident-centered care plans for five residents, leading to potential delays in necessary care and services. Resident 126, who was admitted with diagnoses of trigeminal neuralgia and repeated falls, did not have a care plan for the use of oxygen, despite a physician's order for oxygen administration. The MDS Nurse and the Director of Nursing acknowledged the absence of a care plan, emphasizing its importance for continuity of care and staff guidance. Resident 1, diagnosed with metabolic encephalopathy, multiple sclerosis, and contracture of the right hand, did not have a care plan for Restorative Nursing Assistant (RNA) services for passive range of motion to the bilateral upper extremities, as indicated in the physician's orders. Interviews with the MDS Nurse and Physical Therapist confirmed the lack of a care plan, which is crucial for preventing functional decline and ensuring staff awareness of the resident's needs. Additionally, Resident 37, who had refused RNA services multiple times due to discomfort and pain, also lacked a care plan addressing these refusals, which could have provided interventions and goals to monitor and address the refusals more closely. Resident 59, admitted with contractures and Parkinson's disease, did not have a care plan for the use of a Low Air Loss mattress, which is essential for skin management and preventing pressure ulcers. The absence of a care plan was confirmed by both the Treatment Nurse and a Registered Nurse, who noted the importance of having specific goals and monitoring the effectiveness of the therapy. Similarly, Resident 2, with Parkinson's disease and schizophrenia, did not have a care plan for the use of an indwelling catheter, despite the presence of thick, cloudy sediment in the catheter tubing. The MDS Nurse and the Director of Nursing highlighted the necessity of a care plan to ensure staff are aware of the resident's needs and the interventions required for proper care.
Improper LAL Mattress Settings for Residents
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent the formation and promote the healing of pressure injuries for two residents, as observed during a survey. Resident 1, who was admitted with conditions including quadriplegia, a stage 4 pressure ulcer, and multiple sclerosis, was found to have an improperly set low air loss (LAL) mattress. Despite a physician's order to monitor the LAL mattress setting according to the resident's weight, the mattress was set at a level suitable for a person weighing 210 pounds, while Resident 1 weighed only 107 pounds. This discrepancy was noted during observations and interviews with the resident and staff, where it was confirmed that the incorrect setting could lead to discomfort and ineffective wound management. Similarly, Resident 59, who was admitted with contractures and Parkinson's disease, was also found to have an LAL mattress set incorrectly. The mattress was set for a weight range of 130 to 180 pounds, while the resident's actual weight was 93 pounds. Observations and interviews with nursing staff confirmed that the setting was inappropriate for the resident's weight, potentially leading to discomfort and ineffective prevention of pressure ulcers. The facility's policy and procedure for low air loss therapy, as well as the operation manual for the mattress system, were not adhered to, as they require the mattress setting to be adjusted according to the resident's weight. The facility's failure to ensure the correct settings of the LAL mattresses for both residents was a deviation from the physician's orders and the facility's own policies. This oversight had the potential to compromise the residents' skin integrity and hinder the healing process of existing pressure injuries. The observations and interviews highlighted a lack of adherence to the prescribed care plans and monitoring protocols, which are essential for effective pressure ulcer management and prevention.
Deficient Catheter Care and Monitoring in LTC Facility
Penalty
Summary
The facility failed to provide appropriate care for two residents with indwelling urinary catheters, leading to a deficiency in monitoring and documenting signs and symptoms of urinary tract infections (UTIs). Resident 1, who had a history of benign prostatic hyperplasia, acute kidney failure, and kidney stones, was observed with sediment in the catheter tubing on multiple occasions. Despite the presence of sediment, which was a sign of potential infection, the facility staff did not document these findings or notify the physician as required by the care plan and physician orders. The facility's policy required staff to monitor for signs of infection and report any unusual findings immediately, but this was not adhered to, resulting in a delay in identifying and treating a possible UTI. Resident 2, diagnosed with Parkinson's disease and schizophrenia, also had an indwelling catheter with observed sediment in the tubing. The catheter tubing was noted to be touching the floor, which posed an infection control risk. Despite these observations, the facility staff failed to document the presence of sediment or notify the physician, as indicated in the treatment administration record. The facility's policy emphasized the importance of keeping catheter tubing off the floor and reporting any signs of infection, but these protocols were not followed, leading to a deficiency in care. Interviews with facility staff, including registered nurses and the Director of Nursing, revealed a lack of adherence to the facility's catheter care policy. Staff acknowledged the presence of sediment and the need to notify the physician, but this was not reflected in the documentation or actions taken. The failure to monitor and document signs of infection, as well as maintain proper infection control practices, contributed to the deficiency in providing appropriate catheter care for the residents.
Deficiencies in Respiratory Care Services
Penalty
Summary
The facility failed to provide necessary respiratory care services for four residents, leading to deficiencies in their care. Resident 1's nasal cannula was improperly placed on the cheek instead of the nostrils, and the nebulizer face mask and tubing were not changed weekly or stored properly, increasing the risk of infection. Additionally, the nasal cannula tubing was not labeled or changed weekly as per facility policy. These lapses were confirmed by the Treatment Nurse and Director of Nursing, who acknowledged the potential for infection due to improper storage and labeling. Resident 16 was not provided with a new humidifier when the existing one was empty, contrary to the facility's policy that requires checking and replacing the humidifier to ensure the oxygen remains moist. This was observed by a Restorative Nursing Assistant and confirmed by a Licensed Vocational Nurse and the Director of Nursing. The facility's policy mandates that the humidifying jar should have enough water to bubble as oxygen flows through, and the water levels should be checked every 48 hours. Resident 231 received oxygen therapy without a physician's order, which is against the facility's policy that requires a physician's order for oxygen administration. This was confirmed by the Director of Nursing, who stated that oxygen is considered a medication and should not be administered without an order. Resident 279's oxygen nasal cannula tubing was not stored in a plastic bag when not in use, and the tubing connector was not changed weekly as required, posing a risk for infection. These deficiencies were observed by the Infection Preventionist and confirmed by the Director of Nursing, who emphasized the importance of proper storage and timely changes to prevent contamination.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to administer medications according to its policy for two residents, leading to potential adverse effects. For Resident 228, the facility did not administer aspirin with food as indicated in the physician's order. The resident, who was admitted with diagnoses including anemia and atherosclerosis, was observed receiving aspirin without food, despite the order specifying that it should be taken with food to prevent stomach irritation. The Licensed Vocational Nurse (LVN) acknowledged the oversight and the importance of following the order to prevent potential stomach irritation from the NSAID. For Resident 223, the facility did not administer Simbrinza Ophthalmic Suspension within the prescribed time frame. The resident, diagnosed with glaucoma and other conditions, was supposed to receive the eye drops between 8 AM and 10 AM, but the medication was administered late. The LVN admitted the error, noting that the facility's policy allows for medication administration within one hour before or after the prescribed time. The Director of Nursing confirmed that medications should be given as ordered to prevent adverse reactions, emphasizing the importance of adhering to the physician's orders and facility policy.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in an observed error rate of eight percent. This was identified during a medication pass observation involving two residents. The first error involved the administration of aspirin to a resident without food, contrary to the physician's order which specified that the medication should be taken with food to prevent stomach irritation. The Licensed Vocational Nurse (LVN) responsible for administering the medication acknowledged the oversight and the importance of adhering to the order to avoid potential adverse effects. The second error involved the late administration of Simbrinza Ophthalmic Suspension to another resident. The medication was administered outside the prescribed time window of 8 AM to 10 AM, which is against the facility's policy that allows for administration within one hour before or after the scheduled time. The LVN admitted to administering the medication late and recognized the importance of timely administration to ensure the medication's effectiveness and to prevent adverse effects. The Director of Nursing (DON) confirmed that the facility's policy requires medications to be administered as ordered and within the specified time frame. The DON emphasized the necessity of following the physician's orders and facility policies to prevent adverse reactions in residents. The facility's policy on medication administration also specifies that NSAIDs should be given with food or antacids and fluids, which was not followed in the case of the aspirin administration.
Improper Food Handling and Labeling Practices
Penalty
Summary
The facility failed to adhere to proper food handling practices as per its policy and procedure, which was observed during a survey. The Dietary Supervisor (DS) acknowledged that food items in the kitchen were not labeled with the item name and 'use by' date, and expired food items were not discarded. Specific observations included a gallon bottle of teriyaki sauce with mold, a chunk of ham, a pitcher of dark juice, and several other food items such as peanut butter sandwiches, prepared Jello, and baking powder that were either expired or lacked proper labeling. The facility's policies, including 'Labeling and Dating of Foods' and 'Freezer Storage,' require all food items in storage to be labeled and dated. The DS confirmed that these practices were not followed, which could lead to serving expired or contaminated food to residents. The FDA Food Code also mandates that time/temperature control safety refrigerated foods must be consumed, sold, or discarded by the expiration date, which was not adhered to in this instance.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to its infection control measures, as outlined in its policies and procedures, resulting in several deficiencies. Staff members did not change their N95 respirators after leaving the room of a resident who was in respiratory isolation due to a positive COVID-19 test. This was observed on multiple occasions, and both the Infection Preventionist and the Director of Nursing confirmed that the expectation was for staff to change their masks to prevent the spread of infection. The facility's policy clearly stated that disposable respirators should be removed and discarded after exiting the resident's room. Additionally, a resident was observed taking linen from carts in the hallway, which could potentially contaminate the clean linen. Staff members acknowledged this behavior but did not intervene, and the Infection Preventionist was unaware of the issue. The facility's policy emphasized the importance of maintaining a safe and aseptic environment, which was not upheld in this instance. Other deficiencies included staff not wearing N95 masks in the hallways during a COVID outbreak, a resident's nasal cannula being placed on the floor and reused without being replaced, and suction equipment not being cleaned or replaced as per protocol. Furthermore, a staff member entered a droplet isolation room without wearing the required PPE, such as a face shield or goggles, which was necessary to prevent cross-contamination. These actions and inactions contributed to the potential spread of infections within the facility.
Failure to Provide Accessible Call Light Systems for Residents
Penalty
Summary
The facility failed to accommodate the needs of two residents, leading to deficiencies in their care. Resident 39, who has dementia and depression, was observed on December 11, 2024, without access to a call light, which was placed behind the resident's bed. This resident, who requires assistance with most activities of daily living, was unable to call for help when needed, as confirmed by a Certified Nursing Assistant and the Director of Nursing. The care plan for Resident 39 indicated that the call light should be within reach, but this was not adhered to, resulting in the resident being unable to request assistance for water. Resident 29, diagnosed with functional quadriplegia and bullous pemphigoid, was provided with a call light that required pushing a button, which was inappropriate given the resident's contracted hands. The Director of Nursing acknowledged that the resident needed a touch pad call light, which would be more suitable for their condition. The facility's policy stated that residents should be provided with a means to call for assistance, and if a disability prevents use of the standard system, an alternative should be documented in the care plan. This was not done for Resident 29, leading to a deficiency in meeting the resident's needs.
Failure to Coordinate Hospice Care for Resident
Penalty
Summary
The facility failed to coordinate with the primary physician, the Interdisciplinary Team (IDT), and Hospice 1 regarding a request to place a resident under hospice care. This deficiency resulted in a delay or lack of coordination in the delivery of hospice care and services to the resident. The resident, who was diagnosed with quadriplegia, metabolic encephalopathy, and multiple sclerosis, had intact cognitive skills for daily decision-making but was dependent on assistance for various activities of daily living. Despite the responsible party signing a hospice consent and the facility administrator signing a hospice agreement, there was no physician order for hospice services, and the facility did not collaborate with Hospice 1. Interviews and record reviews revealed that the Director of Nursing (DON) acknowledged the lack of an IDT meeting to discuss the resident's condition and the failure to follow up on the hospice request. The DON admitted that there was no documented evidence of coordination with the IDT, the resident's primary physician, or collaboration with Hospice 1. The responsible party was under the impression that the hospice did not accept the contract, leading to a misunderstanding about the resident's hospice care status. The facility's policy indicated that staff should collaborate with hospice representatives and coordinate care planning, which was not adhered to in this case.
Failure to Provide Ordered Restorative Nursing Services
Penalty
Summary
The facility failed to provide Restorative Nursing Services as ordered by the physician for a resident, leading to a deficiency in maintaining or improving the resident's range of motion (ROM). The resident, who was admitted with diagnoses including metabolic encephalopathy, multiple sclerosis, and contracture of the right hand, was supposed to receive passive range of motion (PROM) exercises for both upper extremities. However, the facility did not include these services in the resident's Restorative Orders for November and December 2024, despite the physician's order for PROM to be performed five times per week. Interviews and record reviews revealed that the resident did not receive the ordered RNA services for the upper extremities, which were crucial for preventing further decline in physical function and contractures. The resident confirmed not receiving these services since November, and the Restorative Nursing Assistant (RNA) stated that the resident's upper extremities were not included in the physician's orders, leading to a lack of PROM exercises for the arms. The Physical Therapist and Registered Nurse confirmed the absence of RNA services and documentation for the upper extremities, which were necessary to prevent worsening contractures and maintain mobility. The facility's policy on Restorative Nursing Services, revised in July 2022, emphasized the importance of supporting residents in maintaining their physiological and psychological resources. However, the failure to implement the physician's orders for PROM on the resident's upper extremities resulted in a deficiency, as the resident was at risk for further decline in physical function and contractures due to the lack of appropriate care and services.
Improper Insulin Storage and Labeling
Penalty
Summary
The facility failed to ensure the safe provision of pharmaceutical services for one of its medication carts, specifically Medication Cart 2, as per the facility's policy. This deficiency was identified during an observation and interview with a registered nurse (RN 2) and involved the handling of insulin medications for a resident. The resident, who was cognitively intact and had a history of chronic kidney disease and type 2 diabetes mellitus, had an open vial of Humalog insulin that was not labeled with an open date, and two unopened Humulin N KwikPens that were improperly stored in the medication cart instead of the refrigerator. During the observation, RN 2 acknowledged that the Humalog vial was opened without an open date label, which she admitted to opening the previous day without documenting. She also confirmed that the Humulin N KwikPens were stored in the cart drawer, contrary to the requirement for refrigeration. The Director of Nursing (DON) further explained that opened insulin must be dated to ensure it is used within its effective period of 28 days, and unopened insulin should be refrigerated to maintain its efficacy. The facility's policy on drug storage and labeling mandates that all medications requiring an open date must be labeled immediately upon opening, and drugs stored under refrigeration must be kept between 36 and 46 degrees Fahrenheit. The failure to adhere to these guidelines for insulin storage and labeling could potentially lead to adverse reactions if the medications were administered to the resident beyond their effective period.
Failure to Provide Palatable Meals
Penalty
Summary
The facility failed to ensure that meals provided to residents were palatable, as evidenced by the experience of a resident who expressed dissatisfaction with the taste of the food. The resident, who has a history of type 2 diabetes mellitus with diabetic neuropathy and gastroesophageal reflux disease, was on a controlled carbohydrate diet with regular texture and thin liquids consistency. Despite the care plan indicating that the resident's reasonable food preferences should be honored, the resident reported that the food was unappealing and that the alternatives offered were not satisfactory. During a test tray sampling conducted with the Dietary Supervisor, it was found that the mashed potatoes served were bland and dehydrated, and the chopped carrots lacked flavor. The Dietary Supervisor acknowledged that the food lacked flavor and noted that the menu for the day was not satisfactory. The facility's policy and procedure on Food and Nutrition Services Staff, revised in October 2017, stated that food should be palatable, attractive, and served at the proper temperature, which was not adhered to in this instance.
Failure to Provide Admission Packet Upon Readmission
Penalty
Summary
The facility failed to inform a resident and their responsible party of the resident's rights and services upon admission. The resident was initially admitted to the facility and later readmitted after a hospital stay. Despite the readmission being considered a new admission, the facility did not provide the admission packet, which includes the resident's rights and responsibilities, until nearly three years later. This delay in providing the necessary documentation was identified during a review of the resident's records. The resident, who was diagnosed with dementia and depression, was admitted back to the facility from a general acute care hospital. The facility's policy required that an admission packet be signed within 48 to 72 hours of admission, but this was not adhered to. The admission packet, which should have been presented at the time of readmission, was only signed by the responsible party almost three years later, indicating a significant lapse in protocol. Interviews with facility staff, including the Admission Coordinator and Director of Nursing, confirmed that the resident's readmission should have been treated as a new admission, necessitating the completion of a new admission packet. However, due to incomplete and missing records, the packet was not presented to the responsible party until much later. This oversight was acknowledged by the facility's staff, highlighting a deficiency in the facility's admission process and record-keeping practices.
Resident Elopement Due to Malfunctioning Exit Door Alarm
Penalty
Summary
The facility failed to prevent the elopement of a resident, identified as Resident 1, who left the facility without staff knowledge or supervision. Resident 1, who had a history of hemiplegia, hemiparesis, alcohol abuse, and traumatic pneumothorax, was admitted with a low risk for elopement. Despite this, the resident managed to leave the facility through a sliding door in his room and an emergency exit door near the laundry room, which had a malfunctioning alarm that did not activate. The incident occurred between 1:38 AM and 1:48 AM, and the resident was not found until the following day, when he was located outside the facility, interacting with unknown individuals and refusing to return. Staff interviews revealed that the sliding door in the resident's room was left open, leading to an alleyway and the emergency exit door, which was unalarmed. The alarm on the exit door had been non-functional since the previous year, and the maintenance staff had not informed the administration about this issue. The facility's policies emphasized the importance of resident safety and supervision, yet the failure to maintain the alarm system compromised these priorities. The maintenance logs did not include checks for the alarm's functionality, and the lack of a working alarm allowed the resident to leave unnoticed, posing a significant safety risk. The facility's administration acknowledged the breach in the supervision system due to the malfunctioning alarm, which was the only tool in place to prevent such incidents.
Failure to Post and Maintain Accurate Nurse Staffing Information
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the posting of daily nurse staffing information, known as NHPPD (Nursing Hours Per Patient Day). Specifically, the facility did not indicate the actual hours worked by licensed and unlicensed nursing staff responsible for resident care on several dates, including 9/4/2024, 9/6/2024, 9/9/2024, and 9/11/2024. Additionally, the NHPPD forms were not posted in a prominent location accessible to residents and visitors, and forms for certain dates were missing entirely. This resulted in the inaccessibility of accurate daily staffing information, which is crucial for ensuring adequate care. Observations and interviews revealed that the NHPPD forms were incomplete, lacking actual nursing hours and resident census data. The Director of Nursing (DON) acknowledged the absence of a Director of Staff Development to manage the projected hours and the failure to compute and post actual hours. The facility's policy requires NHPPD forms to be posted daily at the beginning of each shift and maintained for 18 months, but this was not followed. The DON confirmed that the forms were not posted in areas easily viewable by residents and visitors, and many forms from previous months were missing, indicating they were not completed or retained as required.
Failure to Follow Transfer/Discharge Policy
Penalty
Summary
The facility failed to adhere to its Facility Initiated Transfer/Discharge policy for one of the three sampled residents, identified as Resident 1. The facility did not complete the necessary Transfer Assessment form before transferring Resident 1 to another facility, Facility 2. Additionally, a Discharge Summary was not completed, which should have included documentation of the basis for Resident 1's transfer. Furthermore, there was no Physician's order obtained for the transfer, and Resident 1 was not informed of the specific facility to which he was being transferred. Resident 1 had a history of fluctuating capacity to understand and make decisions due to dementia, as indicated in the History and Physical Examination. The Minimum Data Set assessment showed severe impairment in cognitive skills for daily decision-making. The Care Plan for Resident 1 included a goal for discharge to a different facility, Facility 3, once rehabilitation goals were met and the resident was medically stable. However, due to a recent elopement episode, the Interdisciplinary Team decided to transition Resident 1 to Facility 2's secured unit for safety reasons. Interviews with the Administrator and Director of Nursing revealed that the proper discharge process was not followed. The Administrator admitted to transferring Resident 1 directly to Facility 2 without following the discharge process or ensuring consent was obtained. The Director of Nursing confirmed the absence of a discharge summary and a physician's order, emphasizing the importance of these documents for ensuring coordinated care and safe transitions. The Medical Records department also noted that the wrong form was completed, further highlighting the lack of proper documentation and adherence to policy.
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What surveyors actually found near you
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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.
Illustrative
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Nursing homes near Pasadena
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Saint Vincent Healthcare | 0 mi | ★★★★★ | 15 | 0 |
| Golden Rose Care Center | 0.1 mi | ★★★★★ | 9 | 0 |
| Camellia Gardens Care Center | 0.1 mi | ★★★★★ | 18 | 0 |
| Cedar Pine Post Acute | 0.2 mi | ★★★★★ | 11 | 0 |
| Pasadena Nursing Center | 0.3 mi | ★★★★★ | 27 | 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.