Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Burbank Healthcare & Rehab during CMS and state inspections, most recent first.
Unsafe Resident Discharge Without Required Planning: A cognitively impaired resident with multiple medical diagnoses was discharged without a completed baseline discharge care plan, without an IDT meeting, and without documented discharge needs assessment or caregiver evaluation. The SSD notified the family member that coverage was ending but did not explain appeal rights, and the family member said the discharge process was not explained. The resident was discharged with dermatitis and multiple medications, while the DON stated discharge planning was not documented and the family member was not involved.
A cognitively impaired resident with metabolic encephalopathy, cerebral ischemia, AFib, MI, difficulty walking, and muscle weakness was admitted with personal clothing and shoes inventoried. At discharge, staff could not locate the resident’s clothes, and the family member took the resident home wearing a hospital gown with no shoes. The SSD searched for the missing items but did not find them, and the DON confirmed the resident left without her belongings.
Failure to complete an initial comprehensive assessment for a cognitively impaired resident with metabolic encephalopathy, cerebral ischemia, AFib, MI, difficulty walking, and muscle weakness. The MDS showed impaired daily decision-making and need for partial/moderate assistance with several ADLs, but the SSD and DON stated the baseline assessment was not done on admission and was only completed when the resident was being discharged; there was also no documentation that the caregiver was available or that the resident was assessed as safe to return home.
During a scabies outbreak, staff failed to follow infection control practices, including an RNA not changing gowns between two residents on contact isolation, a CNA entering a contact isolation room without PPE to deliver a meal tray while both the CNA and an LVN were unsure of the resident’s isolation status, and incomplete line listing of exposed residents by the IP. Additionally, housekeeping staff handled isolation trash and linens for residents with confirmed and suspected scabies without gloves, transported these items through common hallways, and deposited them via a chute used for regular laundry, resulting in mixing isolation linens with non-isolation linens instead of following the facility’s process for separate collection and hot-water laundering.
A resident with acute panmyelosis, MS, and PVD, who was dependent for all ADLs but cognitively intact and with decision-making capacity, had an Advance Health Care Directive and a DPOA naming a Resident Representative (RR) as attorney-in-fact. Facility records showed two documented changes in condition, including initiation of new medication for dermatitis and abnormal WBC and platelet counts, where only the resident was notified and there was no documentation that the RR was informed. During interview and record review, the DON acknowledged the RR was not notified and that staff were unaware of the POA, despite facility policies requiring notification of the resident representative for significant changes in condition and recognizing residents’ rights to appoint a legal representative.
A resident admitted with metabolic encephalopathy, pruritus, and a history of falls was placed on contact isolation to rule out scabies, and a skin scraping was ordered. Although the resident’s H&P documented decision-making capacity, the MDS later showed severely impaired cognitive skills and a need for moderate assistance with ADLs. Review of the record with the IP revealed there was no person-centered care plan addressing the ordered skin scraping or related care, despite facility policy requiring comprehensive care plans with measurable objectives and timeframes. The IP and DON both acknowledged that a care plan for the suspected scabies and skin scraping should have been developed to guide nursing staff actions.
A resident with metabolic encephalopathy, pruritus, and dermatitis had a physician order for clobetasol 0.05% cream to be applied to the general body twice daily for four weeks. Review of the Treatment Administration Record showed the evening application on one date was left blank. During interviews, the IP confirmed that a blank entry indicated the treatment was not given and that the nurse did not follow the order, and the DON acknowledged that Treatment Nurses are expected to administer clobetasol according to the physician’s orders. This was inconsistent with the facility’s medication administration policy requiring medications to be given safely, timely, and as prescribed.
A resident with dermatitis and other medical conditions had a physician order for contact isolation precautions every shift, but the MAR entry for one night shift was left blank, indicating the isolation was not documented as ongoing. During interviews, the IP confirmed the blank MAR entry reflected incomplete nursing documentation and a lack of documented evidence that contact isolation was in place, and the DON acknowledged that missing documentation of isolation could lead to spread of scabies. This failure did not comply with the facility’s charting and documentation policy requiring complete and accurate medical records.
A resident with cellulitis and multiple comorbidities was ordered cephalexin and clindamycin four times daily for seven days, but the facility failed to start the 9 p.m. doses on the first day and did not administer the final scheduled doses, resulting in an incomplete antibiotic course. Nursing documentation cited unavailability of the medications, even though both antibiotics were stocked in the facility’s oral e-kit. Review of the MAR, progress notes, and interviews with the IP and DON confirmed that the antibiotics were neither initiated within the required time frame nor extended to fulfill the full ordered duration, contrary to the facility’s medication administration and antibiotic stewardship policies.
A resident with intact decision-making capacity and complex medical conditions was readmitted from a hospital where scabies had been treated with permethrin. On readmission, staff obtained orders for weekly ivermectin and permethrin for four weeks, documented for unspecified dermatitis, and continued administering these medications even after a skin scraping for scabies was negative. Facility records, including the MAR and TAR, showed multiple administrations of both drugs, while interviews with the IP and DON confirmed there was no clear indication for scabies and acknowledged that these medications are scabies treatments that may have been unnecessary under the facility’s own policy on unnecessary drugs.
A resident with multiple chronic conditions, including MS and peripheral vascular disease, was started on clindamycin for leg cellulitis. The MAR shows the antibiotic was administered, and the care plan called for assessment of adverse reactions and side effects with physician notification as needed. However, review of the MAR and Progress Notes revealed no documented monitoring for adverse effects after the dose, despite facility policies on antibiotic stewardship and adverse consequence monitoring. The IP and DON confirmed that residents on antibiotics are expected to be monitored and that such monitoring should be documented.
The facility failed to revise comprehensive care plans for two residents following significant changes in condition and hospital readmissions. One resident, with intact cognition and multiple medical diagnoses, was sent to a GACH for altered level of consciousness and diagnosed with opioid intoxication, then readmitted without the care plan being updated to address this new diagnosis. Another resident, also cognitively intact and requiring moderate ADL assistance, expressed homicidal ideation toward another resident, was transferred for psychiatric evaluation, and later readmitted without the care plan being revised to reflect the psychiatric event or related goals and interventions. The DON and ADON acknowledged during record reviews that the care plans did not reflect these changes, despite facility policy requiring care plan updates after significant changes and hospital readmissions.
A resident with severe cognitive impairment and multiple medical conditions was found lying in a bed positioned with one side against the wall, which staff identified as a form of physical restraint. LVNs and the ADON acknowledged that using the bed in this way required an assessment, MD order, consent from the resident’s representative, and a care plan, but none of these were present. Review of the facility’s restraint policy showed that using equipment to prevent mobility is considered a restraint and must follow specific procedures, which were not followed in this case.
Staff failed to follow the facility’s hand hygiene policy after providing ADLs and incontinent care to a resident with dementia, generalized muscle weakness, and difficulty walking. Two CNAs provided perineal and incontinent care, dressing, and preparation for activities while wearing gloves, then removed and discarded their gloves at the doorway and did not perform hand hygiene with soap and water or ABHR before moving on to other tasks. Both CNAs later acknowledged they did not perform hand hygiene despite knowing it is required before and after resident contact, and the facility’s IP and Administrator confirmed that hand hygiene is required after direct care and glove removal per facility policy.
Improper Feeding Assistance and Lack of Dignity During Meals: CNAs were observed standing while feeding three residents who required assistance with meals. The residents had diagnoses including dementia, Alzheimer’s disease, anxiety disorder, encephalopathy, and dysphagia, and their care plans called for adequate nutrition and respect for their rights. During meal observations, CNAs placed food into residents’ mouths and continued feeding while standing, despite stating they knew they were supposed to sit. The DSD and DON stated feeding should be provided at eye level to maintain dignity, and the facility’s meal assistance and resident rights policies required residents to be fed with attention to safety, comfort, and dignity.
A resident with dementia, polyneuropathy, and CKD had medications kept at the bedside, including OTC eye drops, nasal spray, topical cream, and a cup with ointment and a used applicator. Staff observed the medications in the room over multiple days, but no documented self-administration assessment or physician notification was completed, despite the resident’s record showing she was unsafe for self-administration and needed LVN assistance. Staff also stated the medications should not have been left unattended at the bedside.
A facility used pillows tucked under fitted sheets and a rolled towel as restraints for one resident, placed a bed against the wall and continued a pad alarm despite another resident’s refusal, and used a pad alarm for two other residents without the required assessment and, for one resident, without an order or consent. Staff and the DON stated these practices restricted movement and that the devices or positioning methods were considered restraints.
A facility failed to ensure PASRR Level I screenings were accurate and updated for three residents with mental health or ID-related diagnoses. One resident had mild ID, bipolar disorder, depression, and Alzheimer’s disease, another had anxiety disorder and psychosis, and a third returned with schizoaffective disorder, bipolar type, psychosis, and mood disorder. In each case, the existing PASRR did not match the resident’s record or was not recent, and the DON stated new Level I screenings should have been completed when discrepancies or new mental disorder diagnoses were identified.
Missing Care Plans for Significant Medications and Pain Management: The facility failed to develop and implement person-centered care plans for a resident on Divalproex sodium and enoxaparin, another resident on heparin, a resident with arthritis-related pain, and a resident treated with levofloxacin for UTI. RNs, the IP, and the DON stated these orders required care planning to guide staff, monitor for adverse effects, and support continuity of care, but the records showed no corresponding baseline or comprehensive CPs.
Unsafe environment and failure to maintain ordered fall-prevention measures: Multiple residents with fall risk had furniture or equipment placed on top of floor mats, several residents had medications or ointments left at the bedside despite being ineligible for self-administration, and some alarm and bed safety devices were not properly set up or functioning. The report also notes a fall-related event where an LPN did not follow facility P&P when a resident moved from the bed to the fall mat.
Nebulizer and oxygen tubing were not maintained according to facility policy for three residents. One resident’s NC tubing was observed touching the floor, and two residents had nebulizer masks, tubing, and mouthpieces kept in dated plastic bags beyond the weekly change interval. The DON, RNs, and LVN stated the equipment should be changed weekly, and the facility’s nebulizer P&P required equipment and tubing changes every seven days or per protocol.
A resident with COPD and glaucoma missed ordered Trelegy and brimonidine during medication administration because Trelegy was not available in the facility and the eye drops were not prepared. Record review showed the Trelegy supply had not been reordered or followed up after the last pharmacy delivery, leaving the resident without medication after the initial supply was used. The facility also failed to reconcile multiple eKITs containing CSs and document shift-change counts on the controlled medication accountability log in two medication rooms, despite staff stating these kits should be counted and recorded each shift.
Medication error rate exceeded the 5% threshold after 3 errors were found in 32 opportunities. An LPN failed to administer ordered brimonidine eye drops and Trelegy inhalation to one resident with glaucoma and COPD, and failed to administer Systane eye drops to another resident with glaucoma. The MAR was also documented as if the missed medications had been given.
A resident prescribed Trelegy for COPD did not receive the inhaler as ordered because it was unavailable, and the MAR still showed it as administered. Another resident’s levofloxacin for UTI was not given as ordered. Two residents receiving heparin and one resident receiving insulin also had injection sites that were not rotated as ordered, and staff acknowledged these were medication errors.
Medication storage and labeling practices were found out of compliance in several medication areas. An open Aplisol vial for facility stock was left in the refrigerator without a date opened, a resident’s lorazepam oral concentrate was stored at room temperature instead of refrigerated, a resident’s Trelegy inhaler was not dated when opened, and heparin IV solution was stored in the same bin as oral meds. Staff and the DON acknowledged the storage and labeling issues, and facility policy and manufacturer guidance required dating multi-dose products, refrigerating lorazepam oral concentrate, and separating IV meds from oral meds.
Food storage and prep practices were not maintained when an opened container of hotdogs was found past its best-by date, 6 salad plates in the fridge had no prep date label, and 10 bowls of ice cream in the freezer were also unlabeled. The DSA and DSS stated prepared foods must be dated and labeled, and the facility policy required all food items to be properly covered, dated, and labeled, with no expired items kept in stock.
False MAR Documentation for Unavailable COPD Medication: An LVN documented Trelegy as given to a resident with COPD even though the inhaler was not available in the cart or facility and was not administered. Multiple LVNs acknowledged checking off the MAR for doses that were not actually given, and the DON stated the facility had not received the medication from the pharmacy after the initial supply ran out, leaving the MAR inaccurate for repeated doses.
Infection prevention and control practices were not maintained when a resident’s bed remote was found inside the trash can and was not sanitized before being returned for use. The resident had muscle weakness, difficulty walking, a history of traumatic fracture, and moderate cognitive impairment. The facility also stored clean linens on mobile carts covered with loosely woven, permeable mesh material, and the IP, HKS, and MS stated the covers did not protect the linens from environmental contaminants.
Unsafe equipment maintenance and call light failure were observed when a walk-in freezer had ice build-up and a resident's call light was not properly connected to the wall panel. The freezer showed ice accumulation despite policy requiring freezers to be kept free of excessive ice or frost, and staff described the build-up as a recurring issue. A resident with COPD, DM, and paraplegia had a call light that did not activate until the cable was found not fully plugged in, and the DON stated the call light policy was not followed.
A resident with bipolar disorder, anxiety disorder, and severe cognitive impairment had an ICF for buspirone that listed 5 mg PO BID, while the physician’s order listed 5 mg PO daily. RN and DON interviews confirmed the consent did not match the order, and the DON stated the facility’s informed consent policy was not followed.
Call lights and a bed remote control were left out of reach for two residents. One resident with muscle weakness, difficulty walking, and moderate cognitive impairment had a bed remote found inside a trash can, while another resident with weakness, prior falls, pain medication use, and impaired decision-making had a call light resting on the floor. An LVN and the DON stated these items should be within easy reach, and the DON said the facility’s call light and safety policies were not followed.
Incomplete Advance Directive Acknowledgement Form: A resident with a fractured femur, encephalopathy, and DM2 had an incomplete Advance Directive Acknowledgement Form that contained signatures only and no selections marked. The SSD and DON stated the form was not completed correctly, and the DON noted the resident lacked capacity to make decisions and that staff would not know what to follow in an emergency without an advance directive.
A resident with psychosis, dementia with behavioral disturbance, and mood disorder was given quetiapine for vague “agitation” and “inability to process internal stimuli” without specific, measurable behaviors being used in the order, care plan, or shift monitoring. An LVN and the DON stated agitation was not a specific behavior and that psychotropic use must be monitored for measurable behaviors to support effectiveness and GDR decisions; the DON said the facility policy was not followed.
A facility failed to timely transmit MDS assessments for two residents. One resident with bipolar disorder, anemia, and hyperlipidemia had a Quarterly MDS submitted late after it was missed, and another resident with UTI, COPD, and dysphagia had an admission MDS submitted after the required timeframe. The MDSC and DON stated the MDS contains information about diagnoses, functional abilities, and care needs, and that late submission can result in inaccurate data.
Inaccurate MDS Discharge Coding: A resident with cancer, malnutrition, and paraplegia was sent to the hospital for a blood transfusion and returned within 24 hours, but the MDS was submitted as a discharge with return anticipated. The MDSC and an LVN stated the resident had only gone out for the transfusion and that the discharge assessment was a data entry error. The DON said the MDS is used by the IDT to understand the resident’s clinical picture, and the report stated the inaccurate EHR status could delay care.
A resident with sacral and heel PI, severe cognitive impairment, and high Braden risk had a low air loss mattress ordered for pressure redistribution and wound care. Staff observed the mattress beeping with an orange low-pressure light and becoming softer while the resident appeared sunk into the bed, but it was not replaced promptly. An LVN reported the issue to maintenance and later followed up, and the DON stated the mattress should have been fixed immediately because it was not functioning properly.
Unlabeled and Improperly Stored Urinals: A resident’s urinal was observed hanging on the side of a trash can, and another resident’s urinal bottle was found unlabeled on a side table. Staff stated the urinals should have been kept on a holder to maintain cleanliness and labeled with resident identifiers and the date provided, and the DON confirmed the facility policy was not followed.
Failure to verify g-tube placement before bolus feeding. A resident with a g-tube, diagnoses including gastrostomy and severe protein-calorie malnutrition, had orders for Jevity 1.5 bolus feedings and tube placement checks. An LVN administered the feeding after stating she had checked placement earlier, while the RN and DON stated placement should be verified at the time of administration and that the facility’s enteral tube policies were not followed.
IV Site Not Labeled With Date and Initials: A resident receiving IV antibiotic therapy had a peripheral IV on the left hand that was observed without the date or initials of the nurse who inserted the line or changed the dressing. The resident had orders for peripheral site care, site checks every shift, and dressing changes as needed, and staff stated the IV site should be labeled to track insertion and dressing change timing.
Pain management was not provided consistently for two residents. One resident with chronic pain and severe cervical pain had a pain consult order, but the referral was not clearly completed and no pain referral was found before the later date noted in the record. Another resident with arthritis reported 9/10 pain in the legs and back, but an LVN gave scheduled acetaminophen without first assessing the pain level, did not offer nonpharmacologic measures, and documented the MAR pain score as 2/10 based on an assumption instead of the resident’s report.
A resident with ESRD, dependence on renal dialysis, hypertensive heart and chronic kidney disease, and DM received HD through an outside dialysis center. The facility used an HD Communication Record to exchange pre- and post-HD weights and other information, but the dialysis center did not complete the form on two occasions. An LVN completed the post-HD assessment and signed the forms but did not notice the missing dialysis-center documentation or follow up as required by facility procedure, and the DON stated the facility P&P was not followed.
A resident with acute kidney injury, bone disorder, and immunodeficiency missed an Oncology appointment because transportation was not arranged. The ANF was signed, but the social services section was left incomplete, including the transportation name and pick-up time. RN and DON stated the resident was not picked up for the appointment, and the Oncology specialist did not see the resident.
Failure to Provide Ordered Adaptive Feeding Equipment: A resident with impaired cognition, tremors, and an order for adaptive feeding equipment was observed at lunch without the ordered build-up weighted utensils, though the divided plate was present. RNA and LVN staff confirmed the utensils were missing from the tray, and the DON stated the facility’s adaptive equipment policy was not followed.
A facility failed to carry out its antibiotic stewardship monitoring for two residents. One resident receiving ertapenem had no documented monitoring for adverse effects in the care plan or progress notes, and staff confirmed the omission. Another resident prescribed linezolid for UTI did not receive the first dose within the facility’s 4-hour standard, and the progress notes did not specify monitoring for adverse side effects such as diarrhea, vomiting, headache, or nausea. The DON and IP stated the antibiotic monitoring and documentation were not done as expected.
Insufficient Bedroom Square Footage in Multiple Resident Rooms: The facility failed to provide at least 80 sq ft per resident in 41 of 72 rooms, with several multiple-occupancy rooms measuring below the required minimums listed in the facility’s waiver request. Surveyors observed that residents could move freely and that wheelchairs, walkers, and canes could be used in the rooms, while the DON stated rooms should have enough space between beds and that the waiver request was intended to address the square footage requirement. The facility policy stated bedrooms must meet federal and state requirements for minimum space per resident.
Kitchen staff failed to follow facility policies requiring daily calibration of food thermometers and routine monitoring and documentation of refrigerator and freezer temperatures. Logs reviewed with dietary leadership showed several days without recorded thermometer calibration and missing entries for multiple cold storage units on both morning and evening shifts. The DSS, ADS, and Administrator all acknowledged that without calibration and documented temperature checks, the accuracy of food temperature monitoring cannot be verified and food may spoil, creating a risk of foodborne illness for residents.
A resident with muscle weakness, prior falls, and a recent stroke was assessed as high fall risk and had physician orders and a care plan directing use of a low bed and floor mats to reduce injury. During observation, surveyors noted a fall-risk indicator at the bedside but no floor mats in place. The resident did not recall having a mat, and the IP, DSD, and Administrator each confirmed that floor mats were ordered, required per the care plan, and intended to prevent injury, yet were not present at the time of the survey, creating potential for injury or fracture if a fall occurred.
Staff failed to implement timely contact precautions and appropriate cohorting for a resident who developed diarrhea consistent with CDI and was later confirmed positive. Despite facility policy requiring contact precautions for suspected CDI and private room placement or cohorting only with low-risk roommates, the infected resident remained in a shared room with two roommates, including one who was immunocompromised and receiving chemotherapy. No infection risk assessments were completed for the roommates, they were not informed or educated about their potential CDI exposure or required precautions, and they were not monitored for CDI symptoms, even though an isolation cart and contact precaution signage were present outside the room.
A cognitively intact resident, admitted with muscle weakness and sepsis, reported that a family member visitor took his wallet, left the building, charged $500 to the resident’s credit card, and then returned the wallet. The resident stated he informed the SW of the incident, and the SW confirmed receiving this report. The Administrator acknowledged being aware that the resident had reported the alleged misappropriation but did not report the allegation to the SSA, despite a facility policy requiring immediate reporting of suspected theft or misappropriation of resident property to state authorities within two hours.
Surveyors found that the facility did not develop or implement a comprehensive, person-centered care plan for an immunocompromised resident with diffuse large B-cell lymphoma, undergoing antineoplastic chemotherapy and with an acquired absence of a kidney. Although the resident’s MDS showed intact cognition and a need for substantial/maximal assistance with ADLs such as toileting hygiene, bathing, lower body dressing, and footwear, staff did not initiate a care plan addressing the resident’s high infection risk. The DON confirmed that neither licensed staff nor the MDS Coordinator created a care plan to address the resident’s immunocompromised status, including the need to avoid cohorting with residents who had active infections, contrary to the facility’s policy requiring comprehensive care plans with measurable objectives and timetables based on a thorough assessment.
Unsafe Resident Discharge Without Required Planning
Penalty
Summary
The facility failed to ensure a safe discharge for a cognitively impaired resident who was admitted with diagnoses including metabolic encephalopathy, cerebral ischemia, paroxysmal atrial fibrillation, myocardial infarction, difficulty walking, and muscle weakness. The resident’s MDS dated 4/24/2026 indicated impaired cognitive skills for daily decision making and the need for partial/moderate assistance with toileting hygiene, bathing, and dressing. The baseline care plan form dated 4/22/2026 was blank, indicating the discharge baseline care plan was not completed. The record showed the resident was discharged with generalized body dermatitis with excoriation and was sent home with medications including metoprolol tartrate, ivermectin, amiodarone, apixaban, and hydroxyzine. The self-administration of medication form indicated the resident could not administer medications to self. The IDT record indicated no meeting was done regarding the resident’s discharge, and the DON stated there was no documentation of discharge planning, no evidence that the caregiver was assessed for ability to care for the resident at home, and no documented evidence that discharge back to the community was feasible. The resident’s family member stated the SSD called to say the resident’s insurance would not continue paying and asked him to pick the resident up, but the discharge process and appeal rights were not explained. The SSD stated he informed the family member of the Notice of Medicare Non-coverage but did not explain the appeal process because the family member did not object to discharge. The DON stated the facility did not follow its discharge process, the family member was not involved in discharge planning, and there was no evidence of an IDT meeting or assessment of discharge goals before the resident was discharged.
Lost Resident Clothing at Discharge
Penalty
Summary
The facility failed to ensure the personal clothing and shoes of a cognitively impaired resident were not lost. The resident was admitted with diagnoses including metabolic encephalopathy, cerebral ischemia, paroxysmal atrial fibrillation, myocardial infarction, difficulty walking, and muscle weakness. The admission inventory listed one jacket, two socks, one sweatpants, and one pair of shoes. The resident’s MDS showed impaired cognitive skills for daily decision making and the need for partial/moderate assistance with toileting hygiene, showering, and upper and lower body dressing. On discharge, staff could not find the resident’s clothes, and the family member took the resident home wearing a hospital gown with no shoes. The family member stated the resident was missing all personal clothing items listed on admission and reported that the SSD said he could not find them. The SSD stated he searched for the missing clothing in the facility but did not find it and acknowledged it was inappropriate for the resident to go home in a hospital gown. The DON also confirmed the resident did not have her belongings at discharge and went home without dignity.
Failure to Complete Initial Comprehensive Assessment Before Discharge
Penalty
Summary
The facility failed to conduct a baseline initial comprehensive assessment for functional capacity for one cognitively impaired resident who was admitted with diagnoses including metabolic encephalopathy, cerebral ischemia, paroxysmal atrial fibrillation, myocardial infarction, difficulty walking, and muscle weakness. The resident's MDS, dated 4/24/2026, indicated impaired cognitive skills for daily decision making and the need for partial/moderate assistance with toileting hygiene, showering/bathing, upper body dressing, and lower body dressing. During interview and record review, the Social Services Director stated the resident was admitted on a short-term basis but no initial comprehensive assessment was completed on admission, and the assessment was not completed until the resident was being discharged on 5/1/2026. The SSD stated there was no documentation that the caregiver was available to care for the resident at home and no assessment was done to determine whether the resident was safe to return home. The DON also stated there was no initial comprehensive assessment and that the discharge process starts upon admission, but it was not done for this resident.
Failure to Implement Infection Control Practices During Scabies Outbreak
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program during a scabies outbreak, particularly in the use of contact isolation and handling of contaminated materials for multiple residents. For two residents on contact isolation for dermatitis and suspected scabies, a Restorative Nursing Assistant entered their shared room wearing PPE, assisted one resident to the restroom, then changed only gloves and continued providing care to the other resident while wearing the same gown. The assistant then returned to the first resident without removing gloves or gown. The RNA later acknowledged that both residents were on contact isolation and that both gown and gloves should have been changed between residents to prevent spread of scabies. The DON stated that staff should don gowns and gloves before entering contact isolation rooms and change both between residents. The facility also failed to ensure proper PPE use and staff awareness of isolation status for another resident on contact isolation for unspecified dermatitis. A CNA delivered and set up a breakfast tray for this resident without wearing PPE, then returned to set up a tray for the roommate. The resident’s orders showed contact isolation precautions for four weeks, but an LVN stated the resident was not on contact isolation and instead on Enhanced Barrier Precautions for a wound, and admitted not being sure which residents were on EBP versus contact isolation. The CNA similarly stated she was unsure whether PPE was required when delivering food trays to residents on contact isolation and did not know whether this resident was on contact isolation or EBP, noting she had only worked at the facility for two months and did not know why residents were placed on these precautions. The DON stated that staff should know which residents are on contact isolation versus EBP and should wear proper PPE when delivering food trays and providing care to residents on contact isolation. The Infection Preventionist’s resident line listing for the scabies outbreak was incomplete and did not include two residents who had been roommates of a suspected scabies case. The IP acknowledged that these two residents had been exposed to scabies, were treated, and should have been added to the line list for ongoing monitoring. The DON stated that these residents should have been included on the line list because they were roommates of a suspected scabies resident and that including all affected residents is important so the facility can monitor them for signs and symptoms and notify the physician. The ACDC Scabies Prevention and Control Guidelines reviewed by surveyors indicated that a line listing of symptomatic residents and their contacts should be prepared. The facility also failed to follow its own procedures and external guidelines for handling isolation trash and linens for residents with confirmed or suspected scabies. For a resident with confirmed scabies and another resident on contact isolation to rule out scabies, contact isolation signage and isolation carts were present at the doorways, and trash and soiled linen carts were inside the rooms. A housekeeping staff member, without wearing gloves, removed the isolation trash and soiled linen carts from each room, pushed them along the hallway, tied the clear plastic bags containing isolation trash and linens, and dropped them at a parachute door leading to the laundry room, then returned the empty carts to the rooms. In the soiled laundry room, tied clear bags of soiled linens were observed on top of a large yellow container, and the housekeeping staff member stated he was not sure which bags contained isolation linens. A laundry staff member stated that all linens currently in the soiled laundry room were from non-isolation rooms and that isolation linens were supposed to be collected separately and washed in a dedicated washer and dryer. The laundry supervisor described the facility’s intended process for isolation linens and trash: bringing a cart designated only for isolation to the room doorway, donning gloves and gown, tying and double-bagging trash and soiled linens inside the isolation room, placing them in the cart in the hallway, and transporting them outside the facility so they would not mix with non-isolation linens. The supervisor stated that because the housekeeping staff dropped off isolation linens through the parachute drop-off, they became mixed with regular non-isolation linens, which could contaminate other linens and cause spread of infection. The Infection Preventionist stated that contact isolation rooms had red hampers for trash and soiled linens and that the parachute laundry door was intended for regular soiled linens, not isolation linens, and that mixing laundry with isolation linens could potentially spread scabies to other residents, staff, and visitors. The facility’s scabies policy and the ACDC guidelines reviewed by surveyors specified that linens, towels, and clothing used by affected persons should be bagged inside the resident’s room, handled by gloved and gowned staff without sorting, and laundered in hot water and dried on a hot cycle.
Failure to Notify Resident Representative Holding POA of Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s designated Resident Representative (RR), who also held Durable Power of Attorney (DPOA), of changes in the resident’s condition on two occasions. The resident, admitted in 2014, had diagnoses including acute panmyelosis, multiple sclerosis, and peripheral vascular disease, and was dependent on staff for all ADLs. An Advance Health Care Directive Acknowledgement Form dated 5/14/2024 identified the RR as the resident’s representative, and a DPOA dated and notarized 7/23/2014 appointed the same RR as attorney-in-fact, effective that date. The resident’s MDS dated 3/19/2026 documented intact cognitive skills for daily decisions, and a History and Physical dated 3/26/2026 indicated the resident had capacity to understand and make decisions. On 3/16/2026, a Change of Condition (COC) form documented that the resident had a new medication for dermatitis and that the resident was notified, but there was no indication that the RR was notified. On 3/18/2026, another COC documented elevated WBC and platelet counts, again indicating only that the resident was notified, with no documentation of RR notification. During concurrent interview and record review on 4/24/2026, the DON confirmed that the COCs from 3/16/2026 and 3/18/2026 did not show RR notification and stated the facility was not aware that the resident had appointed the RR as POA, acknowledging this may have violated the resident’s and RR’s right to be informed. In an interview the same day, the resident and RR confirmed that the resident had an Advance Health Care Directive naming the RR. Facility policies on Resident Rights and Change in a Resident’s Condition or Status required that residents be allowed to appoint a legal representative and that the resident representative be promptly notified of changes in the resident’s condition unless otherwise instructed by the resident, which did not occur in this case.
Failure to Care Plan for Skin Scraping to Rule Out Scabies
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for a resident related to a skin scraping ordered to rule out scabies. The resident was admitted with diagnoses including metabolic encephalopathy, unspecified pruritus, and a history of falls. An H&P documented that the resident had the capacity to understand and make decisions, while a subsequent MDS assessment indicated severely impaired cognitive skills for daily decisions and a need for moderate assistance with ADLs. A change of condition note documented that the resident was placed on contact isolation to rule out scabies, and an order summary showed that a skin scraping was ordered. During an interview and concurrent record review, the Infection Preventionist confirmed that there was no care plan developed for the resident’s skin scraping to test for scabies and stated that the care plan serves as a guide for nurses on what to do when the skin scraping results. The DON also stated that a care plan for skin scraping for scabies should have been developed and that without a care plan, nurses would not have a guide on what to do for a suspected scabies resident. The facility’s policy on Comprehensive Person-Centered Care Plans required a comprehensive, person-centered care plan with measurable objectives, timeframes, and services to meet residents’ needs, reflecting recognized standards of practice, which was not followed in this case.
Failure to Administer Ordered Topical Medication as Prescribed
Penalty
Summary
Surveyors identified a deficiency in the facility’s pharmaceutical services related to the administration of a prescribed topical medication for one resident. The resident was admitted with diagnoses including metabolic encephalopathy, unspecified pruritus, and a history of falls. A History and Physical dated 4/20/2026 documented that the resident had the capacity to understand and make decisions, while an MDS dated 4/24/2026 later indicated severely impaired cognitive skills for daily decisions and a need for moderate assistance with ADLs. A physician’s order dated 4/22/2026 directed that clobetasol propionate 0.05% cream be applied to the resident’s general body topically every day and evening for four weeks for unspecified dermatitis. Review of the Treatment Administration Record for April 2026 showed that the clobetasol application for the evening shift on 4/23/2026 was left blank. During a concurrent interview and record review with the Infection Preventionist on 4/24/2026, the IP confirmed that the physician had ordered clobetasol twice daily and stated that a blank entry on the TAR meant the medication was not given and that the nurse did not follow the order. In a separate interview, the DON stated that the resident’s rashes could worsen because the clobetasol was not administered and that Treatment Nurses were expected to apply clobetasol according to the physician’s order. The facility’s “Administering Medications” policy, last reviewed on 2/20/2026, stated that medications are to be administered in a safe and timely manner and in accordance with prescriber orders, including required time frames, which was not followed in this instance.
Failure to Accurately Document Ordered Contact Isolation Precautions
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for one of three sampled residents by not documenting ordered contact isolation precautions on a specific night shift. The resident had been admitted with diagnoses including unspecified emphysema, unspecified dermatitis, and a history of falls. A History and Physical dated 12/5/2025 indicated the resident did not have the capacity to understand and make decisions, while a Minimum Data Set dated 4/2/2026 documented intact cognitive skills for daily decisions. An Order Summary Report dated 4/22/2026 showed a physician order for contact isolation precautions every shift for four weeks due to unspecified dermatitis. However, review of the Medication Administration Record (MAR) for April 2026 revealed that the contact isolation entry for the night shift on 4/22/2026 was left blank. During a concurrent interview and record review with the Infection Preventionist on 4/24/2026, it was confirmed that the MAR entry for contact isolation on 4/22/2026 night shift was blank, which the Infection Preventionist stated meant contact isolation was not documented as ongoing and that the nurses did not complete their documentation task. The Infection Preventionist stated there was no documented evidence that the resident was on contact isolation during that shift and that this could cause confusion in care. In a separate interview, the DON stated that without documentation of contact isolation, it could cause spread of scabies to other residents and staff. Review of the facility’s Charting and Documentation policy, last reviewed on 2/20/2026, indicated that documentation in the medical record must be objective, complete, and accurate, which was not met in this instance.
Failure to Timely Initiate and Complete Ordered Antibiotic Therapy
Penalty
Summary
The facility failed to provide pharmaceutical services by not ensuring timely administration of prescribed antibiotics for a resident with right lower leg cellulitis. The resident was admitted with diagnoses including unspecified multiple sclerosis, acute panmyelosis, and unspecified peripheral vascular disease, and had intact cognitive skills and capacity to make decisions. Physician orders dated 3/14/2026 directed that cephalexin 500 mg and clindamycin 150 mg be given orally four times a day for seven days to treat the cellulitis. The resident was readmitted from a general acute care hospital on the evening of 3/14/2026, but the Medication Administration Record for March 2026 showed that the 9 p.m. doses of both cephalexin and clindamycin were not started as ordered. Progress notes entered on 3/14/2026 at 9:42 p.m. and 9:43 p.m. documented that cephalexin and clindamycin were not available. However, review of the facility’s oral emergency drug supply showed that the e-kit contained cephalexin 250 mg tablets and clindamycin 150 mg capsules at that time. During interviews, the Infection Preventionist and the DON confirmed that the antibiotics were not started on 3/14/2026 and acknowledged that these medications should have been available in the e-kit and started that evening. The facility’s policy on administering medications required that medications be administered in a safe and timely manner, in accordance with prescriber orders and within one hour of the prescribed time. Further review of the resident’s March 2026 MAR showed that cephalexin and clindamycin were also not administered at 9 p.m. on 3/21/2026, resulting in the seven-day antibiotic course not being completed as ordered. The Infection Preventionist stated that because the antibiotics were not started on time on 3/14/2026, the nurses should have extended the medications to complete the full seven days of therapy, and that one dose of each antibiotic was missed, causing an incomplete course of treatment. The DON similarly stated that if the antibiotics were not started as scheduled, they should have been extended to complete the ordered dose. The facility’s antibiotic stewardship policy required that antibiotics be prescribed and administered with complete orders including duration of treatment, and outlined procedures for nurses to follow when removing antibiotics from the emergency supply, including verifying the correct drug and strength and completing pharmacy removal slips.
Unnecessary Scabies Treatment Continued After Negative Diagnostic Test
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s drug regimen was free from unnecessary medications. The resident was admitted with multiple serious diagnoses, including unspecified multiple sclerosis, acute panmyelosis, and unspecified peripheral vascular disease, and had intact cognitive skills and capacity to make decisions. Hospital records from a recent GACH stay documented scabies as an active problem and treatment with topical permethrin, with infectious disease notes indicating suspected chronic scabies and treatment provided. Upon readmission, the facility obtained orders dated 3/16/2026 for a skin scraping, oral ivermectin weekly for four weeks, and topical permethrin weekly for four weeks, with the indication documented as unspecified dermatitis. The facility’s own documentation showed that a skin scraping for scabies performed on 3/24/2026 was negative. Despite this negative laboratory result, the MAR and TAR indicated the resident continued to receive ivermectin and permethrin on multiple subsequent dates in March and April. The Skin Rash Report referenced the prior hospitalization and scabies treatment, but there was no documentation of confirmed scabies in the facility. The facility’s scabies policy stated that diagnosis may be made by signs and symptoms and that treatment is often followed without scraping, but also noted that ivermectin by mouth should be considered during widespread outbreaks or when topical treatment is unsuccessful, and that a single permethrin treatment is generally adequate. During interviews, the family member reported that the resident had been treated for scabies in the hospital and that, upon return, the facility denied the resident had scabies yet continued scabies treatment. The Infection Preventionist stated that the hospital had treated scabies with permethrin and that, on readmission, permethrin and ivermectin were ordered for unspecified dermatitis, acknowledging these medications are treatments for scabies and that the resident could have received unnecessary medication. The IP indicated that Treatment Nurse 1 obtained the orders from the primary physician for unspecified dermatitis. The DON confirmed the resident was medicated with permethrin and ivermectin without a clear indication for scabies, noted the negative skin scraping, and stated that ivermectin is a treatment for scabies and could be unnecessary medication in this case. The facility’s policy on adverse consequences and unnecessary medications defined an unnecessary drug as one used without adequate indication, which was not met for this resident’s continued treatment.
Failure to Monitor and Document Adverse Effects for Resident on Clindamycin
Penalty
Summary
The deficiency involves the facility’s failure to implement its antibiotic stewardship and adverse consequence monitoring policies for a resident who was prescribed clindamycin for right upper and lower leg cellulitis. The resident, admitted with diagnoses including unspecified multiple sclerosis, acute panmyelosis, and unspecified peripheral vascular disease, had documented capacity to understand and make decisions and was dependent on staff for all ADLs. On 3/8/2026, a physician order directed administration of a single 150 mg oral dose of clindamycin from the emergency kit, and the MAR shows the dose was given at 10:26 p.m. The resident’s care plan for antibiotic therapy, initiated on 3/9/2026, included an intervention to assess for signs and symptoms of adverse reactions or side effects and to notify the physician. During interviews and record review, the Infection Preventionist and the DON both stated that residents on antibiotics should be monitored for side effects or adverse effects and that such monitoring should be documented in the resident’s Progress Notes or MAR. Review of the resident’s Progress Notes and MAR for 3/8/2026 showed no documented monitoring for side effects or adverse effects of clindamycin following administration. This lack of documentation and monitoring occurred despite facility policies on Antibiotic Stewardship and on Adverse Consequences, Medication Errors and Unnecessary Medications, which state that antibiotics will be prescribed and administered under the guidance of the antibiotic stewardship program and that residents receiving medications with potential for adverse consequences will be monitored to ensure such consequences are promptly identified and reported, including monitoring mental status and level of consciousness.
Failure to Revise Care Plans After Hospitalization and Significant Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to revise comprehensive, person-centered care plans after significant changes in condition and hospital readmissions for two residents. For Resident 1, the admission record showed an original admission on 12/1/2025 and a later readmission with diagnoses including encephalopathy, acute kidney failure, and type 2 diabetes mellitus. An MDS dated 2/27/2026 documented intact cognitive functioning and a need for substantial assistance with personal hygiene and transfers, and moderate assistance with oral hygiene and dressing. A History and Physical dated 3/20/2026 indicated Resident 1 had the capacity to understand and make decisions. On 3/15/2026, a Change of Condition form documented that Resident 1 was transferred to a general acute care hospital (GACH) for evaluation due to altered level of consciousness. The GACH H&P dated 3/18/2026 indicated a diagnosis of opioid intoxication, with a urine drug screen positive for fentanyl. A facility Progress Note dated 3/18/2026 at 5:55 p.m. documented that Resident 1 was readmitted from the GACH. During an interview and concurrent record review on 4/8/2026, the DON confirmed that Resident 1’s care plan did not address the new diagnosis of opioid intoxication and stated that the admitting nurse should have reviewed the GACH records and revised the care plan to update the plan of care with necessary interventions and monitoring. For Resident 2, the admission record showed an original admission on 3/5/2013 and a later readmission with diagnoses including hemiplegia, epilepsy, and depression. An H&P dated 3/26/2026 indicated Resident 2 had the capacity to understand and make decisions, and an MDS documented intact cognitive functioning and a need for moderate assistance with oral hygiene, toileting hygiene, personal hygiene, and dressing. A Change of Condition form dated 3/11/2026 recorded that Resident 2 verbalized wanting to kill another resident at 10 a.m. A Progress Note dated 3/12/2026 documented transfer to the GACH for psychiatric evaluation, and a Progress Note dated 3/24/2026 at 2 p.m. documented readmission to the facility. During an interview and concurrent record review on 4/7/2026, the ADON stated that Resident 2’s care plan did not address the change of condition and hospital transfer for psychiatric evaluation and that the care plan should have been updated with goals and interventions. The facility’s policy on comprehensive person-centered care plans required the interdisciplinary team to review and update the care plan when there is a significant change in condition and when a resident is readmitted from a hospital stay.
Failure to Assess and Authorize Use of Bed as Physical Restraint
Penalty
Summary
Surveyors identified a deficiency related to the use of physical restraints when a resident’s bed was placed with one side against the wall without appropriate assessment, orders, or care planning. The resident had been admitted with diagnoses including unspecified dementia, age-related osteoporosis, and hypotension, and an MDS dated 1/23/2026 documented severely impaired cognitive skills for daily decision-making and a need for moderate assistance with rolling in bed. During observation, the resident was seen lying in bed with the right side of the bed against the wall. An LVN present during the observation stated that placing a bed against the wall is considered a form of restraint, which requires a physician order, signed consent, and a care plan, none of which were in place for this resident. Further record review and interviews confirmed that there was no physician order, no consent from the resident’s representative, and no care plan addressing the bed being placed against the wall. Another LVN verified that the bed’s position could limit the resident’s movement and acknowledged the absence of documentation supporting its use. The ADON stated that licensed nurses should assess the need for the bed to be against the wall and that such use should be supported by a physician order, consent, and a care plan, and acknowledged that this had not been done. The facility’s restraint policy defined practices that inappropriately utilize equipment to prevent resident mobility as restraints and required assessment, physician order, consent, and care plan, including measures to reduce or eliminate restraint use, none of which were followed in this case.
Failure to Perform Hand Hygiene After Providing ADLs and Incontinent Care
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to hand hygiene practices by CNAs following provision of ADLs. Resident 4, who had diagnoses including generalized muscle weakness, difficulty walking, and dementia, had documented self-care deficits and required assistance with ADLs, including incontinent care. The resident’s MDS indicated dependence for showering, substantial assistance with toileting, partial assistance with oral hygiene and dressing, and supervision with eating. During an observation, CNA 2 was seen at the doorway of the resident’s room wearing gloves after providing care, then removing and discarding the gloves in a trash receptacle near the doorway without performing hand hygiene with soap and water or alcohol-based hand rub (ABHR). Shortly afterward, CNA 1 was observed removing and discarding gloves in the same manner and then proceeding to a table to document, again without performing hand hygiene. In subsequent interviews, CNA 1 stated she had provided incontinent care and assisted the resident to activities, acknowledged she removed her gloves upon exiting the room, and confirmed she did not perform hand hygiene using ABHR, despite stating that hand hygiene should be performed after resident care due to the risk of contamination. CNA 2 reported she had provided perineal care with warm water and mild soap, assisted with dressing, and prepared the resident for activities, and confirmed she did not perform hand hygiene after providing care, while acknowledging that hand hygiene should be performed before and after resident contact. The Infection Preventionist stated staff are required to perform hand hygiene before entering and after exiting resident rooms and after providing direct care, and that CNA 1 and CNA 2 should have performed hand hygiene after removing gloves. The Administrator stated hand hygiene is required before and after resident care and after resident contact. Review of the facility’s Handwashing/Hand Hygiene policy showed that all personnel are required to perform hand hygiene before and after direct resident contact, after contact with bodily fluids, after removing gloves, and as the final step after removal of PPE, and that glove use does not replace the requirement for hand hygiene.
Improper Feeding Assistance and Lack of Dignity During Meals
Penalty
Summary
The facility failed to ensure residents were treated with respect and dignity during feeding assistance when CNAs stood while feeding three residents who required help with meals. Resident 18 was admitted with dementia, diabetes mellitus, and unspecified severe protein-calorie malnutrition. The MDS indicated the resident sometimes understood others and sometimes could make himself understood, and that he required substantial to maximal assistance with eating and other ADLs. During a dining observation, CNA 2 stood next to Resident 18 and placed food into the resident’s mouth while continuing to assist with eating and drinking. CNA 2 later stated she knew she was supposed to sit while providing feeding assistance but did not do so because it was not comfortable. Resident 107 was admitted with Alzheimer’s disease, anxiety disorder, and dementia with behavioral disturbances. The MDS indicated the resident usually understood others and sometimes could make herself understood, and that she was dependent on staff for eating and other ADLs. During a dining observation, CNA 2 stood next to Resident 107 and fed the resident while continuing to assist with eating and drinking. CNA 2 stated she did not sit because she did not like to sit, but she knew she should sit while providing feeding assistance. She then retrieved a chair and sat down to continue feeding assistance. Resident 67 was originally admitted in 2016 and most recently readmitted with diagnoses including dementia, encephalopathy, and dysphagia. The MDS indicated the resident usually understood others, could make herself understood, and required partial to moderate assistance with eating and other care. During a breakfast observation, CNA 5 stood next to Resident 67 and fed the resident while continuing to assist with eating and drinking. The DSD observed this and stated CNA 5 should not have been standing while assisting with feeding, and that CNAs must sit at eye level to show respect and avoid making residents feel rushed. The DON stated CNAs should provide feeding assistance at eye level and that standing over residents was not consistent with the facility’s meal assistance and resident rights policies.
Medication Self-Administration Not Assessed or Authorized
Penalty
Summary
The facility failed to ensure resident medication self-administration was clinically appropriate and failed to honor a resident’s right to self-administer medications when staff knew the resident kept medications at the bedside but did not complete a medication self-administration assessment or notify the physician. Resident 55 had diagnoses including dementia, polyneuropathy, and chronic kidney disease stage three. The resident’s history and physical stated the resident had the capacity to understand and make decisions, and the minimum data set indicated the resident could understand others and make herself understood. Resident 55’s record included a self-administration of medication form dated 12/4/2024 stating the resident was unsafe for self-administration and required additional assistance by LVNs. The record also included physician orders for hydrocortisone cream for red spots on the forearms and neck, along with care plans addressing skin breakdown risk, eye infection risk, and potential pain or discomfort. During observation, the resident was found in bed with a clear plastic medication cup containing white ointment and a used applicator on the nightstand, and an open box on the bedside rolling table containing tetrahydrozoline ophthalmic eye drops, fluticasone nasal spray, and trolamine salicylate topical cream. The resident stated the medications in the box belonged to her. Staff interviews confirmed the medications had been left at the bedside and that the issue had not been properly addressed. A CNA stated it was okay to leave the medication and applicator on the nightstand. A treatment nurse stated used applicators and medication cups should not be left on the nightstand and said she would follow up. Later observation showed the ointment and applicator were removed, but the eye drops, nasal spray, and topical cream remained at the bedside. An LVN stated medications had been seen on and off over the prior three weeks on the bedside table and that the resident’s son left them there, but the LVN did not notify the physician. The ADON and DON both stated residents have a right to request self-administration, but an assessment and physician notification were required, and there was no documented evidence that an assessment was completed or that the physician was notified.
Unapproved restraint use and missing assessments for bed alarms and positioning devices
Penalty
Summary
The facility failed to ensure residents were free from physical restraints when pillows and a rolled towel were tucked under fitted sheets on both sides of two residents in bed. Resident 104 had diagnoses including metabolic encephalopathy, dementia, muscle weakness, reduced mobility, and a history of traumatic fracture, and was documented as lacking capacity to understand and make decisions. On 3/9/2026 and again on 3/11/2026, the resident was observed lying in bed with pillows tucked under the fitted sheet on both sides, and on the later date a rolled towel was used on one side. Staff stated the items were placed there to prevent the resident from falling, and the DSD and DON stated pillows under the sheet are considered a restraint because the resident cannot remove them and cannot move freely. Resident 62 was admitted with low back pain, chronic pain, need for assistance with personal care, and COPD, and was documented as cognitively intact with capacity to make decisions. The resident had an order for a pad alarm in bed/wheelchair and an order for the bed to be against the wall per resident preference. During observation, the pad alarm was disconnected and the resident stated she removed it, did not need it, used the call light, and did not want it. She also stated she did not consent to its use. Staff acknowledged the resident had a pad alarm and that she removed it, and RN 1 stated the resident should not have had it placed back after refusal. RN 1 and the DON also stated the bed against the wall was a restraint and that no restraint assessment had been completed for that placement. Resident 187 had dementia, generalized muscle weakness, and a history of falling, and was documented as lacking capacity to understand and make decisions. The resident had a physician’s order and informed consent for a pad alarm in bed, but the record did not show a restraint assessment completed before the device was used. During observation, the resident was seen trying to get out of bed, with low bed and floor mats in place, and later was observed asleep with pillows tucked under the fitted sheet on both sides of the body and a bed alarm hanging on the side of the bed. Staff stated the pillows were used to keep the resident from rolling over and falling, and the DSD and RN 1 stated pillows tucked under the fitted sheet restrict movement and can be considered a restraint. Resident 78 had Parkinson’s disease, generalized muscle weakness, osteoporosis, and moderately impaired cognition, but was documented as having capacity to understand and make decisions. The record showed no physician’s order, no informed consent, and no device use or physical restraint assessment for the pad alarm in bed/wheelchair, yet the resident was observed sitting on a pad under the fitted sheet with a bed alarm box hanging on the side of the bed. Staff stated the alarm was not working, and LVN 8 and the DON stated the use of the pad alarm without the required order, consent, assessment, and care plan was considered a restraint.
PASRR Screening Not Updated for Residents With Mental Health and ID Diagnoses
Penalty
Summary
The facility failed to ensure PASRR Level I screenings were completed accurately and updated when resident information changed for three sampled residents with mental health or intellectual disability-related diagnoses. For Resident 3, the record showed an admission and later readmission with diagnoses including mild intellectual disabilities, bipolar disorder, depression, and Alzheimer’s disease. The resident’s H&P stated the resident did not have the capacity to understand and make decisions. The original PASRR Level I screening indicated no serious diagnosed mental disorder, no suspected mental illness, and no psychotropic medication use, but the MDS documented depression and bipolar disorder and showed use of antipsychotic and antidepressant medications. For Resident 62, the record showed admission with diagnoses including anxiety disorder, COPD, and unspecified psychosis not due to a substance or known physiological condition. The H&P stated the resident had the capacity to understand and make decisions and could make decisions for ADLs. The order recap showed Ativan 1 mg three times daily for anxiety, and the MDS listed active diagnoses including anxiety disorder and psychotic disorder. The PASRR Level I screening reviewed for this resident was found to have discrepancies, and a new Level I screening was not completed. For Resident 17, the record showed readmission with diagnoses including schizoaffective disorder, bipolar type, psychosis, and mood disorder. The H&P stated the resident had the capacity to understand and make decisions. The prior PASRR Level I screening indicated no serious diagnosed mental disorder, no suspected mental illness, and no psychotropic medication use, while the MDS listed psychosis and schizophrenia. The DON stated the PASRR was not recent and that a new Level I screening should have been submitted when the resident returned with a new diagnosis of mental disorder. The facility policy stated a new Level I PASRR would be submitted if there was an error or discrepancy in the previous screening or if there was a significant change in the resident’s mental or physical condition.
Missing Care Plans for Significant Medications and Pain Management
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for four sampled residents with significant medication and symptom-management needs. The report states that Resident 66 had physician orders for Divalproex sodium for bipolar disorder and enoxaparin sodium for DVT prophylaxis, but RN review found no baseline or comprehensive care plan addressing either medication. RN and the DON stated these medications were significant and required monitoring for side effects and adverse effects, and that the care plan was needed to guide care and support continuity of care. Resident 179 had a physician order for heparin sodium for DVT prophylaxis, but RN review found no baseline or comprehensive care plan for the anticoagulant. The resident’s record showed diagnoses including a left foot fracture, ulcerative colitis, and GERD, and the H&P indicated the resident was awake, alert, communicative, and had the capacity to understand and make decisions. RN and the DON stated heparin was a significant anticoagulant medication and that a care plan was needed to monitor for adverse effects and guide staff in providing care. Resident 142 had diagnoses including bullous pemphigoid, acute chronic systolic congestive heart failure, and arthritis, and the record showed the resident required extensive assistance with multiple ADLs. RN review found there was no care plan for pain related to arthritis. Resident 97 had dementia, a history of falling, and UTI, and the record showed severely impaired cognition and dependence with multiple ADLs. The physician ordered levofloxacin for UTI, but the care plan did not address the UTI or the antibiotic. The IP stated a care plan should have been developed and implemented within 24 hours of receiving the order, and the DON stated the care plan should have been in place so staff would know the current plan of care.
Unsafe Environment and Failure to Maintain Ordered Fall-Prevention Measures
Penalty
Summary
The facility failed to keep the environment free of accident hazards for multiple residents who were identified as being at risk for falls and injury. For several residents with floor mat orders, surveyors observed furniture or equipment placed on top of the mats, including an oxygen concentrator and side tables. Resident 180 had diagnoses including nontraumatic intracerebral hemorrhage and drug-induced hypoglycemia, was assessed as having intact cognition and some mobility needs, and had an order for a floor mat to decrease potential injury. During observation, an oxygen concentrator was found on top of the floor mat in the resident’s room. Similar observations were made for residents 72, 179, and 12, whose floor mats had side tables placed on them even though their records showed fall risk, impaired cognition or mobility needs, and orders for supportive devices such as floor mats and low beds. The facility also failed to keep medications and biologicals from being left at the bedside for residents who were not approved for self-administration. Resident 180 had urea cream at the bedside even though the self-administration assessment showed the resident was not a candidate for self-administration and there was no bedside order for the cream. Resident 1 had packets of A&D ointment left at the bedside, and resident 72 had multiple A&D ointment packets at the bedside, despite both residents being assessed as not candidates for self-administration. Resident 104 also had a clear plastic medication cup containing white ointment and a used applicator left on the nightstand. Staff interviews and the DON’s statements confirmed that these items should not have been left unattended at the bedside. Additional accident-prevention failures involved alarm and bed safety devices. Residents 1, 9, and 78 had tab/pad alarms that were not connected to the alarm console and were not working properly. Resident 183 did not have floor mats in place as ordered by the physician, and Resident 22’s bed was not in the low position. The report also states that LVN 9 did not follow the facility policy and procedures regarding falls when Resident 121 moved from the bed to the fall mat on 2/21/2026. The facility’s records and staff interviews showed that these residents were identified as being at risk for falls, yet the ordered safety devices and environmental protections were not consistently in place.
Nebulizer and Oxygen Tubing Not Maintained per Policy
Penalty
Summary
Respiratory care was not provided in accordance with professional standards for three sampled residents. Resident 128 was admitted with acute respiratory failure, malignant neoplasm of the breast, bone, and brain, and generalized muscle weakness. The H&P stated the resident did not have the capacity to understand and make decisions, and the MDS indicated severely impaired cognition and oxygen therapy in the facility. The OSR directed staff to ensure any tubing, including nasal cannula tubing, was off the floor at all times, and the DON stated extra tubing should be placed inside a plastic storage bag because the floor is contaminated and bacteria can travel up the tubing. During observation, Resident 128’s oxygen via nasal cannula tubing was observed touching the floor. For Resident 1, the admission record showed diagnoses including acute respiratory failure with hypoxia, pneumonitis, and dependence on supplemental oxygen. The H&P stated the resident did not have the capacity to understand and make decisions, while the MDS indicated intact cognition and oxygen therapy. The OSR included orders for nebulized Levalbuterol HCl and Pulmicort. During observation, Resident 1’s nebulizer mask and tubing were found inside a transparent plastic bag labeled with the resident’s name and a date of 2/22/2026. CNA 1 stated she did not know when to discard the mask and tubing and would ask the charge nurse. Resident 66 was admitted with parainfluenza virus pneumonia, pleural effusion, and anxiety disorder. The MDS indicated the resident could make self-understood and usually understands others, with impaired cognition. The OSR included orders for Ipratropium-Albuterol inhalation solution every 12 hours and every 6 hours for shortness of breath and wheezing. During observation, Resident 66’s nebulizer tubing and mouthpiece were found inside a plastic bag dated 2/23/2026. LVN 5 stated licensed staff should have changed the tubing and mouthpiece weekly and as needed for infection control, and RN 3 stated the tubing and mouthpiece should have been changed on 3/4/2026. The facility’s P&P for administering medications through a small volume nebulizer stated equipment and tubing should be changed every seven days or according to facility protocol.
Missed COPD Medication and Unreconciled Controlled Substance Emergency Kits
Penalty
Summary
The facility failed to have Trelegy available for a resident with COPD and glaucoma who had an order for Trelegy 1 puff orally once daily for congestion and brimonidine eye drops three times daily for glaucoma. During medication administration observation, the LVN administered other ordered medications but did not administer brimonidine or Trelegy. The LVN stated Trelegy was not available in the medication cart or in the facility, and stated the missed dose could harm the resident by causing breathing difficulty and potential hospitalization. The DON also stated the resident did not receive the morning dose because the medication was not available in the facility. Record review showed the resident’s Trelegy supply had last been delivered by the pharmacy on 7/16/2025 in a quantity of 28, and the resident’s notice of prescription denial for Trelegy was dated 9/20/2025. The DON acknowledged the denial form was not signed and stated there were no additional manifests or denial forms for Trelegy. The DON stated the facility had not received Trelegy since 7/16/2025, leaving the resident without a supply after the 14-day quantity ended on 7/31/2025. The DON stated the DON and several licensed nurses failed to reorder and follow up with the pharmacy regarding Trelegy beginning 8/1/2025, and that there was no consistent system in place to ensure timely reordering and follow-up of medications. The facility also failed to reconcile six medication emergency kits containing controlled substances and document the counts on the controlled medication accountability log for March 2026 in two medication rooms. In one medication room, a kit labeled REF120 was found in the refrigerator without a reconciliation log for shift-change inventory counts. In another medication room, kits labeled REF60, 122, 490, PO283, and PO598 were found without a controlled medication accountability log for shift-change counts. RN staff stated these kits should be reconciled at every shift and documented on the accountability log, and the DON stated the kits contained controlled substances and were not reconciled or documented as required. The facility policy stated that at each shift change, a physical inventory of all controlled medications, including the emergency supply, is to be conducted by two licensed nurses and documented on the controlled medication accountability record.
Medication Error Rate Exceeded 5 Percent Due to Missed Ordered Medications
Penalty
Summary
The facility failed to keep the medication error rate below 5 percent. Surveyors identified 3 medication errors out of 32 total opportunities, resulting in a 9.38% medication error rate and affecting two residents observed during medication administration. The errors involved omission of ordered medications for Resident 33 and Resident 184. Resident 33 had diagnoses including glaucoma and COPD. The physician’s orders and MAR showed brimonidine eye drops ordered three times daily for glaucoma and Trelegy inhalation ordered once daily for congestion/COPD. During the morning medication pass, LVN 4 administered several oral medications and eye drops to Resident 33, but did not administer brimonidine or Trelegy. LVN 4 later stated that brimonidine was not obtained from the medication room and that Trelegy was not available in the facility at the time of administration. LVN 4 also stated that both medications were documented on the MAR as given even though they were not administered. Resident 184 had a diagnosis including glaucoma. The MAR showed Systane eye drops ordered twice daily for dry eyes. During the morning medication pass, LVN 13 administered multiple oral medications to Resident 184 but did not administer Systane. LVN 13 later stated that Systane was not prepared or given at the scheduled time and acknowledged that the medication was not administered within the facility’s 60-minute window. The DON confirmed that the missed doses for Resident 33 and Resident 184 were medication errors and that the medications were ordered to be given at the scheduled times.
Medication Administration Errors Involving Omitted Doses and Failure to Rotate Injection Sites
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors involving omitted doses, incorrect administration, and failure to rotate injection sites. The report identified four separate medication-related deficiencies affecting multiple residents: Trelegy was not administered to one resident as ordered, levofloxacin was not administered as ordered to another resident, heparin subcutaneous injection sites were not rotated for two residents, and insulin injection sites were not rotated for one resident. For the resident prescribed Trelegy for COPD, the physician order called for one puff daily, but the medication was documented as given on the MAR even though it was not actually administered. On observation, the nurse administered several other medications but did not give Trelegy. During interview, the nurse stated Trelegy was not available in the medication cart or facility and acknowledged the dose was missed. The DON also stated the medication had not been received from the pharmacy since the last delivery and that the resident did not have a supply after the initial 14-day quantity was used. The resident’s record showed diagnoses including glaucoma and COPD. For the resident prescribed levofloxacin for UTI, the MAR showed doses were not marked as given on two dates, and the IP confirmed the medication was not administered as ordered. The resident had diagnoses including dementia, history of falling, and UTI, and the H&P stated the resident did not have capacity to understand and make decisions. For the residents receiving heparin, the orders required subcutaneous injections with site rotation, but the LARs did not show rotation of injection sites as required. For the resident receiving insulin, the order also required rotating injection sites, but staff did not rotate the sites. The DON and RN stated that failure to rotate insulin and heparin injection sites constituted medication errors, and the facility policy and manufacturer information cited in the report required medications to be administered as ordered and injection sites to be rotated.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Medication storage and labeling practices were found out of compliance in multiple medication areas after observation, interview, and record review. In one medication room, an open Aplisol multi-dose vial for facility stock was found in the refrigerator without a date showing when use began. The vial was observed with RN 1, who stated it had been opened and used but was not labeled with a date. RN 1 also stated open Aplisol vials are usually good for 30 days and should be labeled with the date first used so expired product is not administered in error. In Medication Cart 1 Station 1, an opened lorazepam oral concentrate bottle for Resident 128 was found stored at room temperature even though the bottle label indicated it should be refrigerated. LVN 2 stated the bottle had been opened and stored at room temperature, and acknowledged that the product should be refrigerated to maintain potency. In Medication Cart 2 Station 2, an open Trelegy inhaler for Resident 105 was found at room temperature without a date showing when it was first opened. LVN 7 stated the inhaler had been opened and was not labeled with the date it was first used, and stated the manufacturer instructions on the box indicated it should be discarded 6 weeks after opening. In Medication Cart 2 Station 1, heparin intravenous solution was stored in the same bin with oral medications including alendronate, ondansetron, and Advil. LVN 1 stated intravenous medications should be stored separately from oral medications and acknowledged the heparin was stored together with the oral medications in the same bin. The DON also stated the Aplisol vial was considered expired and needed to be removed, the lorazepam was not stored as indicated on the bottle, Trelegy had not been labeled with the date opened, and oral and intravenous medications should be stored separately. Facility policies and manufacturer guidance reviewed in the report stated that multi-dose vials require the date opened, injectable medications must be stored according to manufacturer directions, inhalers must be dated when opened, and intravenous medications are kept separate from oral medications.
Food items were left unlabeled and expired items remained in storage
Penalty
Summary
Safe and sanitary food storage and food preparation practices were not maintained in the kitchen during observation and interview. In the walk-in refrigerator, one opened container of hotdogs was found with an opened date of 1/27/2026 and a best by date of 2/3/2026, and the Dietary Supervisor Assistant stated the hotdogs would be discarded because they were past the best by date. In the refrigerator for milk and side orders, 6 salad plates were observed without a prepared date label, and the Dietary Supervisor Assistant stated they should be labeled with a date right when they were prepared. In the standing freezer, 10 prepared bowls of ice cream were observed without a label showing the date they were prepared. The Dietary Supervisor Assistant stated the bowls contained rainbow sherbet and that there was no open rainbow sherbet in the freezer. During interview, the Dietary Service Supervisor stated prepared foods should be labeled with the date of preparation and best by date because they are time/temperature controlled, and that unlabeled foods could lead to foodborne illness and sickness among residents. The facility policy titled Dating and Labeling stated all food items should be properly covered, dated, and labeled, and that no food item expired or beyond the best buy date should be in stock.
False MAR Documentation for Unavailable COPD Medication
Penalty
Summary
The facility failed to ensure the MAR for a resident with COPD was accurate when Trelegy was documented as administered daily even though the medication was not available in the facility. Resident 33 had diagnoses including COPD and was cognitively intact. The resident’s physician order called for Trelegy, one puff orally once daily for congestion, and the MAR showed the medication scheduled for 9 a.m. administration. During observation on 3/9/2026, an LVN administered several other medications to Resident 33 but did not administer Trelegy. In interview, the LVN stated Trelegy was not available in Medication Cart 2 or in the facility, and acknowledged documenting on the MAR that Trelegy had been given even though it had not been administered that day. The LVN also stated that if a medication was unavailable, it should not have been checked off on the MAR and that marking it as given created an inaccurate clinical record. Record review and staff interviews showed this was not an isolated event. Multiple LVNs stated they had documented Trelegy as administered on numerous dates between 8/1/2025 and 3/9/2026 even though the inhaler was not available in the facility. The DON stated the facility had not received Trelegy from the pharmacy since 7/16/2025, leaving the resident without a supply after the initial 14-day supply ended on 7/31/2025. The DON also stated that when a medication is unavailable, staff must notify the pharmacy, the physician, and the DON, and acknowledged it was unacceptable to sign the MAR as if Trelegy had been administered when it was not available.
Infection Control Failures With Resident Remote and Linen Cart Covers
Penalty
Summary
Infection prevention and control practices were not maintained when Resident 182’s bed remote control was found inside the trash can during a concurrent observation and interview. Resident 182 was admitted and later readmitted with diagnoses including muscle weakness, difficulty walking, and a history of traumatic fracture. The resident’s H&P indicated the resident had the capacity to understand and make decisions, and the MDS showed the resident could make self-understood and understand others, had moderate cognitive impairment, and was independent to needing partial assistance with mobility and ADLs. During the observation, LVN 2 stated the bed remote should always be within easy reach of the resident and should not be inside the trash for infection control purposes. LVN 2 also stated the remote should have been sanitized before being placed back on the resident’s bed. The DON later stated the bed remote should not be inside the trash can because it can cause spread of infection to the resident, and that LVN 2 should have sanitized it prior to placing it back in bed. The facility also failed to maintain clean linen carts in a protected condition. During observation, multiple mobile carts in Station 1 and three mobile linen racks in the laundry hallway were covered with blue loosely woven, permeable mesh material while holding clean linens. The IP stated the covers were permeable to air, water, and dust and that the linens inside were not protected from environmental elements that can contaminate them. The HKS and MS both stated the material was loosely woven and could allow air and water to pass through, and the MS stated the current covers were not protecting the clean linens from environmental contaminants.
Unsafe Equipment Maintenance and Call Light Failure
Penalty
Summary
Keep all essential equipment working safely was not maintained when the walk-in freezer had ice build-up inside it during observation in the kitchen. The Dietary Service Assistant observed the freezer temperature at negative 1 degree Fahrenheit and stated there was ice build-up that should not be present. The Dietary Service Supervisor later stated ice build-up is cleaned as needed, maintenance helps remove it because they use a tool that can reach the back of the freezer, and the build-up occurs because staff frequently open the door throughout the day, causing temperature changes and moisture that freezes. The facility policy required freezers to be maintained free of excessive ice or frost buildup and for dietary staff to report ice buildup to the Dietary Supervisor and Maintenance. The facility also failed to ensure Resident 33's call light was properly connected to the wall panel during observation. Resident 33 was admitted with COPD, type 2 DM, and paraplegia, and the H&P and MDS indicated the resident had capacity to understand and make decisions and was cognitively intact, while requiring extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. During observation, Resident 33 stated staff takes a few minutes to answer the call light and that it can take hours if it is not working. When the resident pressed the pad call light, the light outside the room did not turn on. CNA 13 later checked the wall panel and found the cable was not plugged in all the way; after it was checked again, the call light worked. The DON stated the nurse should have connected the call light and that the facility's call light policy was not followed.
Informed Consent for Psychotropic Medication Did Not Match Physician Order
Penalty
Summary
The facility failed to honor a resident’s right to be informed in advance by the physician or other practitioner of the risks, benefits, and alternatives of proposed psychotropic treatment. For one sampled resident, the informed consent for buspirone did not match the physician’s order. The resident had diagnoses including bipolar disorder, anxiety disorder, and unspecified symptoms and signs involving cognitive functions and awareness, and the MDS indicated severe cognitive impairment while also noting the resident could make self-understood and usually understand others. The resident’s OSR showed an order for buspirone HCl 5 mg, one tablet by mouth one time a day for anxiety, with monitoring for behavior such as inability to relax or stay still causing exhaustion or self-harm. However, the resident’s Psychotherapeutic Drug Informed Consent Form, which was undated, listed buspirone 5 mg PO twice a day for anxiety with the same behavior monitoring language. During interview and record review, RN 3 stated the consent in the chart showed buspirone BID while the physician’s order was once daily, and said the consent needed to match the order to ensure the resident was agreeing to the correct medication and dose. RN 3 also stated the mismatch could potentially cause a medication error affecting residents. The DON stated the consent should match the physician’s order for the resident’s use of buspirone and that the ICF and physician’s order should match so the resident and representative would be aware if the medication was reduced and to prevent adverse side effects. The DON stated the facility’s policy and procedure titled Informed Consent was not followed. The facility policies reviewed also stated residents and/or their representatives must be fully informed of the benefits, risks, frequency/duration, and alternatives before initiating psychotherapeutic drugs, and that a licensed nurse must verify the informed consent information for accuracy and completeness.
Call lights and bed remote controls left out of residents’ reach
Penalty
Summary
The facility failed to keep the call light and bed remote control within reach for two residents. Resident 182 was admitted and later readmitted with diagnoses including muscle weakness, difficulty walking, and a history of traumatic fracture. The resident’s H&P indicated the resident had the capacity to understand and make decisions, and the MDS showed the resident had moderate cognitive impairment and was independent to needing partial assistance with mobility and ADLs. The care plan included keeping frequently used personal items within easy reach. During a concurrent observation and interview, Resident 182’s bed remote control was found on the left side of the bed inside the trash can. An LVN stated the bed remote control should always be within easy reach so the resident can adjust the bed for comfort, and stated the resident could fall while reaching for it inside the trash can and sustain an injury. The DON stated the call light and bed remote should be within the resident’s reach and stated the facility’s Safety and Supervision of Residents policy was not followed. Resident 140 was admitted and later readmitted with diagnoses including muscle weakness, history of traumatic fracture, and history of falling. The H&P described the resident as fairly weak and debilitated after multiple falls with muscle injuries, on pain medications, alert and oriented to person only, and lacking capacity to understand and make decisions. The MDS indicated moderate cognitive impairment and dependence to needing supervision with mobility and ADLs, and the FRE identified the resident as at risk for falls. The care plan directed staff to keep the call light within easy reach and encourage use for assistance. During observation, Resident 140’s call light was found on the left side of the bed resting on the floor. An LVN stated the call light should always be within easy reach so the resident can call for assistance, and the DON stated the facility’s Policy: Call Lights was not followed.
Incomplete Advance Directive Acknowledgement Form
Penalty
Summary
The facility failed to complete the Advance Directive Acknowledgement Form for one of three sampled residents, Resident 14. Resident 14 was originally admitted and later re-admitted with diagnoses including fracture of the neck of the right femur, encephalopathy, and type 2 diabetes mellitus without complications. The resident's H&P dated 10/4/25 stated that the resident did not have the capacity to understand and make decisions. The MDS dated 12/26/2025 indicated the resident was usually able to make self-understood and usually able to understand others, but also had impaired cognition and required extensive assistance from staff with bed mobility, transfer, dressing, toilet use, and personal hygiene. During interview and record review, the Social Services Director stated that the Advance Directive is completed within 72 hours after admission, but Resident 14's form was not completed correctly because it did not show any specifications marked off and only showed signatures. The DON also reviewed the form and stated it was incomplete because it only had signatures and nothing was checked off. The DON stated that upon admission the advance directive should be reviewed with the resident and responsible party, and that without an advance directive staff would not know what to follow in case of emergency when the resident is unable to decide for herself regarding healthcare decisions. The facility policy titled Advance Directives stated that if the resident does not have an advanced directive, staff will offer assistance in establishing one, document the offer and the resident's decision, and ensure the information is displayed in the medical record.
Unnecessary Psychotropic Medication Monitoring
Penalty
Summary
The facility failed to ensure Resident 9 was free from unnecessary psychotropic medication and chemical restraint use when quetiapine fumarate was ordered and monitored without specific, measurable behavioral manifestations. Resident 9 was admitted on 1/22/2025 and readmitted on 12/4/2025 with diagnoses including unspecified psychosis, unspecified dementia with behavioral disturbance, unspecified mood disorder, and alcohol dependence in remission. The resident’s MDS dated 12/19/2025 indicated he was able to understand others and make himself understood, while requiring substantial to maximal assistance with bathing and personal hygiene, partial to moderate assistance with toileting and oral hygiene, and set-up assistance for eating. The Order Summary Report showed quetiapine fumarate 25 mg at bedtime for psychosis manifested by inability to process internal stimuli causing stress manifested by agitation, along with a second quetiapine order for 12.5 mg daily for the same indication. The orders also directed staff to monitor episodes of inability to process internal stimuli causing stress manifested by agitation every shift. The care plan likewise identified the resident as having episodes of psychosis manifested by inability to process internal stimuli causing stress manifested by agitation and directed staff to monitor and record episodes per policy. During interview and record review, LVN 5 stated agitation was not a specific behavior manifestation and that different nurses could interpret agitation differently; she identified the resident’s behaviors as attempting to hit staff and screaming. LVN 3 stated antipsychotic medications are high-risk medications and that behavioral manifestations should be documented each shift to monitor effectiveness, but agreed agitation is not a behavior manifestation and described specific behaviors such as striking or lashing out. The DON stated psychotropic medications must be accurately monitored for measurable behaviors to determine whether the medication can be decreased with a GDR, and stated that when psychotropics are not accurately monitored for specific measurable behaviors it may result in unnecessary administration and be considered a chemical restraint. The DON also stated the facility policy was not followed when quetiapine fumarate was ordered and monitored for agitation.
Late MDS Transmission for Two Residents
Penalty
Summary
The facility failed to ensure timely submission of completed MDS assessments for two residents. Resident 21 was admitted with diagnoses including bipolar disorder, anemia, and hyperlipidemia, and a History and Physical dated 7/7/2025 stated the resident did not have the capacity to understand and make decisions. During interview and record review, the MDS Coordinator stated the resident’s Quarterly MDS was submitted on 3/10/2026 and was late because it was missed; the Coordinator stated it should have been submitted within 14 days by 12/19/2025. Resident 50 was admitted with diagnoses including UTI, COPD, and dysphagia, and a History and Physical dated 10/28/2025 stated the resident did not have the capacity to understand and make decisions. During interview and record review, the MDS Coordinator stated the admission MDS was submitted late on 11/18/2025 and should have been submitted by the 14th day, 11/16/2025, to be considered on time. The MDS Coordinator and DON stated that timely transmission is needed because the MDS contains information about residents’ diagnoses, functional abilities, and care needs, and that late submission may result in inaccurate data and delay identification of changes in condition.
Inaccurate MDS Discharge Coding
Penalty
Summary
The facility failed to accurately code the MDS for one resident when a discharge assessment was submitted even though the resident returned to the facility within 24 hours. Resident 189 had been admitted and later readmitted to the facility, with diagnoses including malignant neoplasm of the left kidney, bone, and left lung, moderate protein-calorie malnutrition, and paraplegia. The resident’s H&P indicated the resident had the capacity to understand and make decisions. The resident’s most recent MDS, dated 2/20/2026, was coded as a discharge with return anticipated and indicated the resident was discharged to an acute hospital. However, the physician’s order on the same date directed transfer to the hospital for a blood transfusion, and progress notes documented that the resident left the facility at 8:40 p.m. and returned at 1:30 p.m. the next day. During interviews, LVN 8 and the MDSC both stated the resident only went to the hospital for the transfusion and returned within 24 hours, and the MDSC acknowledged the submitted discharge assessment was not accurate and was a data entry error. The DON stated discharge MDS assessments were only completed and submitted if a resident was gone for more than 24 hours, and that the MDS is used by the IDT to understand the resident’s clinical picture and type of care being received. The facility policy required timely and appropriate resident assessments, and the CMS RAI Manual states the assessment must accurately reflect the resident’s status. The report states that if the EHR shows the resident as discharged and no longer in the facility, it could cause a delay in care.
Low Air Loss Mattress Not Replaced Timely for Resident With Pressure Injuries
Penalty
Summary
The facility failed to ensure Resident 128’s low air loss mattress was replaced timely when it was beeping with an orange low-pressure light and the resident appeared sunken into the bed. Resident 128 was admitted on 2/10/2026 with diagnoses including pressure ulcer of the sacral region and right heel, malignant neoplasm of the breast, bone, and brain, and generalized muscle weakness. The history and physical dated 2/12/2026 indicated the resident did not have the capacity to understand and make decisions, and the MDS dated 2/17/2026 indicated severely impaired cognition, partial/moderate assistance with eating, and substantial/maximal assistance with all other ADLs. The physician’s orders included a low air loss mattress at the setting per resident weight or comfort for pressure redistribution and wound care management, along with daily treatment orders for the right heel pressure injury and sacrococcyx pressure injury. The care plan initiated on 2/12/2026 and revised on 2/16/2026 directed staff to ensure the low air loss mattress was inflated. Braden Scale evaluations dated 2/10/2026, 2/17/2026, 2/24/2026, and 3/2/2026 indicated the resident was at moderate to high risk for developing pressure injuries. During a concurrent observation and interview on 3/9/2026 at 12:23 p.m., LVN 8 stated the resident’s low air loss mattress had been beeping with an orange light since 10 a.m., had been reported to maintenance, and was getting softer, with the resident appearing sunk into the bed from the middle part up to the head. In a follow-up interview, LVN 8 stated the soft mattress could affect comfort, cause the resident to sink further toward the bedframe, and worsen the pressure injuries on the right heel and sacrococcyx. The DON stated licensed nurses and maintenance personnel were responsible for ensuring the mattress functioned properly, that if it was not functioning the maintenance department should be notified, and that more than 2 hours for the mattress to be fixed was too long.
Unlabeled and Improperly Stored Urinals
Penalty
Summary
Resident 38 was admitted with diagnoses including history of falling, generalized muscle weakness, and difficulty walking. The resident’s record showed intact cognition, ability to understand others and make needs known, and dependence for most ADLs, while remaining continent of bowel and bladder. The care plan for risk for alteration in elimination patterns with the bladder included assessing the resident’s ability to participate with a bladder program and monitoring for signs and symptoms of UTI. During a concurrent observation and interview, the resident’s urinal was found hanging on the side of the trash can. A CNA stated the facility uses a urinal holder that can be hung on the side of the bed frame to keep the urinal clean and accessible, and stated the urinal should have been placed on the holder because the trash can is contaminated. An LVN also stated the urinal should not be placed on the trash can and that doing so placed the resident at risk for infection due to the contaminated urinal. The DON stated urinals are supposed to be monitored and reminded to be placed on the holder, and that hanging the urinal on the trash can is not sanitary and could lead to infection. Resident 180 was admitted with diagnoses including type 2 DM, CKD stage 4, and acquired absence of kidney. The resident’s H&P indicated the resident was awake, alert, oriented, communicative, able to move all extremities, and had the capacity to understand and make decisions. The care plan included incontinence care and keeping skin dry and clean. During observation, the resident’s urinal bottle was found unlabeled on the side table. An LVN stated the urinal should have been labeled with the resident’s name, room number, and the date it was provided to prevent switching of urinals among residents. RN staff stated CNAs were responsible for ensuring urinal bottles were labeled, and the DON stated the urinal bottle should be labeled with the resident’s initials and date provided, noting the staff did not follow the facility policy titled Giving and removing Urinal.
Failure to Verify G-Tube Placement Before Bolus Feeding
Penalty
Summary
The facility failed to ensure staff were aware of, competent in, and followed facility protocols for feeding tube care for a resident with a gastrostomy tube. The resident’s record showed admission and readmission to the facility, diagnoses including gastrostomy, perforation of intestine, and severe protein-calorie malnutrition, and a history and physical stating the resident did not have the capacity to understand and make decisions. The minimum data set indicated the resident had a feeding tube and required assistance with mobility and activities of daily living. The resident had an order for Jevity 1.5 bolus feedings through the g-tube at scheduled times and an order to check tube placement every shift. The care plan included an intervention to check and maintain placement and patency of the g-tube. During observation, an LVN prepared and administered a bolus feeding through the g-tube, including checking residual, flushing the tube with water, and delivering the formula. The LVN stated she had checked the g-tube placement around noon, but she was not observed entering the resident’s room during the earlier observation period when she said the check occurred. During interviews, the LVN and RN described the facility’s practice for verifying tube placement as injecting air into the tube and listening for bubbling or gurgling sounds with a stethoscope. The RN stated the LVN should have checked placement before administering the formula. The DON stated the placement needed to be checked at the time of administration because the tube could be dislodged at any time, and said checking an hour earlier was not acceptable. The DON also stated the facility’s policies for administering medications through an enteral tube and for bolus tube feeding were not followed.
IV Site Not Labeled With Date and Initials
Penalty
Summary
Provide for the safe, appropriate administration of IV fluids when needed was not met for one resident receiving IV therapy for an elevated WBC count and IV antibiotic treatment. Resident 179 was admitted with diagnoses including elevated WBC count, anxiety disorder, and polyneuropathy. The resident was awake, alert, oriented, communicative, non-ambulatory, able to move all extremities, and had the capacity to understand and make decisions. The MDS indicated intact cognition, self-understanding, understanding of others, high-risk antibiotic use, and peripheral IV access. The resident had an order for peripheral site care, site checks every shift, and dressing changes with site change as needed, with peripheral site care every 72 hours and restart IV and subcutaneous site as ordered. The care plan addressed IV antibiotic therapy and peripheral IV line care, including restarting the IV site every 96 hours and PRN, flushing the IV site as ordered, and monitoring for complications and intake and output. During observation, the resident's peripheral IV on the left hand was covered with a net dressing and had no date or initials of the licensed nurse who inserted the line or changed the dressing. During interview, LVN 2 stated the IV site should be labeled with the date and initials of the licensed nurse who inserted the line or changed the dressing to track how long the peripheral line had been in place and when it should be changed to prevent infection. RN 1 stated nurses are responsible for ensuring the IV site is current and that the date and initials should be placed when the line is inserted or the dressing is changed. The DON also stated the licensed staff should have labeled the IV site with the date and initials of the nurse who inserted the line or changed the dressing, and that the purpose of labeling was to know when the dressing and insertion were done.
Pain assessment, referral, and documentation failures
Penalty
Summary
The facility failed to provide pain management consistent with professional standards of practice and the residents’ goals and preferences for two residents. For one resident, admitted with low back pain, chronic pain, and COPD, the record showed vocal complaints of pain on admission, severe constant aching pain in the cervical region, and substantial to maximal assistance needed for multiple ADLs and mobility tasks. The care plan included a goal to reduce pain episodes and interventions that included pain consultation if indicated, and an order recap report showed an order for a pain consult. During interview, the resident stated she had pain in her left knee, felt frustrated, had requested to be seen by a pain specialist because nothing was working, and reported a current pain level of 5/10 after receiving pain medication about an hour earlier. Review of the nursing note and physician orders showed documentation that the MD was notified with new orders for a pain consult and that orders were carried out, but the Assistant DON stated the note was confusing as to whether the order had actually been completed. The MRD stated there was no pain referral prior to 3/11/2026, and the DON stated the referral should be scheduled and documented so the resident would be seen by the pain specialist and her pain addressed. For the second resident, admitted with bullous pemphigoid, CHF, and arthritis, the record showed the resident could make needs known but could not make medical decisions, had impaired cognition, and required extensive assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. During observation, the resident stated she had been in pain since the prior night, rated her pain as 9/10 in her legs and back, had not slept all night, and asked for pain medication. LVN 4 entered with acetaminophen but did not ask the resident for her pain level, did not offer nonpharmacological interventions, and later documented the pain level in the MAR as 2/10 based on an assumption rather than the resident’s report. The resident’s only pain order was acetaminophen 325 mg, 2 tablets twice daily for mild pain (1-3), and staff interviews confirmed that the resident’s pain should have been assessed, the provider notified for pain above 3/10, and the documentation should have reflected the resident’s stated 9/10 pain level.
Failure to Follow Up on Incomplete HD Communication Records
Penalty
Summary
The facility failed to ensure residents receiving hemodialysis received treatment consistent with professional standards of practice for one sampled resident. Resident 59 had diagnoses that included ESRD, dependence on renal dialysis, hypertensive heart and chronic kidney disease, and diabetes mellitus. The resident’s care plan included interventions for the HD center to administer medications as ordered, communicate with the HD center as indicated, follow protocol for labs as ordered, and use post-HD dry weights for weight management. Resident 59 was scheduled for HD at HDC 1 on Monday, Wednesday, and Friday. The facility used an HD Communication Record form to exchange information between the facility and the HD center, including pre- and post-HD weights and other notes. LVN 3 stated that if the form was not completed by the HD center, the LVN should call the HD center and follow up. On review of the HD Communication Record forms for 3/6/2026 and 3/9/2026, the forms were not completed by HDC 1. LVN 4 stated she cared for Resident 59 on those dates, completed the post-HD assessment, and signed the forms, but did not notice that HDC 1 had not completed them. She stated she should have followed the procedure and called HDC 1 to follow up, but did not. The DON stated the HD Communication Record is a communication tool between the facility and the HD center, and if the form is not completed the LVN should follow up to obtain pertinent information and document that communication. The DON stated the facility P&P was not followed.
Missed Oncology Appointment Due to Unarranged Transportation
Penalty
Summary
The facility failed to ensure medically-related social services were provided to arrange transportation for Resident 153’s Oncology appointment. Resident 153 was admitted on 12/15/2025 with diagnoses including acute kidney failure, elevated white blood cell count, and disorder of bone. The record also showed immunodeficiency due to conditions classified elsewhere, and the resident was cognitively intact, able to make self understood, and able to understand others. The resident required partial to moderate assistance with several activities of daily living, including toileting hygiene, bathing, dressing, and transfers. Physician orders documented an Oncology appointment initially scheduled for 3/10/2026 at 1:30 p.m. with Social Services Department to schedule transportation, followed by later orders on the same day changing the appointment to 12 p.m. and then back to 1:30 p.m., with one order discontinued per the doctor’s office request. The Appointment Notification Form was signed by Social Services Assistant 1, but the social services section was not completed with transportation details such as the transportation name, pick-up time, or whether the resident would be accompanied by family or an escort. Social Services Assistant 2 stated the form did not need to be filled out because the resident was going to be picked up by the facility van, and she was not aware of the earlier appointment time change. On 3/11/2026, RN 2 stated the resident missed the Oncology appointment because there was an issue with transportation and the resident was not picked up. RN 2 stated the social services section needed to be completed so nursing staff would know transportation had been set up and the resident would be ready at the time of pick-up. The DON stated licensed nurses enter the appointment order and fill out the ANF to notify Social Services to arrange transportation, and that when transportation details are not filled out, it means it was not done and the resident missed the appointment. The DON also stated the resident was not seen by the Oncology specialist, and the specialist would not be able to provide treatment and orders.
Failure to Provide Ordered Adaptive Feeding Equipment
Penalty
Summary
The facility failed to provide adaptive feeding equipment for Resident 160 during lunch dining observation. Resident 160 was admitted with diagnoses including type 2 diabetes mellitus, hydrocephalus, and presence of a cerebrospinal fluid drainage device. The resident’s H&P stated he did not have the capacity to understand and make decisions, and the MDS indicated impaired cognition and extensive assistance needs with several activities of daily living. The resident’s OSR included an order for adaptive feeding equipment, specifically a divided plate and built-up weighted utensils for all meals while sitting supported in a wheelchair. During a concurrent observation and interview, RNA 2 was seen feeding Resident 160 in the dining area and stated the resident’s hands shake a lot and that build-up weighted utensils were special utensils used to make it easier for him to eat. RNA 2 stated she did not see the build-up utensils on the tray and only saw the divided plate, and she was not sure why the resident no longer received them. She also stated the resident used to get the build-up utensils before and that the meal ticket indicated they should be on the tray. During record review and interview, LVN 12 confirmed the resident had an order for build-up utensils and stated the resident did not have them on the tray. The DON stated the protocol for build-up utensils should include a doctor’s order, immediate provision of the utensils, and a care plan for their use, and stated the facility’s Adaptive Equipment policy was not followed.
Antibiotic Stewardship Monitoring and Timely Start Deficiencies
Penalty
Summary
The facility failed to implement its antibiotic stewardship program for two residents receiving antibiotics. For one resident admitted with ulcerative colitis, elevated WBC count, and cholangitis, the record showed an order for ertapenem sodium 1 gram IV every 24 hours for elevated WBCs for 7 days, to begin once blood cultures were drawn. The resident’s care plan addressed risk for infection and reducing MDRO transmission, but it did not include any intervention to monitor for adverse effects from ertapenem. During interview, the RN stated there was no order or care plan intervention for monitoring adverse effects, and the DON stated the antibiotic should have been monitored for adverse side effects and documented in progress notes. The facility’s antibiotic stewardship policies required documentation of antibiotic use, adverse events, and monitoring of outcomes, but those elements were not reflected in the resident’s record. For the second resident, admitted with UTI, sepsis, and generalized muscle weakness, the physician ordered linezolid 600 mg by mouth every 12 hours for 7 days, with a start date of 3/11/2026 and end date of 3/18/2026. The care plan for UTI included administering antibiotic therapy as ordered and monitoring for adverse reactions. The MAR showed the first dose of linezolid was administered on 3/11/2026 at 9 a.m., and the IP stated the facility’s standard practice was to start new antibiotic orders within 4 hours of receiving the order. The IP and DON both stated the first dose should have been started within 4 hours, but the record did not show that the medication was started timely. The progress notes for the resident receiving linezolid did not specify monitoring for adverse side effects. During interview, the IP stated residents on antibiotics are supposed to be monitored every shift and that documentation should include the specific adverse effects being monitored. The IP also stated the notes did not specify adverse side effects to watch for, and the DON stated monitoring should be specific and documented so the physician can be notified immediately if needed. The manufacturer information reviewed by the facility listed common adverse reactions to linezolid as diarrhea, vomiting, headache, and nausea. The facility policies also stated that residents receiving medications with potential adverse consequences should be monitored and that adverse events related to antibiotic use should be tracked and reported.
Insufficient Bedroom Square Footage in Multiple Resident Rooms
Penalty
Summary
The facility failed to provide at least 80 square feet per resident in 41 of 72 rooms, including Rooms 101, 103, 105, 106, 116, 119, 120, 121, 122, 123, 125, 126, 128, 130, 131, 133, 135, 201, 202, 203, 204, 205, 208, 209, 210, 211, 214, 216, 217, 218, 219, 220, 221, 222, 224, 225, 228, 229, 230, 231, and 232. The room sizes listed in the facility’s Room Waiver Request Letter showed multiple rooms measuring 209 sq ft for three-bed capacity, 220 sq ft for three-bed capacity, 154 sq ft for two-bed capacity, 154 sq ft for three-bed capacity, and 294 sq ft for four-bed capacity, with per-resident space below the stated minimum requirements. The facility policy stated that bedrooms must meet federal and state requirements, including at least 80 square feet per resident in double rooms and at least 100 square feet in single rooms. During observations from 3/9/2026 to 3/12/2026, surveyors observed a sufficient amount of space for residents to move freely inside the rooms with an application for room variance. The observations also noted adequate room for the operation and use of wheelchairs, walkers, or canes. The facility’s waiver request letter stated that the space in these multiple resident rooms was sufficient to provide access and freedom of movement, did not have adverse effects on residents’ health and safety, and did not impede residents’ ability to reach their highest practicable well-being. During interview, the DON stated that residents’ rooms should have enough space between beds to allow movement, and that the room waiver request was submitted to meet the required square footage for each resident. The DON also stated staff check for environmental hazards and clutter in rooms, especially those with room waivers, and stated that insufficient room size could leave residents without enough space to move around and create risk for falls and injury.
Failure to Calibrate Thermometers and Document Cold Storage Temperatures
Penalty
Summary
Surveyors identified a deficiency in safe and sanitary food preparation practices when kitchen staff failed to calibrate food thermometers and to monitor and document refrigerator and freezer temperatures as required. Review of the Thermometer Calibration Log with the Dietary Service Supervisor (DSS) showed that thermometer calibration had not been done or documented for multiple consecutive days, including 3/2, 3/3, and 3/4. Review of the Refrigerator & Freezer Temperature Log showed that the p.m. shift temperatures for multiple refrigerators and freezers on 3/3 were not documented, and the a.m. shift temperatures for 3/4 had not yet been logged. The DSS stated that if temperatures and calibrations are not logged, the facility cannot confirm they were done. During interviews, the Assistant Dietary Supervisor (ADS) explained that cooks are responsible for checking refrigerator and freezer temperatures at the start of the a.m. and p.m. shifts and that thermometers are to be calibrated before temperature checks and logged in the morning and monitored throughout the day. The ADS acknowledged that failure to calibrate thermometers and to record refrigerator and freezer temperatures could result in inaccurate readings and potential foodborne illness, and that undocumented temperatures cannot be verified. The Administrator confirmed that calibration is required daily to ensure accurate temperatures and that refrigerator and freezer temperatures must be taken to prevent food from spoiling or going bad, which could cause residents to become ill. Review of facility policies showed written requirements that thermometers be calibrated before each shift and that dietary staff check and record refrigerator and freezer temperatures at the beginning of each shift, with specified acceptable temperature ranges.
Failure to Implement Ordered Floor Mats for High Fall-Risk Resident
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to implement ordered fall-prevention interventions for a resident assessed as high risk for falls. The resident was admitted with diagnoses including muscle weakness, history of falling, and cerebral infarction, and had a fall risk score of 11, indicating high fall risk. Physician orders dated 2/24/2026 directed the use of a low bed and floor mat to decrease potential injury, and the care plan for fall and injury risk instructed staff to utilize safety and supportive devices as ordered and provide adequate supervision and safety cues. The facility’s Falls and Fall Risk, Managing policy stated that staff will identify interventions based on evaluations and current data to prevent falls and minimize complications. On 3/4/2026, during observation of the resident’s room, surveyors noted a yellow star behind the bed indicating the resident was a fall risk and should have a low bed and floor mats in place, but no floor mats were present. The resident reported a history of falls but did not recall having a mat by the bed. The Infection Preventionist confirmed that the star signified the need for a low bed and floor mats and acknowledged that the absence of floor mats was not following the plan of care and could lead to a fall with possible injury. The Director of Staff Development stated the resident uses two landing mats and confirmed that at the time of observation the mats were not in the room and that the mats are intended to prevent injury when a resident falls. The Administrator also confirmed the resident had an order for floor mats, was a fall risk, and should have floor mats while in bed, and that without them there was potential for a fall resulting in injury or fracture.
Failure to Implement Contact Precautions and Risk Assessment for Suspected and Confirmed C. difficile
Penalty
Summary
The deficiency involves the facility’s failure to implement contact isolation precautions for a resident who developed signs and symptoms consistent with Clostridioides difficile infection (CDI) and was later confirmed positive. The resident was admitted with diagnoses including pulmonary embolism and sepsis and subsequently developed diarrhea meeting the facility’s criteria for suspected CDI on 1/18/2026. A physician ordered a stool test for CDI on that date, but the resident was not placed on contact precautions at the time of suspicion, despite facility policy requiring contact precautions for residents with diarrhea and suspected CDI while awaiting laboratory results. The resident’s change in condition evaluation on 1/20/2026 documented CDI with onset of symptoms on 1/18/2026, and the resident was not placed on contact isolation until 1/20/2026, after the physician ordered contact isolation for a positive CDI result. During this period, the CDI-positive resident continued to share a room with two roommates. One roommate had diffuse large B-cell lymphoma, was actively receiving antineoplastic chemotherapy, and was identified as immunocompromised and at high risk for infection. This roommate’s care plan, initiated later, identified her as at high risk for nosocomial infection and indicated staff should perform hand hygiene and wear gowns and gloves during high-contact activities, but there was no evidence that this high-risk status was used to prevent her from being cohorted with a resident with active CDI. The other roommate had multiple chronic conditions, including hypertrophic cardiomyopathy, chronic kidney disease, type 2 DM, depression, and anxiety, and required substantial assistance with ADLs. Both roommates remained in the same room with the CDI-positive resident while an isolation cart and contact precaution sign were posted outside the room. The facility did not complete infection risk assessments for either roommate before or during their cohorting with the resident who had CDI. The DON confirmed there was no documented evidence of infection risk assessments for these roommates between 1/17/2026 and 1/30/2026, and stated that such assessments should have been completed by the Infection Preventionist or a licensed nurse to determine appropriate roommate placement when a resident had an infection. The Infection Preventionist Nurse and DON acknowledged that the immunocompromised roommate should not have been placed with the CDI-positive resident and that the facility failed to follow its own CDI and isolation policies, which required private rooms when possible or cohorting only with low-risk roommates. The facility also failed to inform and educate the two roommates about their potential risk of acquiring CDI and the infection control guidelines they should follow. One roommate reported not understanding why the room was on isolation and stated that staff did not provide any explanation when asked. The other roommate, aware of her compromised immune system and ongoing chemotherapy, stated she was not told why staff were wearing gowns when caring for her roommate and was reassured that it had nothing to do with her, despite her expressed concerns. The Infection Preventionist Nurse confirmed there was no documented evidence that staff notified or educated the roommates about their risk for CDI or appropriate precautions. Additionally, the facility did not monitor the two roommates for signs and symptoms of CDI after their exposure to the infected resident. The Infection Preventionist Nurse stated that no monitoring was conducted for these roommates for CDI-related symptoms such as fever, abdominal pain or spasms, diarrhea, nausea, or vomiting. The Medical Director stated that staff were aware of appropriate infection control measures but failed to implement them, and that staff did not follow facility policy or CDC guidelines regarding cohorting and isolation for CDI. The DON described this as a failure in the facility’s system process, including lack of staff training on isolation precautions and infection risk assessments, which contributed to the deficient practice. The facility’s written policies required that residents with diarrhea and suspected CDI be placed on contact precautions while awaiting lab results, and that residents with diarrhea associated with CDI be placed on contact precautions. The isolation policy further required that residents on contact precautions be placed in a private room if possible, or, if not, that the Infection Preventionist assess risks and cohort only with low-risk roommates. Despite these written requirements, the resident with CDI remained in a shared room with an immunocompromised roommate and another medically complex roommate, without documented risk assessments, without timely initiation of contact precautions at the time of suspicion, without education of roommates about their risk and needed precautions, and without monitoring of the roommates for CDI symptoms. These actions and omissions formed the basis of the cited infection control deficiency under F880.
Removal Plan
- Moved Resident 2 to Room B with no roommates due to immunocompromised condition and initiated RN Supervisor monitoring every shift for 40 days for CDI signs/symptoms.
- Designated Room A as a single isolation room and assigned Resident 1 no roommates.
- Reviewed and revised Resident 2’s care plan to reflect immunocompromised status and that Resident 2 should not share a room with a resident who has an active infection.
- Conducted in-service training for all nursing staff on Infection Control policy, with written quizzes to validate understanding; provided phone/follow-up training for staff not present prior to next shift; removed from schedule any staff who did not complete training until completed.
- Provided one-on-one in-service to the Administrator and DON on the admission process for residents requiring isolation precautions and appropriate cohorting.
- Provided one-on-one in-service training to the Infection Preventionist Nurse on infection control practices, including proper PPE use and appropriate cohorting.
- Conducted record review of all residents with changes in condition to identify residents with signs/symptoms consistent with CDI; found no other affected residents.
- Assessed all residents for CDI signs/symptoms; found no additional affected residents.
- Implemented process for DON and Infection Preventionist Nurse to review all incoming admissions to determine need for isolation/precautions and arrange appropriate room placement/cohorting.
- Implemented Infection Preventionist Nurse tracking log for all residents with active infections, including CDI, to prevent spread.
- Established monthly infection control meetings led by Administrator and IDT to ensure adherence to infection control and PPE policies and to promptly identify/address room placement and cohorting issues.
- Developed a QAPI plan for Infection Control practices including root cause analysis to be reviewed and updated during monthly QAPI meetings for three months to ensure corrective actions are effective and sustained.
Failure to Report Allegation of Misappropriation of Resident Property to SSA
Penalty
Summary
The facility failed to report an allegation of misappropriation of resident property to the State Survey Agency (SSA) as required by regulation and facility policy. A resident admitted with muscle weakness and sepsis had documentation in the History and Physical and Minimum Data Set indicating intact cognitive function and capacity to understand and make decisions. During an interview, the resident reported that a family member visitor took his wallet, left the facility, charged $500 to his credit card, and then returned the wallet and card. The resident stated he had informed the Social Worker of this incident, though he could not recall the exact date and time of either the event or the report. The Social Worker confirmed that the resident had reported that the family member took the wallet and charged $500 to the resident’s credit card, without specifying the date and time. The Administrator acknowledged that the resident had informed the Social Worker of the allegation and that she did not report this allegation of misappropriation of property to the SSA. The facility’s abuse, neglect, exploitation, and misappropriation reporting policy, last reviewed on 8/15/2025, states that all reports of theft or misappropriation of resident property must be reported to local, state, and federal agencies as required, and that suspected misappropriation must be reported immediately to the Administrator and to the state licensing/certification agency, with “immediately” defined as within two hours for allegations involving abuse or misappropriation. Despite this policy, the allegation was not reported to the SSA.
Failure to Care Plan for Immunocompromised Resident at High Risk for Infection
Penalty
Summary
Surveyors identified that the facility failed to develop and implement a comprehensive, person-centered care plan with measurable objectives and timetables for a resident who was immunocompromised and at high risk for infection. The resident’s face sheet showed an original admission with a readmission date and diagnoses including diffuse large B-cell lymphoma, encounter for antineoplastic chemotherapy, and acquired absence of kidney. The resident’s MDS indicated intact cognition and a need for substantial/maximal assistance with toileting hygiene, showering/bathing, lower body dressing, and footwear. Despite these documented conditions and functional needs, there was no care plan addressing the resident’s immunocompromised status. During an interview and concurrent record review with the DON, it was confirmed that licensed staff or the MDS Coordinator did not initiate a care plan upon admission to address the resident’s immunocompromised condition related to diffuse large B-cell lymphoma. The DON acknowledged that the care plan should have included interventions such as not cohorting the resident with others who had active infections and that the existing care plan was not comprehensive or person-centered. Review of the facility’s policy on comprehensive, person-centered care plans showed that care plans were required to include measurable objectives and timetables, be derived from a thorough assessment, describe needed services, and reflect recognized standards of practice, which was not done for this resident’s immunocompromised status.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Burbank
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Griffith Park Healthcare Center | 0 mi | ★★★★★ | 42 | 1 |
| Alameda Care Center | 0.1 mi | ★★★★★ | 15 | 0 |
| Dreier's Nursing Care Center | 1.7 mi | ★★★★★ | 4 | 0 |
| Broadway Manor Care Center | 2.5 mi | ★★★★★ | 18 | 0 |
| Royal Palms Post Acute | 2.5 mi | ★★★★★ | 35 | 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.