Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at California Post-acute Care during CMS and state inspections, most recent first.
Staff were not trained or in-serviced on trauma, trauma-informed care, PTSD, or trauma assessments, despite the facility’s policy requiring all staff to receive education on these topics and nursing staff to be trained on screening tools and identifying triggers. The in-service schedule showed no trauma-related training, employee files for sampled CNAs, an LVN, and RNs had no documentation of such training, and the SSD, DSD, and DON all stated that these topics had not been part of routine training or onboarding.
A resident with cancer, morbid obesity, severe debility, and a painful abdominal catheter was held in place and had her arms restrained by two CNAs during perineal care after repeatedly saying no and asking them to stop. The resident yelled that they were killing her, reported extreme pain and feeling assaulted, and said she did not feel safe. The CNAs said they continued because they were focused on finishing care and did not want to fall behind, while the ADM stated staff should stop when a resident refuses care.
Failure to Provide Ordered 1:1 Supervision After Altercation: A resident with hemiplegia, schizophrenia, and psychosis was involved in a resident-to-resident altercation and was ordered 1:1 supervision due to the physical aggression. Facility staffing records did not show the resident was assigned 1:1 supervision across multiple shifts and days, despite the DON stating the resident needed a pre-designated staff member at all times and the DSD stating a CNA would typically provide the supervision.
Failure to Provide Daily Bathing per Care Plan: A resident with no cognitive impairment, generalized muscle weakness, morbid obesity, and OA of both knees required substantial to maximal assistance with bathing and was care planned for a daily bath/shower. Facility documentation showed CNAs were to provide bathing, but the record did not indicate the resident received daily bathing as planned, and the DON confirmed the documentation did not show the care was provided.
A resident with hemiplegia, schizophrenia, and psychosis was involved in a resident-to-resident altercation and was ordered 1:1 supervision by the MD. However, the care plan was not updated to include that intervention, and the DON confirmed the 1:1 supervision was not reflected in the care plan even though care plans were revised after such incidents.
Failure to Provide Required ADL Assistance: A resident with generalized muscle weakness, morbid obesity, and osteoarthritis required substantial to maximal assistance for bathing and toileting hygiene per the MDS, but CNA documentation did not show that this level of assistance was provided. The DON stated the MDS guided the plan of care and that the resident should receive the level of care indicated for bathing and toileting hygiene.
Failure to identify a decline in ADLs and mobility delayed consideration of renewed rehab services for a resident with generalized muscle weakness, morbid obesity, and bilateral knee OA. After OT/PT discharge at maximum potential, later MDS assessments showed the resident still needed substantial to maximal assistance for toileting hygiene and bed mobility, but the RC was not notified of the decline and the DON stated there was no documentation that the physician was notified to consider new PT/OT evaluations.
Physician Discharge Summary Not Completed by Physician: The facility failed to ensure a physician completed the discharge summary assessment for two residents transferred to the hospital. One resident had CHF, weakness, morbid obesity, and OA and was sent out by EMS for low BP, low O2, and flushing. Another resident had weakness, abnormal gait, bipolar disorder, delusions, anxiety, depression, and right-sided paralysis after a CVA and was transferred after an altercation. RN and DON stated the discharge summary was completed by an RN, with the physician’s name entered in the electronic signature area.
A resident with hemiplegia, severe malnutrition, PVD, bowel incontinence, and dependence for ADLs developed a stage 3 sacral pressure ulcer. Records showed the care plan called for q2h repositioning, skin checks each shift, and keeping the resident clean and dry, but turning logs, CNA shower skin checks, and shift documentation were blank or did not show the resident was repositioned. The SBAR and PA wound note documented the new sacral wound, and an LVN stated it was related to prolonged pressure and lack of turning.
Delayed reporting and investigation of an unexplained eye injury. A resident with dementia and severe cognitive impairment was found with swelling and a hematoma above the right eye, and he could not explain how it happened; he later said an unidentified person hit him. Staff notified the RN and DON, but the DON did not treat the injury as an injury of unknown origin right away and waited before reporting it to the SA. The facility’s investigation record did not include the resident’s allegation, and the report was not sent to the SA until hours after the injury was first identified.
A resident with an indwelling urinary catheter and nephrostomy tube had both drain bags observed on the floor, and the nephrostomy tube gauze dressing was soiled and dirty. Staff stated the bag placement could lead to infection and that the dressing should be changed when soiled, while the facility catheter care policy required drainage bags to be kept off the floor at all times.
DON Wore Smart Glasses With Camera Capability in Facility: The DON was observed wearing Smart Glasses with built-in video and photo capabilities while inside the facility. The DON stated he wore them as prescription eyeglasses and was not recording, but also acknowledged the glasses had camera functions. The ADM stated devices with camera or recording capabilities are prohibited in areas with confidential information and said the DON should not have worn them around residents, resident records, or confidential documents.
Unsafe Food Storage, Handling, and Dishwashing Practices: A Dietary Aid and surveyor observed an open bag of bread left uncovered on the counter, crumbs and food debris on the tray line, used utensils left out, pasteurized eggs unattended on a cart, uncovered applesauce in the refrigerator, soiled dishes and forks left on the tray line, and a dishwashing area with water on the floor and visible debris. Unsealed, unlabeled sandwiches were also found in the refrigerator, and the RDM reviewed policies requiring food to be covered, labeled, dated, and stored in a sanitary manner.
Aspirin orders for two residents were not clarified before administration, with an LPN giving enteric coated aspirin when the orders did not specify the form. The facility also did not reconcile an eKIT containing controlled meds at shift change, delayed reordering an opioid for a resident with MS and chronic pain until after doses were depleted, and left five unidentified pills unattended on another resident’s bedside table instead of disposing of them.
A resident with bipolar disorder, dementia, anxiety, and depression received Divalproex Sodium without a clear seizure diagnosis, and staff stated the medication was actually being used for behavioral symptoms. The order did not identify a specific target behavior, and a later order for mood cycling monitoring was entered incorrectly so no documentation was required, leaving the MAR without behavioral tracking. RN and DON interviews confirmed the medication’s indication and monitoring were unclear, and the facility policy required rationale, specific target behaviors, and efficacy monitoring for behavioral medications.
Medication administration errors caused the facility’s error rate to exceed 5%. An LVN gave a resident famotidine and an unprescribed multivitamin with minerals, but omitted ordered aspirin for CVA PPX and did not give famotidine within the required time window. The DON confirmed the nurse failed to follow the five rights and facility medication administration guidelines.
Medication storage and labeling were not maintained as required in several med carts and a med refrigerator. Staff stored Med Pass with resident meds in a med refrigerator, left multiple insulin pens and a Lantus vial at room temperature without open dates, and kept opened budesonide inhalation solution pouches without dating them. An unopened box of Bengay cream was also found at a resident’s bedside despite staff stating meds and topicals should not be kept there.
Failure to identify a responsible party for a resident without decision-making capacity. A resident with hemiplegia, hemiparesis, and aphasia was documented as severely cognitively impaired and unable to understand or make decisions, yet the Face Sheet listed the resident as self-responsible. The SSD stated the listed EC could not be reached, other contacts were also unreachable, and no RP was established to make medical decisions on the resident’s behalf.
A facility failed to obtain or verify informed consent before giving influenza and COVID-19 vaccines to a resident with severely impaired decision-making capacity and before administering Divalproex Sodium for another resident’s behavioral symptoms. Records showed one resident was documented as unable to understand and make decisions, yet consent was recorded as coming from the resident, while the other resident received the medication before the RP’s consent was verified. Staff and the DON stated informed consent was required from the resident or RP before these treatments.
Failure to notify the physician and RP of resident changes in condition: one resident with dementia and self-scratching behavior had facial scratches observed, but the RP and MD were not notified; another resident with aphasia, hemiplegia, and severely impaired decision-making had a low O2 sat episode and a g-tube tear, yet SBARs listed the resident as self-responsible and staff did not contact the EC/family as required by the resident’s condition.
A resident with COPD, dysphagia, acute respiratory failure with hypoxia, asthma, pulmonary embolism, hemiplegia/hemiparesis from stroke, and dementia had a nebulizer with cannula left on the floor beside the bed. Staff also observed multiple wall scuffs and dry brown matter on a coax cable near the bed. CNA, MDHS, and IPN interviews confirmed the equipment placement and room conditions were not consistent with a clean, sanitary, and homelike environment.
Failure to Report Injury of Unknown Origin: A resident with dementia and impaired decision-making was found with a purple-blue discoloration under the left eye that staff could not explain. The CNA, LVN, DON, and ADM all described the cause as unknown after interviews and review of the event, but the injury was not reported to the State agency, Ombudsman, or law enforcement as required by policy.
A resident with schizophrenia, dysphagia, HTN, and severely impaired cognition had a PASARR Level 1 screening that indicated the need for a Level 2 evaluation, but the evaluation was not completed. Record review showed facility staff were unresponsive to repeated attempts at communication, and the MDSC stated staff should have responded and completed another Level 1 screening to prompt the Level 2 process.
The facility failed to develop comprehensive care plans for two residents with significant needs. One resident with dementia, bipolar disorder, and depression had a long history of scratching his face and body, and staff observed facial scratches, but the care plan did not address the behavior. Another resident with COPD, CKD, HTN, severe cognitive impairment, and continuous O2 therapy had a physician order for oxygen at 2 LPM via nasal cannula with monitoring every shift, but the record did not include a care plan for oxygen use or related respiratory assessments and safety precautions.
Untrimmed and Dirty Fingernails Not Maintained for a Dependent Resident: A resident with Parkinson’s disease, dysphagia, muscle weakness, and impaired decision-making was dependent on staff for ADLs, yet staff observed the resident’s fingernails to be long, untrimmed, and dirty with debris under the nails. An LVN, IPN, and DON all stated nail care was part of routine ADL care and should be checked daily, but the resident’s nails remained unclean and untrimmed during observations.
A resident with CKD, DM, CHF, and an unhealed pressure injury did not receive ordered wound dressing changes for several days because wound care orders were not transcribed into the EMR in a timely manner. The resident reported daily dressing changes were required for a left heel pressure injury and bilateral shin wounds, but the TAR showed no documented treatments during the gap between orders. TN and PA staff stated the orders should have remained active and that the DON, ADON, and treatment nurse were responsible for transcribing the wound care updates.
Blocked Wheelchairs in Resident Room: A resident with Alzheimer’s Disease, impaired decision-making, and dependence for ADLs was observed with wheelchairs blocking the room entrance and bathroom doorway, including one wheelchair with footrests extended on the floor. Staff stated wheelchairs should not block resident pathways, and the DON confirmed that blocked pathways and bathroom entrances can interfere with safe mobility, transfers, and bathroom access. The facility’s Homelike Environment policy stated the environment should remain safe and orderly.
A resident with a suprapubic urinary catheter did not receive ordered daily catheter care, irrigation, or stoma dressing care. The resident was observed with the catheter exposed and no dressing over the stoma, and both the resident and TAR review indicated the care was not completed on the affected days. Staff interviews confirmed the LPN/RN and treatment nurse did not complete the ordered care, and the DON stated the missed care increased the resident’s risk for UTI.
Failure to Provide Ordered Continuous Oxygen Therapy: A resident with COPD, acute respiratory failure w/ hypoxia, and severe cognitive impairment was ordered continuous O2 at 2 L/min via NC, but records showed O2 sats documented on room air and an observation found the NC wrapped around the concentrator with the machine off. RN confirmed the resident was not receiving O2 continuously as ordered.
A resident receiving divalproex sodium for mood stabilization had a pharmacist MRR recommending a valproic acid level, CMP, and CBC to monitor for toxicity. The MRR showed physician approval, but the lab orders were never entered into the chart, and the DON confirmed the orders were not inputted after approval despite the facility policy requiring pharmacist recommendations to be acted upon and documented.
Failure to Honor Food Preferences and Offer Meal Alternatives: A resident with intact cognition, DM, and mild protein-calorie malnutrition reported skipping breakfast because she disliked the meals being served and said staff did not ask about her food preferences or offer substitutes with adequate nutritive value. A CNA observed an untouched breakfast tray at the bedside, took it back to the kitchen after the resident declined it, and did not offer an alternative; the RDM and RD stated meal alternatives are important to meet nutrition needs and food preferences.
A resident with hemiplegia, hemiparesis, and aphasia was documented as self-responsible on the Face Sheet even though the MDS and H&P showed severely impaired decision-making and no capacity to make decisions. The SSD said communication about the resident’s care should have gone to EC 1, and RN and DON interviews confirmed the Face Sheet and SBARs were inaccurate and led to the plan of care being discussed with the wrong individual.
Missing Current Hospice Plan of Care: A resident receiving hospice services had a hospice binder that did not contain the most recent hospice POC. The resident had dysphagia, schizophrenia, HTN, and severely impaired cognitive skills, and was dependent on staff for toileting, bathing, and personal hygiene. The HCM said the POC should be in the binder and updated weekly, while the SSD stated she had not been checking the binders to ensure the current POC was obtained.
The facility failed to follow infection control measures for two residents. One resident with a G-tube and severe cognitive impairment did not have the required EBP sign posted outside the room, and a CNA confirmed the sign should have been displayed to alert staff to use PPE. For another resident with CKD, DM, CHF, and an unhealed pressure injury, an LPN began a wound dressing change without an isolation gown and cleaned the wound without removing soiled gloves or performing hand hygiene, despite EBP and wound care policies requiring gown use, hand hygiene, and new gloves.
Call Lights Not Kept Within Resident Reach: Two residents were observed with call lights out of reach. One resident with severe cognitive impairment and significant medical diagnoses had the call light hanging behind and under the bed while lying in bed. Another resident with intact cognition and needing supervision or touching assistance had the call light on the floor on the opposite side while seated in a wheelchair next to the bed. The DON stated call lights should remain within reach at all times, and the facility policy required the call light to be within easy reach when a resident is in bed or confined to a chair.
A resident with schizophrenia and severe cognitive impairment received Depakote 250 mg twice daily as a mood stabilizer based on a physician order that did not specify the particular mood or behavior it was intended to treat. The DON acknowledged that psychotropic orders should identify specific, quantifiable behaviors to allow staff to monitor effectiveness and necessity, but this resident’s Depakote order lacked such detail, resulting in no behavior monitoring. Facility policy required identification and documentation of symptoms to justify antipsychotic use and stated that diagnosis alone was insufficient, yet the medication was continued without documented target symptoms or monitoring, placing the resident at risk for serious adverse effects.
A resident with metabolic encephalopathy and severe cognitive impairment had an MDS that documented impaired vision but did not specify the severity of the impairment and failed to code ongoing anticonvulsant (divalproex) use within the look‑back period. Observations showed the resident could not track objects, misidentified numbers of fingers and colors, and a CNA reported the resident frequently walked into objects and felt her way around. The vision section of the MDS was completed by a Social Services Assistant who had not been trained on MDS vision assessment, did not test the resident with printed material, and was unsure of the MDS’s purpose. The DON reported there was no nurse assigned to assist with MDS completion, despite facility policy requiring qualified staff and accurate reflection of the resident’s status during the observation period.
A resident with severe cognitive impairment, metabolic encephalopathy, and schizophrenia had a documented history of intrusive sexualized behaviors, including entering others’ rooms, touching and attempting to kiss male residents, and making inappropriate comments. A COC assessment and care plan required 1:1 supervision and close monitoring when the resident was near others or in shared areas, but staffing records and CNA interviews showed that this supervision was not implemented over several days. During this period, the resident repeatedly wandered into another resident’s room, upsetting him, and later approached him in a hallway while he was in a wheelchair and touched his genitals without permission, leading him to grab her wrist to stop the contact. The DON confirmed that the care plan called for 1:1 monitoring and that it was not carried out, despite facility policy requiring implementation of individualized safety interventions.
A resident with severe cognitive impairment and impaired vision, requiring supervision for ADLs and ambulation, did not have a care plan addressing visual impairment despite MDS findings. The resident, identified as high risk for falls, experienced a fall in the lobby and later an unwitnessed fall in the rehab room after tripping on a weight scale, but staff did not complete a post-fall risk assessment or a COC assessment as required by facility policy. The DON confirmed that these assessments and care planning steps should have been completed to address fall risks and changes in condition.
Surveyors found unsanitary conditions in the kitchen utility room, including dirty, standing water and debris under the manual dishwashing and sanitizing stations. A dietary aide reported that the sanitizing station had been leaking for weeks and that the utility room was dirty and cluttered, without having been cleaned or organized. A dietary cook confirmed ongoing pooling of dirty water and debris under the sanitizing station and stated staff were expected to remove food waste from sink strainers after dishwashing. Review of the facility’s sanitation policy showed requirements for maintaining equipment in working order, maintenance support for Food & Nutrition Services, and a cleaning schedule designated by the FNS Director.
Surveyors found that multiple closets and resident rooms were not maintained in a clean, safe, and sanitary condition. The Maintenance Director acknowledged broken and detached baseboards, cluttered and dirty floors, debris, and employee files and boxes stored on dirty floors in several closets, and could not state when some rooms were last cleaned. A resident with muscle weakness and HTN, who had decision-making capacity and required assistance with ADLs, reported that her room and bathroom had not been cleaned for several days, were dirty, and had ants present, and she felt dehumanized by these conditions. Observations showed stained furniture where she stored clothes, moldy food in a dresser drawer, and multiple cups left in the room. A shared restroom for two rooms contained multiple basins with pooled dirty water and yellowing towels under the sink. The IP stated that moldy food could cause infections and attract pests and that housekeeping should clean storage areas daily, while a CNA acknowledged the dirty basins and towels should have been removed and cleaned, contrary to facility sanitation and homelike environment policies.
The facility failed to maintain an effective pest control program and adequate sanitation, as shown by a pest control report noting damaged, peeling baseboards at an entry door that could harbor roaches and recommending sealing and improved sanitation. The Maintenance Director acknowledged detached baseboards and cracks in a shared restroom that could allow roach entry. A resident reported that her room and bathroom had not been cleaned for several days, described them as dirty, and pointed out ants crawling on a drawer, stating she felt dehumanized by the conditions, despite a written pest control policy requiring the building be kept free of insects and rodents.
Surveyors found that multiple resident rooms and adjacent hallways were not kept clean or sanitary, including dirty hallway floors with food crumbs and trash, dirty towels on bathroom floors, towels and trash on a resident room floor, a bedpan with smeared feces placed on a vanity, and smeared feces on a toilet flush handle. During observation, the DON acknowledged that these conditions could attract pests, spread germs, cause infections, make residents uncomfortable, and create tripping hazards. Review of the facility’s cleaning and disinfection policy showed that environmental and housekeeping surfaces, including floors, furniture, and bed rails, were required to be regularly cleaned when visibly soiled and disinfected with an EPA-registered hospital disinfectant, but these practices were not followed in Rooms A, B, C, D, E, F, and G.
A resident with muscle weakness, difficulty walking, and fluctuating decision-making capacity, but generally able to communicate, required varying levels of assistance with ADLs per the MDS. The resident’s attorney requested the resident’s medical records from the MRD by phone and email, but the records were not released within the timeframe required by facility policy, which specified provision as soon as practicable within 5 days, up to 30 days from a written request. The MRD delayed sending the records while awaiting corporate review and supervisor verification, resulting in the request exceeding 30 days and violating the resident’s and representative’s rights to access the medical record.
A resident with muscle weakness and cellulitis had a sacral skin tear documented on an SBAR form, but this wound was not recorded on the Transfer Sheet when the resident was sent to a GACH for fever. In addition, the required weekly skin assessment for the sacral skin tear was not completed during the week it was due because no wound care provider was available, despite facility policies requiring skin condition documentation at discharge and comprehensive weekly skin assessments.
A resident with paraplegia and major depressive disorder, who was dependent on staff for transfers and most ADLs, had his wheelchair, ice chest, and other personal belongings removed from his room for fumigation and not returned in a timely manner. Staff, including CNAs, cleared the room and stored the items; afterward, the resident reported feeling harassed and controlled and stated that his wheelchair and ice chest were taken and not brought back. CNAs and an LVN confirmed the removal of the property, and the DON indicated the SW was responsible for returning it, while the ADM stated he had instructed staff to return the items after cleaning. This handling of the resident’s belongings conflicted with facility policy that residents be provided a homelike environment and encouraged to use their personal possessions.
Staff failed to follow Enhanced Barrier Precautions (EBP) by not wearing required gowns and gloves during high-contact care for three residents with indwelling devices or a colostomy. One resident with quadriplegia and a Foley catheter received mobility assistance from a CNA whose hands, arms, and uniform contacted the resident and linens without PPE. Another resident with quadriplegia and a suprapubic catheter was fed by a CNA who did not wear a gown, despite EBP orders. A third resident with a colostomy and severe cognitive impairment was repositioned and fed by CNAs who did not wear gowns or gloves, even though posted EBP signage and facility policy required PPE for high-contact activities such as feeding, turning, and repositioning, as confirmed by an LVN and the DON.
A resident with hypertension and legal blindness was involved in a verbal altercation with a CNA, during which inappropriate language was exchanged and the CNA allegedly yelled at the resident. Although staff witnessed or were aware of the incident, it was not reported to CDPH as required by facility policy, resulting in a delay in investigation.
A resident with hypertension and legal blindness was involved in a verbal altercation with a CNA, during which both parties used inappropriate language and the CNA yelled at the resident. Although the incident was documented in progress notes, no investigation was initiated within the required 24-hour period due to a delay in reporting the event to the ADM, contrary to the facility's abuse policy.
A resident who was dependent on staff for all care and incontinent of bowel was readmitted without a documented skin assessment, contrary to facility policy. Wounds including deep tissue injuries and abrasions were not identified or treated until days later, resulting in delayed wound care.
Staff Not Trained on Trauma-Informed Care
Penalty
Summary
The facility failed to implement its Trauma Informed Care policy by not ensuring staff received training or in-services on trauma, trauma-informed care, PTSD, or trauma assessments. A review of the 2026 in-service schedule did not show any trauma-related education scheduled for staff, and employee files for five sampled staff members, including CNAs, an LVN, and RNs, did not contain records of training on these topics. During interviews, the LVN stated she had not received trauma-related training or in-services. The SSD stated that she or the SSA were primarily responsible for completing the Brief Trauma Questionnaire and that, to her knowledge, no other staff were trained to complete the questionnaire or assess residents for trauma and triggers. The DSD stated that trauma-informed care or PTSD in-services had not been conducted and had never been on the training calendar, and the DON stated that trauma-related in-services were not provided and were not part of routine onboarding or ongoing training. The facility policy stated that all staff were to receive in-service training about trauma, its impact on health, and PTSD, and that nursing staff were to be trained on screening tools, trauma assessments, and identifying triggers associated with re-traumatization.
Resident Held Down During Refused Care
Penalty
Summary
The facility failed to ensure a resident was free from the use of physical restraints when two CNAs held the resident down during personal care after the resident repeatedly refused the care. The resident had diagnoses including malignant neoplasm of the ovary, liver, and bile duct, morbid obesity, widespread metastatic disease, generalized weakness, severe debility, and required extensive assistance with ADLs. The resident also had a PleurX catheter to the right abdomen and reported moderate pain at the catheter site. The resident was bedbound, had clear speech, and had no cognitive impairment or disorganized thinking. During the early morning care episode, two CNAs entered the resident’s room to provide perineal care and change an incontinent brief. While the resident was being turned and cleaned, she became increasingly agitated, yelled that they were killing her, and repeatedly asked them to leave her alone and stop touching her. One CNA continued to hold the resident in a side-lying position while the resident struck her, and the other CNA restrained one of the resident’s hands and then both arms when the resident continued to move and resist. The CNAs continued the care despite the resident repeatedly saying no and asking them to stop. The resident later reported that two CNAs attempted to hold her down while providing care and stated she felt physically assaulted. In interview, the resident said the turning caused extreme pain and that she did not feel safe in the facility. The CNAs stated they continued because they were focused on completing the care and did not want to fall behind, and one CNA stated they felt short-staffed. The Administrator stated that if a resident was refusing care or saying no while care was being attempted, staff should respect the refusal and stop the care. The facility’s policies defined restraints as any manual method that restricts freedom of movement and stated restraints were not to be used for staff convenience.
Failure to Provide Ordered 1:1 Supervision After Resident Altercation
Penalty
Summary
The facility failed to ensure adequate abuse prevention for one resident by not providing ordered 1:1 supervision after the resident was involved as the aggressor in a resident-to-resident altercation. The resident had diagnoses including left-sided hemiplegia following cerebral infarction, schizophrenia, and psychosis not due to a substance or known physiological condition. The resident’s MDS dated 3/27/2026 indicated no cognitive impairment and that she required supervision/touch assistance from staff to wheel her wheelchair. A Change of Condition assessment dated 6/16/2026 at 10:59 a.m. documented that the resident was aggressive toward others and involved in an altercation with another resident, during which she pulled the other resident to the floor. A physician order dated 6/16/2026 directed 1:1 supervision from 6/16/2026 to 6/22/2026 due to the physical altercation, but the facility staffing record for the evening and night shifts on 6/16/2026 and 6/17/2026 did not indicate the resident was assigned 1:1 supervision, and staffing records from 6/17/2026 through 6/22/2026 also did not show 1:1 supervision. The DSD stated a CNA would typically be assigned to provide 1:1 supervision and that the facility had enough staff to provide it, while the DON stated 1:1 supervision required a pre-designated staff member to be with the resident at all times and that he was responsible for notifying the DSD when such orders were entered.
Failure to Provide Daily Bathing per Care Plan
Penalty
Summary
Resident 3, who had diagnoses of generalized muscle weakness, morbid obesity, and osteoarthritis of both knees, was admitted and later readmitted to the facility. Her MDS dated 3/27/2026 indicated she had no cognitive impairment and required substantial to maximal assistance from staff for showering and bathing, as well as mobility while in bed. Her care plan, created 9/22/2025 and revised 1/8/2026, stated that she was totally dependent on one staff member to provide a bath or shower daily and as necessary. A review of the facility record titled Documentation Survey Report for 5/1/2026 through 5/31/2026 and 6/1/2026 through 6/30/2026 showed that CNAs were to provide baths/showers to Resident 3, but the records did not indicate that she received a daily bath or shower from 5/1/2026 through 5/31/2026 or from 6/1/2026 through 6/23/2026. During interview, the DON stated the care plan indicated Resident 3 was to receive a daily bath, that this was important to meet her needs, and that frequent baths/showers aided in prevention of skin breakdown and were important for maintaining dignity and overall well-being. The DON also stated the medical record did not indicate staff provided Resident 3 with a daily bath as indicated in her care plan.
Care Plan Not Updated for Ordered 1:1 Supervision After Altercation
Penalty
Summary
The facility failed to ensure that Resident 5’s care plan was updated within 7 days of the comprehensive assessment and revised by the interdisciplinary team to reflect the physician’s order for 1:1 supervision after a resident-to-resident altercation. Resident 5 was admitted with diagnoses including left-sided hemiplegia following cerebral infarction, schizophrenia, and psychosis not due to a substance or known physiological condition. The MDS dated 3/27/2026 indicated Resident 5 had no cognitive impairment and required supervision/touch assistance to wheel her wheelchair. A Change of Condition assessment dated 6/16/2026 documented that Resident 5 was aggressive toward others and was involved in an altercation in which she pulled another resident to the floor. A physician order dated 6/16/2026 directed 1:1 supervision from 6/16/2026 to 6/22/2026 because of the physical altercation. During interview, the DON stated care plans were revised after resident-to-resident altercations and that the interventions should be included on the care plan so staff would be aware of them and implement them. The DON confirmed that Resident 5’s 1:1 supervision intervention was not included in her care plan.
Failure to Provide Required ADL Assistance
Penalty
Summary
The facility failed to provide Resident 3 with the level of assistance required for activities of daily living, specifically bathing and toileting hygiene. Resident 3 was admitted and later readmitted to the facility with diagnoses including generalized muscle weakness, morbid obesity, and osteoarthritis of both knees. Her MDS dated 3/27/2026 indicated she did not have cognitive impairment and required substantial to maximal assistance from staff for showering, bathing, and toileting hygiene. A review of the facility record titled Documentation Survey Report for 5/1/2026 through 6/30/2026 showed that CNAs were to document baths/showers and toileting hygiene provided to Resident 3, but the records did not indicate staff provided substantial to maximal assistance for bathing or toileting hygiene. During interview, the DON stated the MDS guided the plan of care and staff should provide the level of care indicated in the MDS, and that failure to provide the required assistance could result in the resident not being adequately cleaned, which could result in a UTI, skin breakdown, or negatively impact her dignity.
Failure to Identify Decline for Rehabilitative Services
Penalty
Summary
Provide or get specialized rehabilitative services as required for a resident was not ensured for one resident after a decline in ADLs and mobility. The resident had diagnoses of generalized muscle weakness, morbid obesity, and osteoarthritis of both knees. Her MDS showed she was independent in daily decision making but required substantial to maximal assistance for showering, bathing, toileting hygiene, rolling side to side in bed, and moving from lying to sitting. She had previously received OT and PT from 10/7/2025 to 12/11/2025, and both therapy discharge summaries stated she had achieved her maximum potential at discharge, with improvement to standby assistance for hygiene and grooming and standby assistance for rolling in bed, and minimal assistance for moving from lying to sitting. Later MDS assessments showed the resident continued to require substantial to maximal assistance for toileting hygiene and for rolling and moving from lying to sitting in bed. During interview, the RC stated she was not notified of the resident’s decline in hygiene tasks or mobility identified in the MDS assessments, and stated prompt notification was important so interventions could be implemented. The RC also stated that if there were a decline after therapy discharge, the resident would have benefited from renewed services and the physician could have been notified to determine whether new PT and OT evaluations were appropriate. The DON stated there was no documentation that the physician was notified of the resident’s decline in ADLs and mobility, and stated staff should have notified the physician so the care plan could be revised and the change in condition addressed.
Physician Discharge Summary Not Completed by Physician
Penalty
Summary
The facility failed to ensure the physician completed the Physician Discharge Summary assessment for two sampled residents. Resident 3 was admitted with congestive heart failure, generalized muscle weakness, morbid obesity, and osteoarthritis of both knees. The resident’s Discharge MDS dated 6/10/2026 indicated the resident was independent in daily decision-making but required substantial to maximal assistance for showering, bathing, and mobility in bed. A progress note dated 6/10/2026 documented that Resident 3 was transferred to the hospital via EMS due to low blood pressure, low blood oxygen levels, and a flushed appearance. Resident 4 was originally admitted with generalized muscle weakness, abnormal gait and mobility, bipolar disorder, delusional disorders, anxiety disorder, major depressive disorder, and inability to move the right side of the body following a cerebral infarction. The resident’s MDS indicated no cognitive impairment and set-up/clean-up assistance for most ADLs. A progress note dated 6/16/2026 documented that Resident 4 was transferred to the hospital after an altercation with another resident. During interview, RN 3 stated the Physician’s Discharge Summary was completed by an RN, not a physician, and that the physician’s electronic signature section was populated with the physician’s name. RN 3 also stated it was rare for the physician to see residents before transfer or complete transfer-related documentation. The DON stated the Physician’s Discharge Summary was an assessment completed by the RN performing the transfer.
Stage 3 Sacral Pressure Ulcer Linked to Missed Repositioning and Skin Checks
Penalty
Summary
Resident 4 developed a stage 3 pressure ulcer on the sacrum/coccyx area while at the facility. The resident had multiple risk factors documented in the record, including hemiplegia and hemiparesis following a cerebral infarction, muscle weakness and wasting, severe protein-calorie malnutrition, a left below-knee amputation, peripheral vascular disease, dysphagia, an indwelling catheter, and bowel incontinence. The admission skin assessment noted an ulcer on the left hip, and the Braden Scale on 4/7/2026 and 4/14/2026 identified the resident as at risk for pressure ulcers. The facility’s care plan for impaired skin integrity related to immobility, incontinence, poor perfusion, and malnutrition directed staff to reposition the resident every 2 hours and as needed, assess skin every shift for breakdown, keep skin clean and dry after each incontinence episode, and offload pressure to bony areas. However, the Nursing Weekly Summary for 4/8/2026, 4/15/2026, 4/22/2026, and 4/29/2026 did not indicate the resident was included on the turning and repositioning program or that skin was assessed. The CNA Shower Review form from 4/7/2026 through 5/5/2026 had blank visual assessment sections, and the ADL Repositioning Rounds Monitoring log for the afternoon and night shifts on 5/3/2026 and 5/3/2026 to 5/4/2026 did not include the resident or show that the resident was turned or repositioned every 2 hours. The every-shift documentation report for 5/3/2026 and 5/5/2026 day shifts had blank sections for turning/repositioning and skin observation. On 5/4/2026, the SBAR documented a stage 3 pressure injury at the sacrum/coccyx area and stated the condition was worsened by not being repositioned every 2 hours or changed when soiled. The PA wound progress note also documented a newly developed stage 3 sacral pressure ulcer acquired on 5/4/2026, measuring 4 cm by 4 cm with 0.10 cm depth and areas of granulation and slough. During interview, the LVN stated the wound developed from lack of turning and prolonged pressure and that CNAs did not check the resident’s skin and report changes during ADL care.
Delayed reporting and investigation of an unexplained eye injury
Penalty
Summary
The facility failed to follow its policies and procedures for injuries of unknown origin and for reporting and investigating abuse, neglect, exploitation, or misappropriation after a resident was found with swelling and a hematoma above the right eye. The resident had dementia, severe cognitive impairment, and was dependent on staff for toileting, personal hygiene, lower body dressing, footwear, and all mobility in and out of bed. On the morning the injury was identified, staff noted a new bump and swelling above the resident’s right eye, and an ice pack was applied. The resident was unable to give a clear or consistent explanation for the injury, and later stated that an unidentified person had struck him in the eye. Staff interviews showed the injury was recognized by a CNA, reported to the charge nurse, and then relayed to the RN and DON. The RN stated he assessed the resident and immediately notified the DON and Administrator. The DON stated he did not consider the swollen eye to be an injury of unknown origin because there was no discoloration, pain, or skin tear, and said other causes needed to be ruled out before reporting. The DON also stated the resident’s later statement that someone hit him was reported to the Administrator, but the Administrator stated he was not made aware of that allegation by the DON and only learned of the injury later that morning. The facility’s follow-up investigation report documented the swelling as having an unknown cause, but it did not include the resident’s allegation that he had been hit by an unidentified individual. The report showed the injury was not reported to the State Agency until several hours after it was first identified. The facility policies stated that unexplained injuries and suspicions of abuse, including injuries of unknown origin, were to be promptly reported and investigated, but the DON stated the incident should have been reported sooner and that staff should not have waited to verify the validity of the allegation before reporting.
Infection Control Failure With Catheter and Nephrostomy Tube Care
Penalty
Summary
The facility failed to implement infection control measures for Resident 4 by not ensuring the indwelling foley catheter drain bag and nephrostomy tube drain bag did not touch the floor. Resident 4 was admitted and readmitted to the facility with diagnoses including muscle weakness, muscle wasting, and atrophy. The MDS dated 4/11/2026 indicated the resident was usually able to understand and be understood by others, was dependent for multiple activities of daily living, had an indwelling urinary catheter, and was always incontinent of bowel. The care plan for risk of catheter-associated urinary infection included changing the dressing per physician order and facility protocol using aseptic technique. During observation and interview, Resident 4's nephrostomy tube gauze dressing was seen soiled with dark, yellow, and light brown discoloration, and staff stated it did not appear clean. RN 2 observed that the foley catheter and nephrostomy tube bags were on the floor and stated this could lead to infection and that the bag should be below bladder level but off the floor. The treatment nurse stated the nephrostomy tube connector was dirty and old in appearance and that the dressing should be changed daily or as needed when soiled because it could be a source of infection. LVN 1 also stated that when the foley and nephrostomy tube drain bags touch the floor, it could be a source of infection that could lead to UTI and hospitalization. The facility policy on catheter care indicated catheter drainage bags should be kept off the floor and should not touch the floor at any time.
DON Wore Smart Glasses With Camera Capability in Facility
Penalty
Summary
The facility failed to ensure the Director of Nursing (DON) did not wear Smart Glasses with built-in camera capabilities while inside the facility. During an observation in the hallway, the DON was seen wearing the Smart Glasses, and during a later concurrent interview and record review, the DON was again observed wearing them. The DON stated the eyeglasses were prescription glasses and said he was not recording at that time. He also stated the Smart Glasses had video and photo capabilities, but those functions were not active because the battery was depleted. During interview, the DON stated he wore the Smart Glasses to the facility because they were prescription eyeglasses and that he used them strictly for vision while in the building. The Administrator reviewed the Employee Handbook, which stated that phones and other devices with cameras or recording capabilities are strictly prohibited in work areas containing proprietary information or confidential documents. The Administrator stated the DON should not have worn the Smart Glasses inside the facility because of their photo and recording capabilities and said such devices should not be used or worn in the presence of confidential documents, resident documents, or residents themselves.
Unsafe Food Storage, Handling, and Dishwashing Practices
Penalty
Summary
Food safety and food handling practices were not maintained in the kitchen during a surveyor observation and interview with the Dietary Aid. An open bag of wheat bread was left exposed on the kitchen counter without protective covering or proper storage, and the kitchen tray line counter had accumulated crumbs, food debris, and used utensils and scoops resting on the surface between food preparation activities. The Dietary Aid stated the uncovered bread and leftover food after breakfast increased contamination risks, and that used utensils left out could spread germs, cause cross-contamination, and make meals unsafe. Additional unsafe storage and sanitation issues were observed in the kitchen and refrigerator. A tray of pasteurized eggs was left unattended on a cart near the kitchen sink, and a plastic container of apple sauce was left uncovered inside the refrigerator. Three soiled plates and two used forks were left unattended on the tray line, while the dishwashing area had water on the floor, cluttered dishes, and visible debris. Six peanut butter and jelly sandwiches on white bread and eight ham sandwiches on wheat bread were found unsealed and unlabeled in the refrigerator. The Regional Dietary Manager reviewed the facility policies on storage, cleaning, and labeling and stated these errors could expose residents to unsafe food, cross-contamination, unclean meal service areas, and foodborne illness.
Medication administration, controlled substance reconciliation, delayed opioid reorder, and improper disposal of bedside pills
Penalty
Summary
The facility failed to ensure safe medication administration for two residents when aspirin orders were not clarified before administration. One resident with heart disease was ordered aspirin 81 mg daily for CVA prophylaxis, and another resident with cerebral infarction was ordered aspirin 81 mg daily. During medication administration, an LVN gave both residents aspirin 81 mg enteric coated tablets even though the orders did not specify whether the aspirin should be chewable or enteric coated. During interview, the LVN stated the orders did not indicate which form to administer and that clarification was needed to ensure safe and appropriate absorption. The DON also stated the orders did not indicate which form to administer and that staff had failed to clarify the orders. The facility also failed to reconcile an emergency kit containing controlled medications in Medication Room Station A for May 2026. The DON stated the eKIT labeled 580, stored in the refrigerator in Medication Room A, contained controlled medications and was not reconciled at each shift change. The facility’s policy stated controlled substances in emergency kits are to be accounted for at each shift change or exchange of keys, and controlled substances are to be reconciled upon receipt, administration, disposition, and at the end of each shift. The facility failed to timely reorder oxycodone-acetaminophen for a resident with MS and chronic pain syndrome. The resident’s order was for oxycodone-acetaminophen 5-325 mg by mouth every four hours as needed for moderate to severe pain. The resident reported left leg pain and stated she had been told the medication was not delivered yet. Staff later stated the medication had not been reordered in time, and the resident’s controlled record showed the last dose was given on 5/11/2026. RN 1 stated the reorder process should have started when approximately 14 doses remained, and the DON stated the medication should have been reordered sooner and not after the doses were depleted. The facility also failed to properly dispose of five unidentified pills left on another resident’s bedside table. During observation, five pills were found in a medicine cup on the resident’s bedside table, and the resident stated she did not know whether the pills were hers or when they had been left there. RN 1 stated the nurse should not leave medications unattended at the bedside and should dispose of them in the waste medication container if the resident does not take them. The DON stated the pills should not have been left in the room and should have been properly disposed of immediately.
Unclear Divalproex Order Lacked Target Behavior and Monitoring
Penalty
Summary
The facility failed to ensure one resident’s drug regimen was free from unnecessary drugs when Divalproex Sodium was ordered without a clear, specific target behavior and without proper behavioral monitoring. Resident 79 had diagnoses including bipolar disorder, dementia, anxiety disorder, and depression, and the record did not show a diagnosis of seizures. The resident’s MDS indicated severely impaired cognitive skills for daily decision making and use of an anticonvulsant medication, but did not indicate seizures. During record review and interviews, the resident’s physician orders showed Divalproex Sodium 125 mg was ordered at different times for seizures and later for mood stabilizer related to anxiety disorder. RN 1 stated the resident never had a seizure diagnosis and that the medication was actually being used for behavioral symptoms. RN 1 and the DON both stated that the seizure indication was incorrect and that clarifying the order was necessary because use for seizures versus behavioral symptoms would require different monitoring and affect the plan of care. A later order directed staff to monitor episodes of mood cycling every shift, but the order also stated “No documentation required,” and RN 1 stated the order had been inputted incorrectly, resulting in no documentation of the number of episodes. RN 1 and the DON stated the medication should have had a specific target behavior and behavioral monitoring to determine effectiveness. The facility policy titled Behavioral Assessment, Intervention, and Monitoring stated medications prescribed for behavioral symptoms must include rationale for use, specific target behaviors, and monitoring for efficacy.
Medication Error Rate Exceeded Allowed Threshold
Penalty
Summary
The facility failed to ensure its medication error rate remained below 5 percent. Surveyors observed LVN 5 administering famotidine 20 mg and a multivitamin with minerals to Resident 110 during the morning medication pass, but aspirin 81 mg EC was not administered. LVN 5 later stated she gave famotidine and the multivitamin but did not prepare or administer the aspirin during the morning medication administration, and acknowledged that the resident did not receive famotidine and aspirin within the facility’s 60-minute medication window. LVN 5 also stated the multivitamin with minerals had not been prescribed by the resident’s physician and that she failed to follow the five rights of medication administration. Resident 110’s record showed diagnoses of cerebral infarction, dysphagia, and hypertension. The physician’s orders listed aspirin EC 81 mg daily for CVA prophylaxis and famotidine 20 mg daily for heartburn, while the MAR did not include an order for multivitamin with minerals. The DON stated the nurse failed to administer famotidine within one hour of the scheduled time, omitted aspirin, and administered multivitamin with minerals without a physician order. The facility calculated 3 medication errors out of 27 opportunities, for an overall error rate of 11.11 percent.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Drugs and biologicals were not stored and labeled in accordance with facility policy and manufacturer requirements in multiple medication storage areas. In Medication Room Station C, surveyors observed a medication refrigerator containing resident medications together with one open carton and one closed carton of Med Pass 2.0. The LVN present stated the refrigerator should be used only for medications and acknowledged that the nutritional drink was stored with resident medications, creating a risk of cross contamination. The facility’s policy stated medications are to be stored separately from food, and the food receiving and storage policy stated medications, blood, or blood products may not be stored in the same refrigerator with food. In Medication Cart C, surveyors found an opened and used insulin Lispro pen for one resident, an opened and used insulin Lantus pen for another resident, an opened and used insulin Humulin N pen for a third resident, and an opened budesonide inhalation solution foil pouch for a fourth resident, all stored at room temperature without a date showing when room-temperature storage or opening began. The LVN stated the insulin pens were multi-dose medications and that the dates were needed to determine when they expired. The LVN also stated the budesonide inhalation solution pouch should have been dated when opened and that the remaining inhalation solutions should be discarded after two weeks. The DON later stated several LVNs failed to label the budesonide foil pouches when opened and failed to label insulin pens and vials when opened or stored at room temperature. In Medication Cart D, surveyors found two opened Humalog pens and one opened glargine pen stored at room temperature without dates, along with one unopened Lantus vial stored at room temperature without a date showing when room-temperature storage began. The LVN stated the pens and vial were multi-dose medications and that the dates were needed to determine expiration. In Medication Cart B, surveyors found an opened budesonide inhalation solution foil pouch for another resident stored at room temperature without a date indicating when the pouch was opened. In a resident room, an unopened box of Bengay cream was observed on the dresser of a resident who had moderate cognitive impairment and did not have medical decision-making capacity. The resident stated his son had brought the cream for leg pain, and the LVN stated residents should not have medications, including topical creams, at bedside because they require physician order and pharmacy approval.
Failure to Identify a Responsible Party for a Resident Without Decision-Making Capacity
Penalty
Summary
The facility failed to identify and determine a responsible party for Resident 63, a resident with hemiplegia and hemiparesis following cerebral infarction and aphasia. The resident’s Face Sheet listed the resident as self-responsible and identified three family members as emergency contacts, along with two additional family members without a contact type. However, the resident’s MDS dated 3/5/2026 indicated severely impaired cognitive skills for daily decision making and dependence on staff for multiple activities of daily living, and the H&P dated 8/29/2025 stated the resident did not have the capacity to understand and make decisions. During interview, the SSD stated Resident 63 was aphasic, could not understand the plan of care, and could not make medical decisions, and that communication regarding the resident’s health was supposed to be with Emergency Contact 1. The SSD also stated she had been unable to reach Emergency Contact 1 for the last two care conferences, had attempted to call the other listed emergency contacts without success, and did not contact the two additional family members because no contact type was listed for them. The SSD stated she should have realized the resident had no RP because Emergency Contact 1’s phone number was not valid. The DON stated that having a designated RP for residents without decision-making capabilities was important for communication and for making critical decisions if an emergency or change in condition occurred. The facility policy stated that if a resident was determined to be incompetent, the resident’s rights would be exercised by the resident representative on the resident’s behalf.
Failure to Obtain Informed Consent for Vaccines and Psychotropic Medication
Penalty
Summary
The facility failed to obtain informed consent before administering influenza and COVID-19 vaccines to a resident whose records showed severely impaired cognitive skills for daily decision making and a history indicating he did not have the capacity to understand and make decisions. The resident’s face sheet listed him as self-responsible, but his MDS and H&P documented severe impairment and lack of capacity. The Vaccine Consent forms for both vaccines indicated the resident provided verbal consent, and the immunization records showed the vaccines were administered, even though the IPN stated he should not have consented because he did not have decision-making capabilities. The facility also failed to verify informed consent before administering Divalproex Sodium to another resident for behavioral symptoms. That resident’s records showed diagnoses of bipolar disorder, dementia, and depression, with severely impaired cognitive skills for daily decision making and fluctuating capacity to understand and make decisions. A physician order directed Divalproex Sodium 125 mg by mouth three times daily for sudden outbursts of anger related to restlessness and agitation, and the MAR showed the medication was given before the facility verified that consent had been obtained from the RP. During interviews, the RN and DON stated Divalproex Sodium was being used to treat behavioral symptoms and required informed consent from the RP, and that informed consent should be obtained and verified before administration. The resident’s Psyche Consent showed the RP consented for Divalproex Sodium for angry outbursts, but the medication had already been administered before verification of that consent. The facility policy on consents stated that when a new order for a psychotropic drug is obtained, the licensed nurse verifies with the resident and/or legal representative that informed consent has been obtained.
Failure to Notify Physician and RP of Resident Changes in Condition
Penalty
Summary
The facility failed to notify the physician and/or responsible party of changes in condition for two residents. One resident had a history of bipolar disorder, dementia, and depression, with severely impaired cognitive skills and fluctuating capacity to understand and make decisions. During observation, the resident was seen lying in bed with multiple thin, red lines on his face and nodded when asked if he had scratched himself. The resident’s RP stated she was not notified of the incident, and the LVN stated the scratches were a change of condition that should have been reported to the physician and RP. Review of the resident’s SBAR forms showed no documentation of a change of condition related to the facial scratches, and the LVN stated the physician and RP were not notified. The LVN also stated that without physician notification there were no orders to monitor or treat the scratches, and without RP notification the RP was unable to advocate for the resident’s care. The DON stated the physician and RP should have been notified of the scratches, and that each incident of self-scratching should be reported. The second resident had diagnoses including hemiplegia, hemiparesis, and aphasia following cerebral infarction, with severely impaired cognitive skills and no capacity to understand and make decisions. Staff interviews indicated communication about the resident’s health changes should have been with the emergency contact because the resident was unable to make medical decisions. However, SBAR forms for a low oxygen saturation episode and a tear in the g-tube identified the resident as self-responsible, and staff stated the emergency contact or family members should have been notified. The DON stated the resident was not self-responsible and that the emergency contact or family members should have been contacted after the changes of condition.
Resident Room Equipment and Surfaces Not Kept Clean and in Good Repair
Penalty
Summary
The facility failed to ensure resident care equipment was stored appropriately and that resident room surfaces were maintained in a clean, repaired condition for one resident. During observation in the resident’s room, a nebulizer machine with an attached cannula was found on the floor next to the bed. In the same room, approximately 16 scuffs were observed on the wall next to the bed, and a coax cable near the bed had dry brown matter on it. The resident involved had multiple serious diagnoses, including COPD, dysphagia, acute respiratory failure with hypoxia, asthma, pulmonary embolism, hemiplegia and hemiparesis due to stroke, and dementia. The resident’s H&P stated the resident did not have the capacity to understand and make decisions. The MDS indicated the resident’s cognitive skills for daily decision making were severely impaired and that the resident was dependent on staff for ADLs. During interview, CNA staff stated that bodily fluids or other substances on walls, cables, or other surfaces were expected to be cleaned immediately and housekeeping notified, and that damaged items in a resident’s room were to be reported to maintenance promptly. The Maintenance Director/Housekeeping Director stated the wall scuffs should not have been present, the dry brown matter on the coax cable was unacceptable and should have been cleaned immediately, and the nebulizer should not have been on the floor. The Infection Preventionist Nurse stated nebulizer machines should not be placed on the floor because they could become contaminated from dirt, dust, and other pathogens, and that room surfaces and resident care equipment should be maintained in a clean and sanitary condition.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin involving Resident 79 to the State Agency, the Ombudsman, and local law enforcement after the resident was found with a purple-blue discoloration under the left eye. Resident 79 had diagnoses including bipolar disorder, dementia, and depression, and assessments documented severely impaired cognitive skills for daily decision making, supervision or touching assistance needed for several activities of daily living, and fluctuating capacity to understand and make decisions. On 4/22/2026, staff observed discoloration at the left lower eyelid. A progress note, post-event note, SBAR form, and skin observation tool all documented that Resident 79 could not explain how the discoloration occurred. The DON interviewed staff who cared for the resident, and all denied knowledge of any incident, trauma, fall, contact injury, or other event that could have caused the discoloration. The post-event note stated that the cause of the bruising/discoloration remained undetermined. During interviews, LVN 2 stated the discoloration looked like a purple bruise and that Resident 79 was unable to say what happened. CNA 1 stated she noticed a dark discoloration under the resident’s left eye while changing the brief and that the resident could not communicate what happened. The DON and ADM both stated they were unable to determine the cause and acknowledged that the injury should have been considered an injury of unknown origin and reported to the three agencies. The facility policy stated that alleged abuse, neglect, exploitation, mistreatment, including injuries of unknown source, must be reported to the State licensing/certification agency, the Ombudsman, and law enforcement.
PASARR Level 2 Evaluation Not Completed
Penalty
Summary
The facility failed to ensure that a PASARR Level 2 evaluation was completed for one sampled resident with diagnoses including schizophrenia, dysphagia, and hypertension. The resident’s MDS showed severely impaired cognitive skills for daily decision making and dependence on staff for toileting, bathing, and personal hygiene. A PASARR Level 1 screening dated 10/17/2025 indicated the need for a Level 2 evaluation. During record review, the resident’s medical records showed that the PASARR Level 2 evaluation had not been completed. The Notice of Attempted Evaluation stated the Level 2 evaluation was not completed because facility staff were unresponsive to two or more separate attempts of communication within 48 hours of the Level 1 screening. The MDS consultant stated staff should have responded to the calls and should have completed another PASARR Level 1 screening to prompt another Level 2 evaluation. The DON stated PASARR evaluations were important to ensure the facility was correctly identifying the level of care each resident required and providing the appropriate services.
Failure to Care Plan Scratching Behavior and Continuous Oxygen Use
Penalty
Summary
The facility failed to develop a care plan addressing Resident 79’s scratching behavior. Resident 79 was admitted and readmitted to the facility with diagnoses including bipolar disorder, dementia, and depression. The MDS dated 3/13/2026 indicated severely impaired cognitive skills for daily decision making and the resident required supervision or touching assistance with toileting, lower body dressing, putting on/taking off footwear, and personal hygiene. The H&P dated 12/9/2025 indicated fluctuating capacity to understand and make decisions. During observation on 5/18/2026, Resident 79 was seen lying in bed with multiple thin, red lines on his face, and he nodded yes when asked if he scratched himself on his face. The resident’s RP stated he had a long history of scratching himself on various parts of his body and face. An LVN stated Resident 79 was known to scratch himself on his body and face and that the scratches on his face were scabbed over and healing. Review of the care plans dated 5/1/2026 through 5/20/2026 showed no care plan addressing the scratching behavior. The LVN stated a long-term care plan should have been developed to address the recurring behavior. The facility also failed to develop a care plan addressing Resident 29’s continuous oxygen use. Resident 29 was admitted with diagnoses including COPD, CKD, and HTN, and the H&P dated 4/8/2026 indicated the resident did not have the capacity to understand or make decisions. The MDS indicated severe cognitive impairment, dependence on staff for eating, toileting, and bathing, and that the resident was receiving oxygen therapy. The physician’s order dated 4/8/2026 directed continuous oxygen at 2 LPM via nasal cannula, titrated to 2-4 LPM to keep O2 saturation at or above 92%, with O2 saturation monitored every shift. Review of the medical record with RN 1 showed no care plan addressing continuous oxygen use, and RN 1 stated oxygen interventions should include respiratory assessments and safety precautions. The DON stated residents on continuous oxygen should have a care plan that addresses oxygen use and related respiratory assessments and monitoring.
Untrimmed and Dirty Fingernails Not Maintained for Dependent Resident
Penalty
Summary
The facility failed to ensure that Resident 7’s fingernails were maintained in a trimmed and clean manner. Resident 7 was admitted and later readmitted to the facility, had diagnoses including Parkinson’s disease, dysphagia, and muscle weakness, and was assessed as having moderately impaired cognitive skills for daily decision making. The MDS indicated the resident was dependent on staff for activities of daily living. During an observation at the resident’s bedside, Resident 7’s fingernails were noted to be long and untrimmed with black debris underneath the nail bed. On a later observation, the fingernails were again long and untrimmed, and an LVN stated the nails were sharp, long, and required trimming. The LVN stated nail care was part of CNA responsibilities and that residents’ nails should be checked daily. The IPN stated nail care should be assessed daily and that residents needing help with cleaning or trimming nails should be assisted by CNAs or licensed nurses. The DON stated fingernail care was part of the resident’s ADL routine and that dirty fingernails were not acceptable. The facility’s ADL policy stated residents unable to perform ADLs independently would receive services necessary to maintain grooming and personal hygiene.
Wound care orders were not transcribed, and dressing changes were missed
Penalty
Summary
The facility failed to ensure wound care orders were transcribed and dressing changes were performed for one resident with a left heel pressure injury and bilateral shin wounds. The resident had diagnoses including CKD, DM, and CHF, and the MDS indicated intact cognitive skills for daily decision making, substantial staff assistance needed for toileting and bathing, setup assistance for eating and personal hygiene, and an unhealed pressure injury. During interview, the resident stated she had a pressure ulcer on her left heel and bilateral shin wounds that required daily dressing changes, but she did not receive dressing changes from 5/15/2026 to 5/17/2026 and did not know why they were not performed. Review of the TAR showed no dressing changes documented for the left heel PI, left medial leg TW, or right lateral shin TW during that period. The physician orders reviewed showed wound care orders ending on 5/15/2026 and new wound care orders beginning on 5/18/2026, leaving no active orders for 5/16/2026 and 5/17/2026. TN 1 stated the treatment orders should have been placed with a start date of 5/16/2026 so the resident would receive treatment as prescribed, and that failure to transcribe the wound care orders resulted in the resident not receiving dressing changes for three days. PA 1 stated the DON, ADON, and treatment nurse were responsible for transcribing orders into the EMR, and the DON stated timely transcription was important to ensure residents received ordered care.
Blocked Wheelchairs in Resident Room
Penalty
Summary
The facility failed to ensure Resident 98’s room was free from accident hazards and provided adequate supervision when wheelchairs were observed blocking the room pathways and bathroom entrance. Resident 98 was admitted with diagnoses including Alzheimer’s Disease, atrial fibrillation, acute embolism, and deep vein thrombosis of the right lower extremity. The resident’s H&P indicated fluctuating capacity to understand and make decisions, and the MDS showed impaired cognitive skills for daily decision making and dependence on staff for ADLs. During observation, one wheelchair was positioned at the resident’s bedside, a second wheelchair blocked the room entrance door, and a third wheelchair obstructed the bathroom entrance with the footrests extended and resting on the floor. On a later observation, a wheelchair was again blocking the room entrance door and another wheelchair was blocking the bathroom door. CNA 4 stated wheelchairs should not block pathways inside residents’ rooms and that blocked pathways, including the bathroom entrance, may place residents at risk for falls, injury, and difficulty with safe mobility and bathroom access. The DON stated that wheelchairs blocking bedroom pathways and bathroom entrances may place residents at risk for falls, injuries, delayed bathroom access, and difficulty with safe mobility and transfers. The facility policy titled Homelike Environment stated the facility would provide an environment that remained safe and orderly.
Missed Suprapubic Catheter Care and Irrigation
Penalty
Summary
The facility failed to provide suprapubic urinary catheter care for one resident with neuromuscular dysfunction of the bladder and urinary retention. The resident’s record showed orders for daily irrigation of the suprapubic catheter with normal saline and daily cleansing of the suprapubic stoma with normal saline, pat dry, and application of a silver alginate dressing and dry dressing. The care plan also directed daily indwelling urinary catheter care. During a concurrent observation and interview, the resident was seen sitting in a wheelchair with the urinary catheter bag hanging on the side of the chair and the suprapubic catheter exposed without a dressing over the stoma. The resident stated he did not receive the suprapubic catheter care or irrigation on the prior day and again stated he did not receive the care on the following day. Review of the treatment administration record showed no documentation that the daily suprapubic catheter irrigation and cleansing were performed on those dates. Staff interviews confirmed the care was not completed. One RN stated the resident kept saying “later” and that the care should have been completed by the end of the shift and endorsed to the oncoming shift. A treatment nurse stated she did not perform the care and thought it had been endorsed to the RN. Another RN stated he did not provide the treatment and irrigation. The DON stated the catheter went directly into the bladder, cleansing was done daily to prevent infection and maintain site integrity, irrigation was done daily to prevent sediment buildup and keep the catheter patent, and the missed treatment and irrigation placed the resident at risk for UTI.
Failure to Provide Ordered Continuous Oxygen Therapy
Penalty
Summary
The facility failed to ensure oxygen therapy was administered continuously via nasal cannula as ordered for Resident 83. Resident 83 was admitted with diagnoses including dysphagia, muscle weakness, acute kidney failure, anemia, encephalopathy, COPD, and acute respiratory failure with hypoxia. The resident’s MDS indicated severely impaired cognitive skills for daily decision making and dependence on staff for ADLs, and the H&P stated the resident did not have the capacity to understand and make decisions. A physician’s order dated 4/25/2026 directed continuous oxygen at 2 liters per minute via nasal cannula every shift for COPD. Record review showed oxygen saturation values documented on 4/16/2026, 4/17/2026, 4/20/2026, and 5/4/2026 were recorded while Resident 83 was on room air. During observation on 5/18/2026, Resident 83 was lying in bed with the nasal cannula wrapped around the oxygen concentrator, and the concentrator was off, so the resident was not receiving supplemental oxygen. During interview and record review on 5/20/2026, RN 3 stated continuous oxygen therapy meant the oxygen was to remain in use at all times as ordered, and stated the resident was on room air on the dates reflected in the oxygen saturation record and was not receiving oxygen continuously as ordered.
Pharmacist Lab Monitoring Recommendation Not Entered
Penalty
Summary
The facility failed to ensure the consulting pharmacist’s recommendation for valproic acid level, CMP, and CBC laboratory tests was ordered for one resident receiving divalproex sodium. Resident 79 was admitted with diagnoses including bipolar disorder, dementia, anxiety disorder, and depression, and the MDS indicated severely impaired cognitive skills for daily decision making. The resident’s H&P noted fluctuating capacity to understand and make decisions, and the physician order directed divalproex sodium 125 mg by mouth daily for mood stabilization related to anxiety disorder. During review of the resident’s medication regimen review, the pharmacist identified divalproex sodium for behavior control and recommended obtaining orders for a valproic acid level, CMP, and CBC on the next available lab day to monitor for toxicity. The MRR showed the recommendation was approved by the physician and marked as done under follow-through, but the laboratory orders were not entered into the resident’s chart. The DON confirmed the orders were never inputted after the recommendation was approved, and the facility policy stated the consulting pharmacist’s recommendations were to be acted upon and documented by facility staff and/or the physician.
Failure to Honor Food Preferences and Offer Meal Alternatives
Penalty
Summary
The facility failed to honor food preferences and failed to offer meal substitutes of the same nutritive value for one sampled resident. Resident 122 was admitted and later readmitted to the facility and had diagnoses including osteoarthritis of the right knee, DM, and mild protein-calorie malnutrition. The MDS dated 4/2/2026 indicated the resident’s cognitive skills for daily decision making were intact, that the resident required setup and clean-up assistance with meals, and that the resident required moderate assistance with ADLs. The H&P dated 5/7/2026 indicated the resident had the capacity to understand and make decisions. During an interview on 5/18/2026, Resident 122 stated she did not like the breakfast meals being served and reported skipping breakfast because she was unhappy with the food provided. She stated that no staff asked for her food preferences and no meal substitutes with adequate nutritive value were offered. During a concurrent observation and interview on 5/20/2026, CNA 4 observed an untouched and covered breakfast tray with scrambled eggs and oatmeal at the bedside table and stated the resident declined the tray, it was taken back to the kitchen, and no meal alternative or food preference was offered. The Regional Dietary Manager stated not providing meal alternatives could lead to poor intake, and the RD stated it was important to offer other food choices when a resident refused a meal to help meet nutrition needs and food preferences. The facility’s Dignity policy stated the facility culture supports dignity and respect for residents by honoring resident food choices and preferences.
Incorrect Self-Responsible Status on Resident Face Sheet
Penalty
Summary
The facility failed to ensure that one sampled resident, who did not have decision-making capabilities, was not listed as self-responsible on the admission Face Sheet. Resident 63 had diagnoses including hemiplegia and hemiparesis following cerebral infarction and aphasia following cerebral infarction. The resident’s MDS indicated severely impaired cognitive skills for daily decision making and dependence on staff for multiple activities of daily living, and the H&P stated the resident did not have the capacity to understand and make decisions. During interviews, the SSD stated Resident 63 was aphasic and that communication about health and changes in condition was to be directed to EC 1, because the resident could not understand the plan of care or make medical decisions. RN 1 reviewed the Face Sheet and SBAR forms and confirmed they incorrectly identified the resident as self-responsible. RN 1 stated the Face Sheet was the facility’s primary tool for determining who to notify of changes, and the DON stated the resident’s Face Sheet should not have indicated self-responsible because the resident lacked decision-making capability. The DON also stated the resident’s plan of care was discussed with the incorrect individual.
Missing Current Hospice Plan of Care
Penalty
Summary
The facility failed to ensure the most recent hospice plan of care was obtained for one resident receiving hospice services. Resident 12 was admitted and later readmitted to the facility, and had diagnoses including dysphagia, schizophrenia, and hypertension. The resident's MDS dated 4/24/2026 indicated severely impaired cognitive skills for daily decision making, dependence on staff for toileting, bathing, and personal hygiene, and receipt of hospice care. During a phone interview on 5/19/2026, the Hospice Case Manager stated the hospice plan of care should be present in the resident's hospice binder and updated weekly. However, during a concurrent interview and record review, Resident 12's hospice binder did not contain the most recent plan of care. The RN stated that having the most recent plan of care accessible was important because it addressed interventions and resident-specific goals. The Social Services Director stated she was the hospice coordinator and had not been checking the hospice binders to ensure the most recent plan of care was obtained, and the DON stated the hospice plan of care was important because it supported collaboration between the facility and hospice agency and ensured the resident's needs were being followed and addressed.
Infection Control and EBP Failures During Resident Care
Penalty
Summary
The facility failed to follow infection control measures for two sampled residents. For Resident 124, the record showed diagnoses including dysphagia, COPD, and osteomyelitis, and the resident was documented as having severe cognitive impairment and dependence on staff for eating, toileting, and bathing. During observation of the room entrance, no Enhanced Barrier Precaution sign was displayed outside the room, even though CNA 3 stated the resident had a G-tube and should be on EBP with signage posted to alert staff to use PPE during direct care. For Resident 5, the record showed diagnoses including CKD, DM, and CHF, and the MDS indicated intact cognitive skills for daily decision making, substantial staff assistance needed for toileting and bathing, setup assistance for eating and personal hygiene, and an unhealed pressure injury. A physician order directed EBP related to the dialysis site central line/permacath and wound. During observation of a wound dressing change, TN 1 began the procedure without donning an isolation gown and removed the old dressing and cleaned the wound without removing soiled gloves or performing hand hygiene. During interview, TN 1 stated she should have worn an isolation gown for the dressing change and should have removed soiled gloves and washed her hands after removing the old dressing and before cleaning the wound. The IPN stated nurses should wear isolation gowns for wound dressing changes and wash hands and don new gloves after removing an old soiled dressing. The facility policy for EBP stated to post clear signage outside the resident room, and the wound care policy stated to remove the dressing, discard it appropriately, wash and dry hands thoroughly, and put on new gloves.
Call Lights Not Kept Within Resident Reach
Penalty
Summary
The facility failed to ensure resident call lights were within reach for two sampled residents. Resident 3 was admitted with diagnoses including dysphagia, paranoid schizophrenia, COPD, hemiplegia, and hemiparesis. The MDS dated 3/20/2026 indicated Resident 3’s cognitive skills for daily decision making were severely impaired and that the resident was dependent on staff for assistance. During an observation on 4/18/2026 at 10:54 a.m., Resident 3 was lying in bed and the call light was hanging behind and under the bed, out of reach. Resident 51 was admitted with diagnoses including muscle weakness, acute kidney failure, difficulty walking, hearing loss, and anemia. The MDS indicated Resident 51’s cognitive skills for daily decision making were intact and that the resident required supervision or touching assistance with daily activities. During an observation on 4/20/2026 at 11:36 a.m., Resident 51 was sitting in a wheelchair next to the bed, and the call light was on the floor on the opposite side of the resident, out of reach. During interview, the DON stated call lights should be within each resident’s reach at all times and that staff were expected to ensure call lights remained accessible during and after care, transfers, repositioning, housekeeping activities, and routine rounds. The facility policy titled Answering the Call Light stated that when the resident is in bed or confined to a chair, the call light should be within easy reach.
Unnecessary Psychotropic Medication Use Without Defined Target Behaviors or Monitoring
Penalty
Summary
The facility failed to ensure a resident was free from unnecessary psychotropic medication use when Depakote was prescribed and administered without adequate clinical justification and monitoring. The resident, who had diagnoses including metabolic encephalopathy and schizophrenia and was assessed on the MDS as having severe cognitive impairment requiring supervision or touch assistance with eating, personal hygiene, and ambulation outside her room, had a physician’s order dated 3/18/2026 for Depakote 250 mg twice daily as a mood stabilizer related to schizophrenia. The order did not specify the particular mood or behavior that Depakote was intended to treat or manage, and thus lacked a documented, quantifiable target symptom. During interview, the DON stated that psychotropic medication orders should include the specific behavior the medication is intended to treat or manage so staff can monitor effectiveness and determine ongoing necessity, and acknowledged that this information was missing from the Depakote order. The DON further stated that, as a result, the resident received Depakote without any behavior monitoring. Review of the facility’s policy on antipsychotic medication use indicated that the attending physician, with input from other disciplines, was to identify and document symptoms that may warrant use of such medications and that diagnoses alone were not sufficient to warrant their use. The report stated that this deficient practice placed the resident at risk for potential adverse effects from continued Depakote use, including liver failure and severe pancreatitis.
Inaccurate MDS Coding for Vision and Anticonvulsant Use
Penalty
Summary
The facility failed to ensure that the MDS accurately reflected a resident’s visual and clinical status. The resident, admitted with diagnoses including metabolic encephalopathy and severe cognitive impairment, had an MDS dated 1/29/2026 that indicated impaired vision but did not specify the level of visual impairment and did not indicate that the resident was receiving anticonvulsant medication. Observation in the dining room showed the resident did not make eye contact, could not track objects, misidentified the number of fingers held up at close range, and misidentified the color of clothing. A CNA reported that the resident could barely see, walked into objects, required clear walkways, and often reached out to feel her way around. Despite these findings, the MDS lacked detail on the severity of the resident’s visual impairment. The Social Services Assistant, who completed the vision section of the MDS, stated she had never been trained on how to complete the MDS vision assessment and was unsure of the purpose of the MDS. She reported that she marked the resident as having vision impairment based on inability to track objects and minimal blinking, but did not ask the resident to read any text or printed material to determine severity. Review of physician’s orders and the MAR showed the resident was receiving divalproex sodium within the MDS 7‑day look‑back period, but this anticonvulsant use was not coded on the MDS. The DON stated there was no nurse currently assigned to assist with completing MDS assessments and acknowledged that the RAI manual should guide MDS completion. Facility policy required that professionals participating in the assessment be qualified and that assessment information reflect the resident’s status during the look‑back period, which did not occur in this case.
Failure to Implement Care-Planned 1:1 Supervision for Resident With Intrusive Sexual Behaviors
Penalty
Summary
The deficiency involves the facility’s failure to implement a care-planned intervention for one-to-one (1:1) supervision for a resident with severe cognitive impairment and intrusive sexualized behaviors. The resident, diagnosed with metabolic encephalopathy and schizophrenia, had an MDS dated 1/29/2026 indicating severe cognitive impairment and a need for supervision or touch assistance for eating, personal hygiene, and walking outside her room. On 1/1/2026, a Change of Condition (COC) assessment and progress note documented that she was entering other residents’ rooms, approaching male residents, caressing their faces, attempting to kiss them, and asking them to have sexual intercourse. On 1/2/2026, she was again observed entering a male resident’s room and continued to approach him despite his repeated requests for her to leave, and staff had to redirect her as she continued to wander for another hour. On 1/3/2026, a progress note documented that she made inappropriate verbal comments to other residents and needed reminders about appropriate boundaries. On 3/29/2026, a COC assessment documented that the same resident touched another resident while that resident was in bed and was redirected by staff. This COC assessment specifically indicated that she required 1:1 supervision to ensure the safety of other residents and prevent further intrusive behavior. A care plan titled “Risk for Injury to Others related to intrusive behavior,” dated 3/29/2026, directed nursing staff to initiate one-on-one supervision as indicated to ensure resident safety and prevent intrusive contact with other residents, and to provide close supervision when she was near other residents or in shared areas. Despite these documented behaviors and the explicit care plan interventions, staffing documents for 3/30/2026, 3/31/2026, and 4/1/2026 did not show that she was on 1:1 monitoring. On 4/2/2026, a COC assessment recorded that the resident was in the hallway near the kitchen with another resident who was cognitively intact, had generalized muscle weakness, difficulty walking, and depression, and required supervision or touch assistance for wheelchair mobility. During this encounter, the second resident reported that the first resident approached him while he was sitting in his wheelchair and touched his genitals without his permission, leading him to grab her wrist to move her hand away. Certified Nursing Assistants interviewed stated that the first resident had a known history of touching others and wandering into other residents’ rooms, that many residents had problems with her behavior, and that she had wandered into the second resident’s room multiple times in the days before the hallway incident, causing him to yell at her to leave. Both CNAs confirmed that she was not on 1:1 supervision at the time of these events or at the time of the altercation, and the DON acknowledged that the care plan required 1:1 monitoring and that he did not know why it was not implemented, despite the facility’s policy requiring staff to ensure implementation of individualized safety and supervision interventions.
Failure to Care Plan for Impaired Vision and Complete Post-Fall Assessments
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure accident hazards and fall risks were identified and care planned for a resident with significant cognitive and visual impairment. The resident, admitted with diagnoses including metabolic encephalopathy and schizophrenia, had an MDS dated 1/29/2026 showing severe cognitive impairment and impaired vision, and required supervision or touch assistance for eating, personal hygiene, and walking outside her room. Despite this, there was no care plan developed to address her impaired vision, even though facility policy required that the comprehensive care plan be based on the MDS and developed within seven days of completion of the assessment. The DON confirmed that a care plan should have been developed for the resident’s impaired vision to ensure her safety, including possible falls. The facility also failed to follow its own procedures for fall risk assessment and change-of-condition documentation after the resident experienced falls. The resident had been identified as high risk for falls on a Fall Risk Assessment dated 10/3/2026. A progress note dated 10/6/2025 documented that the resident fell in the lobby, but no subsequent Fall Risk Assessment was completed, contrary to the DON’s stated expectation that such an assessment be conducted after any fall to identify risks and interventions. Another progress note dated 3/20/2026 documented that the resident was found on the floor in the rehabilitation room after an unwitnessed fall, appearing confused and having tripped on a weight scale. No Change of Condition assessment was completed following this event, despite facility policy requiring detailed observations prompted by a COC assessment form, physician notification after accidents, and documentation of changes in the resident’s condition in the medical record. The DON acknowledged that both the post-fall Fall Risk Assessment and the COC assessment were missing.
Unsanitary Kitchen Utility Room and Dishwashing/Sanitizing Areas
Penalty
Summary
Surveyors identified a deficiency related to unsanitary conditions in the facility’s kitchen, specifically in the kitchen utility room and around the manual dishwashing and sanitizing stations. During observation with a dietary aide, there was dirty, standing water and debris under the manual washing station and sanitizing station. The dietary aide reported that the sanitizing station had been leaking for several weeks, that maintenance had checked and fixed it, but water continued to spill due to water pressure. The aide also stated the kitchen utility room was dirty and cluttered, and that they had not had the chance to clean and organize it, despite acknowledging that the utility room should always be kept clean. In a separate observation and interview with the dietary cook later the same day, surveyors again noted dirty, standing water and debris under the sanitizing station. The dietary cook stated there was no point in cleaning under the sanitizing station because water kept pooling, and although the sanitizing station had already been cleaned, they did not know the source of the standing water. The cook also stated that staff were supposed to remove all food waste from the sink strainer after washing dishes to keep the area clean. Review of the facility’s sanitation policy indicated that all equipment must be maintained and kept in working order, that the Maintenance Department assists Food & Nutrition Services with equipment and janitorial duties as needed, and that the Food & Nutrition Services Director is responsible for writing a cleaning schedule designating who performs cleaning tasks.
Failure to Maintain Clean, Safe, and Sanitary Resident Areas and Storage Spaces
Penalty
Summary
Surveyors identified that the facility failed to maintain a clean, safe, and sanitary environment in multiple areas, including three closets and several resident rooms. The Maintenance Director acknowledged that Closets A, B, and C had broken or detached baseboards, cluttered and dirty floors, debris, and a dirty sink, and that employee files and boxes were stored directly on dirty floors. He stated he did not know when certain rooms were last cleaned and confirmed that files should not be on the floor and that he had not obtained authorization for a cabinet to organize documents. Observations of specific resident rooms showed dirty floors, a dirty restroom with towels on the floor, and a shared restroom for two rooms with dirty basins containing pooled dirty water and yellowing towels stored under the sink. Baseboards in these areas were detached, and the Maintenance Director stated that detached baseboards and cracks could be an entry point for roaches. Resident 1’s records showed admission with muscle weakness and hypertension, with assessments indicating she had decision-making capacity, could understand and be understood, and required varying levels of assistance and supervision for ADLs such as eating, hygiene, dressing, transfers, and mobility. During interviews and observations, Resident 1 reported that her room and restroom had not been cleaned for four days, were dirty, and had bugs present, pointing out ants on a drawer. She stated she felt dehumanized by the condition of her room. Further observation revealed stains in her armoire where she placed clothes, a tray of old food (hamburger and moldy fries) in a dresser drawer, and multiple cups left in the room because staff did not want to pick them up. The Infection Prevention Nurse stated that old moldy food in drawers could lead to infections, sickness, and pests, and that housekeeping should check and clean armoires and dressers daily. A CNA acknowledged that nine piled basins with dirty water and yellowing towels under the shared restroom sink should have been removed and cleaned. Facility policies on sanitation and homelike environment required a safe, clean, comfortable environment and outlined responsibilities for cleaning schedules and maintenance support, which were not followed in these instances.
Failure to Maintain Effective Pest Control and Sanitation
Penalty
Summary
The facility failed to maintain an effective pest control program as evidenced by unresolved structural issues and inadequate sanitation contributing to the presence of pests. A pest control service report dated 3/4/2026 documented that the baseboard on the right side of the entry door was peeling and damaged, creating a potential entry point and harborage area for roaches, and recommended sealing the peeling baseboards and maintaining high sanitation standards, including preventing food particles and water leaks around kitchen appliances and in patient rooms. On 3/10/2026, the Maintenance Director confirmed that the shared restroom for Rooms 2 and 3 had detached baseboards and acknowledged that cracks could serve as entrance points for roaches. During the same survey, a resident reported that her room and restroom had not been cleaned in four days, described them as dirty, and pointed out ants crawling on a drawer, stating she felt dehumanized being in such a dirty room. These conditions occurred despite a written pest control policy dated 1/2026 stating the facility should maintain an ongoing pest control program to keep the building free of insects and rodents.
Failure to Maintain Clean and Sanitary Resident Rooms and Bathrooms
Penalty
Summary
Surveyors identified a deficiency in maintaining a safe, clean, comfortable, and homelike environment when multiple resident rooms and adjacent hallways were found to be unsanitary. During observation with the DON, the hallway floors by Rooms A, B, and E were noted to be dirty with food crumbs and pieces of trash. The shared bathroom for Rooms A and B had dirty towels surrounding the toilet floor, and Room C had three towels and trash on the floor, creating clutter. In Room D, a bedpan with smeared feces was observed placed on top of the vanity. In the shared bathroom for Rooms F and G, the toilet tank flush handle had smeared feces. The DON acknowledged that dirty floors with food crumbs and trash could attract pests and be a source of germs leading to infections, that dirty towels on the bathroom floor could cause residents to feel uncomfortable, that towels and trash on the floor could cause residents or others to trip and fall, and that feces on the toilet handle could lead to cross-contamination and infections. Review of the facility’s “Cleaning and Disinfection of Environmental Surfaces” policy dated 1/2018 showed that environmental and housekeeping surfaces, including floors, furniture, and bed rails, were to be cleaned regularly when visibly soiled and disinfected with an EPA-registered hospital disinfectant according to label directions. These observations demonstrated that the facility did not follow its own cleaning and disinfection policy for environmental surfaces in Rooms A, B, C, D, E, F, and G and their shared bathrooms and hallways, resulting in an environment that was not clean, sanitary, or home-like for the affected residents.
Failure to Provide Timely Access to Requested Medical Records
Penalty
Summary
The facility failed to provide timely access to a resident’s medical records as required by its policy and procedure titled Access to Personal and Medical Records. One resident, originally admitted and later readmitted to the facility, had diagnoses including muscle weakness and difficulty walking. A History and Physical dated 1/9/2026 documented that the resident had fluctuating capacity to understand and make decisions, while a Minimum Data Set (MDS) dated 10/14/2025 indicated the resident was usually able to understand and be understood by others. The MDS further showed the resident required supervision for eating and oral hygiene, was dependent for toileting hygiene, showering/bathing, lower body dressing, and footwear, required maximal assistance for upper body dressing, and moderate assistance for personal hygiene. On 12/23/2025 at 11:15 a.m., the resident’s attorney’s office contacted the Medical Records Director (MRD) to request the resident’s medical records, followed by an email at 4:10 p.m. the same day, for which no confirmation was received. The attorney later spoke with the MRD on 1/8/2026 and was informed that the MRD was waiting for supervisor verification before releasing the records. In a subsequent interview, the MRD stated she received the written request on 12/23/2025 after 4:00 p.m. but did not send the records because the corporate office had to review them first and had told her she had a month to send them. On 1/26/2026, the MRD acknowledged that more than 30 days had passed since the request and confirmed that the facility’s policy required that requested medical records be provided as soon as practicable within 5 days, up to 30 days from the date of the written request. This delay resulted in the facility’s failure to release the resident’s medical records within 30 days, violating the resident’s and resident representative’s rights to access records.
Failure to Document Sacral Skin Tear and Complete Weekly Skin Assessment
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident by omitting documented skin issues from transfer documentation and not completing required weekly skin assessments. The resident was admitted with diagnoses including muscle weakness and cellulitis of the left lower limb and had an H&P indicating lack of capacity to understand and make decisions, while an MDS assessment indicated the resident could understand and be understood and required varying levels of assistance with ADLs. On 12/26/2025, an SBAR form documented a sacral skin tear measuring 3 cm by 0.5 cm by 0.5 cm. However, when the resident was transferred to a general acute care hospital on 1/4/2026 for fever, the Transfer Sheet completed at 5:02 p.m. did not include the resident’s sacral skin tear or skin condition, contrary to the facility’s discharge policy requiring assessment and documentation of the resident’s condition at discharge, including skin assessment. The facility also failed to complete the weekly skin assessment for the sacral skin tear that was due during the week of 12/28/2025 to 1/3/2026. Review with the DON showed there was no weekly skin assessment documented for the sacral skin tear identified on 12/26/2025, and the DON stated this was because there was no wound care provider available that week. This omission was inconsistent with the facility’s policy on prevention of pressure injuries, which required a comprehensive skin assessment with each weekly risk assessment and upon changes in condition according to the resident’s risk factors.
Failure to Timely Return Resident’s Wheelchair and Personal Belongings After Room Fumigation
Penalty
Summary
The facility failed to honor a resident's right to be treated with respect and dignity and to retain and use personal possessions when the resident's wheelchair and ice chest were not returned in a timely manner after his room was fumigated. The resident, who had paraplegia, neuromuscular bladder dysfunction, benign prostatic hyperplasia, and major depressive disorder, was dependent on staff for toileting, transfers, and most ADLs. His history and physical indicated he had capacity to understand and make decisions. On the day of fumigation, staff, including CNAs, cleared his room and removed his wheelchair, ice chest, and other personal property for storage. The LVN reported that CNAs helped clear the room and that he did not know where the resident's property was, and also noted that the resident did not like people touching his property. Following the fumigation, the resident reported that his wheelchair and ice chest were not returned and stated he felt harassed, bullied, and controlled, and that he did not trust the facility with his belongings because items had previously gone missing or been broken. He stated he requested the return of his wheelchair and ice cooler from the Administrator the day after fumigation, and the Administrator told him he would look into it. CNAs confirmed that the resident said the social worker took his wheelchair and ice cooler and did not bring them back, and one CNA stated the items were removed from the bedside to fumigate the room. The DON stated the social worker was responsible for returning residents' property, and the Administrator stated he had instructed staff, including the social worker, to return the resident's wheelchair and ice chest after the room was cleaned, and acknowledged that if they had told the resident to place his property in storage, he would have become upset. The facility's policy on a homelike environment indicated residents are to be provided a safe, comfortable, homelike environment and encouraged to use their personal belongings to the extent possible, which was not followed in this instance.
Failure to Use Required PPE During Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves the facility’s failure to implement its own Enhanced Barrier Precautions (EBP) and infection prevention and control measures for three residents who required gown and glove use during high-contact care. Facility records showed that Residents 1 and 2 had quadriplegia and neuromuscular dysfunction of the bladder, with indwelling urinary catheters (a Foley catheter for Resident 1 and a suprapubic catheter for Resident 2). Their care plans and order summaries directed staff to follow EBP and to use gowns and gloves during high-contact activities to prevent MDRO infection. Resident 3 had a colostomy, cellulitis, diabetes mellitus, and severe cognitive impairment, with orders indicating EBP due to the colostomy. The facility’s EBP policy stated that gowns and gloves were required prior to high-contact care activities for residents with indwelling medical devices or wounds. Surveyors observed multiple instances where staff did not follow these requirements. In Resident 1’s room, CNA 1 was observed providing mobility assistance without wearing a gown or gloves, while their uniform, hands, and arms came into direct contact with the resident and the resident’s linens. For Resident 2, CNA 4 was observed feeding the resident breakfast without wearing a gown, despite the resident’s EBP status related to a suprapubic catheter and care plan instructions for gown and glove use during high-contact activities. These observations occurred even though both residents had documented orders and care plans specifying EBP and the need for PPE during high-contact care. For Resident 3, who had an order for EBP due to a colostomy, CNA 1 and CNA 3 were observed repositioning and moving the resident without wearing gowns and gloves, with their uniforms and hands touching the resident and linens. In a concurrent observation, CNA 3 was also seen feeding Resident 3 without a gown and gloves. The EBP informational sign posted for Resident 3 indicated that staff were required to wear gowns and gloves for all high-contact activities, including feeding and repositioning. During interviews, CNA 3, LVN 1, and the DON all confirmed that high-contact activities such as feeding, turning, and repositioning required gown and glove use under the facility’s EBP policy, and acknowledged that staff should have been wearing this PPE when providing care to these residents.
Failure to Timely Report Alleged Verbal Abuse to Authorities
Penalty
Summary
The facility failed to report an alleged incident of verbal abuse involving a certified nurse assistant (CNA) and a resident to the California Department of Public Health (CDPH) as required. The incident occurred when a resident, who had diagnoses including hypertension and legal blindness and was assessed as having the capacity to understand and make decisions, was involved in a verbal altercation with CNA 1 at the nurse's station. According to progress notes and interviews, both the resident and CNA 1 exchanged inappropriate language, and the resident alleged that CNA 1 yelled and made an unprofessional remark. Multiple staff members, including a registered nurse (RN 1) and a licensed vocational nurse (LVN 1), witnessed or were aware of the incident. Despite the facility's policy requiring immediate reporting of suspected abuse to supervisors and the appropriate authorities, the incident was not reported to the CDPH. RN 1, who witnessed the event, acknowledged that yelling at a resident could be considered abuse and recognized the need to file a Report of Suspected Dependent Adult/Elder Abuse (SOC 341), but only reported the incident to the incoming RN on the next shift. RN 2, the incoming RN, stated that no such report was made to him, and LVN 1 did not escalate the incident further, assuming the supervisor was already aware. The facility's policy clearly outlines the requirement for anyone witnessing suspected abuse to report it immediately to a supervisor and for the administrator or designee to submit a written report to the Licensing and Certification Program District Office. The failure to follow these procedures resulted in a delay in notifying the CDPH and investigating the alleged abuse, as the incident was not reported through the proper channels as required.
Failure to Timely Investigate Allegation of Verbal Abuse
Penalty
Summary
The facility failed to investigate an allegation of verbal abuse involving a resident and a Certified Nurse Assistant (CNA) within 24 hours, as required by its Abuse and Neglect Prohibition Policy. The incident occurred when the resident, who had diagnoses including hypertension and legal blindness and was assessed as having the capacity to understand and make decisions, had an argument with the CNA at the nurses' station. Both the resident and the CNA used indecent language toward each other, and the resident reported that the CNA yelled and made an inappropriate comment. The progress notes documented the altercation but did not indicate that an investigation was initiated. Interviews revealed that the Registered Nurse (RN) present during the incident recognized that yelling at residents could be considered abuse and acknowledged that the incident should have been reported immediately to the Administrator (ADM) for investigation. However, the ADM was not informed of the incident until the following day, resulting in a delay in starting the investigation beyond the 24-hour requirement outlined in the facility's policy. This delay was acknowledged by both the RN and the ADM, and it was noted that the lack of timely investigation could have led to further incidents.
Failure to Perform Timely Skin Assessment on Readmission
Penalty
Summary
The facility failed to perform a skin assessment for a resident upon readmission, as required by facility policy. The resident, who had diagnoses including urinary tract infection and muscle weakness, was dependent on staff for all activities of daily living and was always incontinent of bowel. Upon review of the clinical record, there was no documentation of a skin assessment being conducted at the time of readmission. Orders for wound care were initiated after wounds were identified days later, including deep tissue injuries to both feet, abrasions on the left medial ankle and right hip, and a stage 2 pressure injury on the left hip. A licensed vocational nurse confirmed that no wound or skin assessment was performed at the time of readmission, and that the physician did not assess the resident until six days later. The facility's policy required a comprehensive skin assessment within eight hours of admission or readmission, but this was not completed. As a result, there was a delay in identifying wounds and initiating appropriate wound care for the resident.
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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 Lynwood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lynwood Post Acute Care Center | 0 mi | ★★★★★ | 39 | 0 |
| Granada Post Acute | 0 mi | ★★★★★ | 13 | 0 |
| Downey Post Acute | 1.4 mi | ★★★★★ | 20 | 0 |
| Briarcrest Nursing Center | 2.2 mi | ★★★★★ | 41 | 0 |
| Paramount Convalescent Hosp. | 2.5 mi | ★★★★★ | 24 | 0 |
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