Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Camino Healthcare during CMS and state inspections, most recent first.
Failure to Clarify Knee Immobilizer Skin Inspection Order: A resident with a right tibia/fibula fracture wore a knee immobilizer, and staff monitored only the skin around it because there was no clarified MD order to inspect underneath. The resident later returned from the hospital with a Stage 3 pressure ulcer at the edge of the splint, and a subsequent skin check documented an unstageable ulcer on the right lateral calf. The LVN stated the inside of the immobilizer was not inspected, and the DON stated the order had not been clarified with the PCP.
A resident with severe cognitive impairment, muscle weakness, bone density disorder, and lack of coordination was allowed to go out on pass without nursing staff completing or documenting required assessments and vital signs before departure or upon return. Facility records showed no progress notes or clinical documentation related to the out-on-pass period, despite policies requiring continuous nurse’s notes and documentation when a resident returns from leave. The next day, staff documented swelling and discoloration of the resident’s left lower extremity, and the resident’s family reported the leg had been hit while in a vehicle during the outing; subsequent SBAR communication and imaging revealed a nondisplaced fracture of the left ankle and foot. During interviews, an LVN and the DON confirmed that no assessments were performed or documented around the out-on-pass, contrary to facility policy.
Failure to Inform Residents During Medication Administration: An LVN gave two residents multiple medication cups without explaining the medications before administration, and neither resident was given an opportunity to participate. One resident had DM, HF, and osteoporosis with limited decision-making capacity noted in the H&P, and the other had hemiplegia/hemiparesis, facial weakness, and DM with limited decision-making capacity noted in the H&P. The DON stated nurses are trained to explain medications before giving them, but the facility's medication administration policy did not include the federally required explanation of the medication type and procedure.
A resident with ESRD and dependence on dialysis did not have a dialysis e-kit kept in the room, and staff could not explain where it was located. An LVN said the kit should be available for emergencies, while the DSD stated it was kept at the nursing station because the resident had thrown out the contents and did not want the bag at bedside. The resident's record showed scheduled dialysis treatments and routine assessment of the dialysis site, but the care plan did not address the e-kit being kept away from the room.
Care plans were not revised to match current physician orders for two residents. One resident with respiratory failure, CHF, asthma, pulmonary hypertension, and acute pulmonary edema had a care plan listing oxygen at 4 L/min NC even though the order was for 2 L/min continuous. Another resident with Parkinson's disease, Alzheimer's Disease, and a g-tube had a care plan listing tube feeding at 70 mL/hour for 20 hours even though the order was for 60 mL/hour for 20 hours. The DON stated nursing staff were responsible for keeping care plans aligned with current orders.
Failure to report sediment in an indwelling catheter tubing was identified for a resident with COPD, pressure ulcers, and paraplegia. Staff observed a large amount of sediment in the catheter tubing, and both the DSD and an LVN stated the physician should have been notified because the finding could indicate possible UTI or infection. The resident’s care plan directed staff to monitor, record, and report signs and symptoms of UTI.
Oxygen administration and storage were deficient for two residents. One resident with respiratory failure, CHF, asthma, pulmonary hypertension, and pulmonary edema was observed receiving oxygen at 3.5 L/min even though the physician order was for 2 L/min continuous, and the LVN confirmed the setting did not match the order. Another resident with COPD, oxygen dependence, and dementia had an oxygen tank left upright without a holder in the room; the DSD and an LVN both stated the tank was not secured, and the facility policy required oxygen tanks to be safely secured.
Delayed Foot Care After Podiatry Orders: A resident with COPD, pressure ulcers, and paraplegia had podiatry recommendations for daily Clotrimazole 1% cream and A&D ointment, but staff did not follow the orders after the physician visit. The DSD and SSD both confirmed the treatment was not started and stated the orders should have been communicated to nursing and initiated promptly.
Opened Ferrous Sulfate Bottle Not Dated. An LVN administered Ferrous Sulfate from an opened bottle that did not have the date it was first opened. The LVN stated the container should have been dated when opened so it could be removed after 30 days, and the facility policy required broken manufacturer containers or vials to be dated.
Food Storage and Labeling Deficiencies: Staff observed an unlabeled and undated bag of spinach with a milky white substance in the kitchen refrigerator, an uncovered oatmeal bin in dry storage, cardboard boxes stored under the handwashing sink, two bottles of Gatorade in the meat freezer, and a bottle labeled Spice without an ingredient list or use-by date. DS and the DM stated the spinach should have been dated and discarded, the oatmeal should have been covered, the boxes could harbor pests, the Gatorade should not be stored with residents' food, and the Spice container needed labeling to avoid unknown ingredients.
Improperly Covered Outdoor Trash Bins: Two of three outdoor trash bins were observed overfilled and only partially covered during a joint observation and interview with the DSD. The DSD stated the bins should be covered because rodents and other animals can get into the trash, and later stated the facility had no policies for cardboard box disposal or outdoor trash bin disposal. A review of SOM-Appendix PP indicated refuse must be properly contained and disposed of properly.
Missing EBP Signage for Resident with Wound Infection: A resident with a right lower extremity wound infection, MRSA, and hemiplegia had an isolation cart outside the room, but no EBP sign was posted on the door or inside the room. CNA staff stated they would not know what PPE to wear without a sign, and the IP later said the sign had been found on the floor near the bed and placed on the wall at the head of the bed.
A CNA entered a resident’s room and touched the resident’s forehead without performing hand hygiene, despite facility policy requiring use of alcohol-based hand rub or soap and water before and after direct resident contact. The resident had dementia, Alzheimer’s disease, and dysphagia following a nontraumatic intracerebral hemorrhage and lacked capacity to make decisions, with orders for a fortified puree diet, pain assessments with pain management, and monitoring of both lower extremities for redness, discoloration, swelling, and pain related to immobilizer use. In a concurrent interview, the CNA acknowledged they were supposed to clean their hands before touching residents because failure to do so could cause an infection.
Failure to perform hand hygiene and change gloves occurred during wound care for a resident with a stage 4 sacrococcyx pressure ulcer. An OT was observed wearing gloves, pulling the privacy curtain, and administering Ultramist therapy without changing gloves or cleaning hands first; the OT stated this could spread germs and increase infection risk. The resident was dependent on staff for oral hygiene, toileting hygiene, and bathing, and the facility’s hand hygiene policy required hand hygiene before invasive procedures and after removing PPE.
A deficiency was cited when a facility area was found to contain accident hazards and lacked adequate supervision to prevent accidents. The environment did not meet required safety standards, resulting in insufficient oversight.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A resident with Alzheimer’s and multiple health issues was discharged to a board and care facility with a large quantity of Norco, a controlled narcotic, without proper documentation or reconciliation of medications as required by facility policy. The discharge plan lacked details on medication names, dosages, and amounts, and the attending physician was not informed about the medications provided. Staff interviews revealed that standard procedures for documenting and verifying controlled substances at discharge were not followed.
A resident with multiple health conditions received Norco, a controlled pain medication, but several administrations were not documented in the e-MAR as required. The medication was removed from inventory and not properly recorded, as confirmed by a nurse and facility records, in violation of facility policy for controlled substances.
A nurse failed to disinfect a wrist blood pressure monitor before and after use on a resident with dementia, COPD, and a wound infection. The device was placed back in the medication cart without cleaning, contrary to facility infection control policy, increasing the risk of infection transmission.
Two residents experienced deficiencies in fall prevention when the facility failed to individualize care plans, conduct timely IDT meetings, accurately assess fall risk, and implement recommended safety interventions such as bed railings and cushion pads. These lapses occurred despite the residents' high risk for falls and the facility's policies requiring such measures.
A resident with nicotine dependence and COPD was found with cigarettes in their possession, contrary to facility policy prohibiting residents from keeping tobacco products. The care plan included outdated interventions, and the required quarterly Smoking Evaluation was not completed or updated, as confirmed by the DON and RN. These failures resulted in a lack of a safe and hazard-free environment.
A resident with a history of stroke, bipolar disorder, and aphasia was found with scratch marks on the left hand. Facility staff did not perform a skin assessment or notify the physician as required by policy, despite the resident's communication difficulties and need for substantial assistance with daily activities. This deficiency was confirmed through staff interviews and record review.
A resident with cognitive impairment and recent aggressive behavior did not receive a physician-ordered urinalysis after a change in condition. Despite facility policy requiring prompt implementation of new orders, the UA was not performed, resulting in a failure to provide timely laboratory services.
The facility failed to maintain a clean environment and adequate room temperatures for its residents. A resident's air vent was covered with dust, and multiple residents reported feeling cold due to room temperatures below the required range. The Maintenance Supervisor confirmed the issues, noting that the thermostat could be adjusted by anyone, affecting multiple rooms.
The facility did not replace sharps containers on Medication Carts #2 and #4 when they reached the Full line, with objects protruding from one container. An LVN confirmed the containers were overfilled and acknowledged the risk of injury.
A facility failed to accurately complete the MDS for a resident with End Stage Renal Disease, heart failure, and cirrhosis. The resident's MDS inaccurately indicated receipt of the Influenza Vaccine, despite no documentation supporting this. The facility's policy requires accurate certification and transmission of MDS data.
A resident with diagnoses of depression, schizophrenia, and anxiety did not receive a required PASRR level II assessment, despite a positive PASRR level I indicating the need for further evaluation. The resident's care plan required adherence to PASRR level II recommendations, but the assessment was not completed, potentially impacting the resident's receipt of necessary mental health services.
A facility failed to implement a comprehensive care plan for a resident with End Stage Renal Disease and heart failure, who was non-compliant with a physician-ordered fluid restriction. Despite the resident's cognitive ability to understand the risks, staff did not inform him about the dangers of excessive fluid intake, and no care plan was in place to address this non-compliance. The DON confirmed the absence of a care plan and the resident's risk for fluid overload.
A resident with diabetes and severe cognitive impairment did not receive necessary nail care, resulting in long, thick nails with debris. The LVN failed to notify the SSD for podiatry services, contrary to the facility's policy requiring podiatrist care for diabetic residents.
A resident with severe cognitive impairment and multiple diagnoses experienced a 10-pound weight loss over 30 days, which was not reported to the physician as required by the facility's policy. The necessary change of condition form was delayed, and an Interdisciplinary Team meeting was not conducted to address the resident's care needs.
A resident with severe cognitive impairment and multiple health issues had an IV line left in place after the completion of antibiotic therapy, contrary to the facility's policy. The IV line, used for administering Meropenem, was not removed after the therapy ended, as observed during a survey. A nurse confirmed the oversight, acknowledging the risk of infection due to the failure to remove the IV line promptly.
A resident with cerebral infarction and heart failure did not have her oxygen saturation levels checked frequently enough to maintain them above 90% as per physician's orders. Despite having an oxygen concentrator and nasal cannula by her bedside, the equipment was not in use. The resident's oxygen saturation was only checked once in October and November, and twice in December, which was insufficient. An LVN confirmed that vital signs should be taken at least once a day, and the staff should have clarified the frequency with the doctor.
The facility failed to implement a resident's fluid restriction order accurately, leading to potential health risks. Additionally, there was a lack of communication with the dialysis center regarding medication management for another resident, and an emergency kit was not available at the bedside for a third resident, posing a risk of complications.
A resident with multiple health conditions, including multiple myeloma and hypertension, did not receive necessary behavioral health care services due to a lack of communication within the facility. Despite a physician's order for a psychiatric evaluation, the Social Service Director was not informed, resulting in the resident not being evaluated by a psychiatrist. This oversight occurred even though the resident exhibited refusal of care behaviors, which could have been addressed with appropriate psychiatric intervention.
A resident with urinary retention and an indwelling catheter did not receive a timely urology follow-up due to the facility's failure to schedule the appointment. Despite a physician order for a consult, the Social Services department did not arrange the necessary referral or appointment, potentially delaying care.
A LTC facility failed to provide appropriate pharmaceutical services for two residents. One resident missed doses of critical medications due to untimely ordering, while another was at risk of receiving a duplicate dose of Carvedilol due to delayed documentation by an LVN. The facility's policies require timely reordering and documentation to prevent such issues.
A resident with diabetes, hypertension, and dementia did not receive her prescribed Jardiance dose due to its unavailability, as observed during a medication administration. The LVN confirmed the missed dose, which could lead to high blood sugar levels. Facility policies require timely medication administration, and the LVN's role includes ensuring medications are given as ordered.
The facility failed to properly label and store medications, as an emergency kit and three bags of ertapenem were found past their discard dates in the medication refrigerator. The ADON confirmed these items should not have been there, and their use could harm a resident. Facility policy requires outdated medications to be immediately removed from inventory.
A resident with severe cognitive impairment and multiple diagnoses did not receive ordered lab tests, including CBC, CMP, HgA1c, TSH, and Lipid panel, as per physician's orders. The facility's failure to conduct these tests was confirmed by an LVN, who could not explain the oversight. This deficiency was contrary to the facility's policy on obtaining and reporting lab results.
A facility failed to ensure hospice services met professional standards by not having a hospice representative participate in the IDT care conference for a resident with severe cognitive impairment and multiple diagnoses. The SSD confirmed the absence of the hospice representative in the October meeting, despite the facility's policy requiring their involvement in care planning.
A resident with a Stage 4 sacral ulcer had their low air loss (LAL) mattress set incorrectly at 350 instead of matching their weight of 141 pounds. This discrepancy was observed during a facility review, and interviews with nursing staff confirmed the importance of setting the mattress to the resident's weight to prevent further skin breakdown. The facility's manual and policy also emphasized the need for correct mattress settings to promote wound healing.
A resident's urinal containing urine was placed on a bedside table next to a meal tray, violating infection control protocols. The resident, diagnosed with schizophrenia, required assistance with daily activities. Staff interviews confirmed the urinal should have been removed and the table cleaned before meal service to prevent contamination.
A resident's telephone order for Hydroxyzine was not entered into the EMR, preventing the medication from being ordered or administered. The resident, who was cognitively intact and had conditions including osteoarthritis and hip pain, had a psychiatric provider's order for Hydroxyzine for anxiety. However, the order was not recorded in the system, contrary to the facility's medication administration policy.
A resident with COPD and pneumonitis did not receive continuous oxygen as ordered by the physician, and their oxygen equipment was not labeled or dated according to facility policy. The resident was observed without the nasal cannula, and staff incorrectly believed the oxygen was to be given as needed. The DON confirmed the oversight and the importance of following physician's orders.
A resident with chronic conditions reported being hit, but the Social Services Director failed to report the abuse allegation to the Administrator or other staff as required. The facility's policy mandates immediate reporting of such allegations, which was not followed, posing a risk of further abuse.
A resident did not receive a prescribed medication, Bethanechol, for urinary muscle spasms in a timely manner due to a staff oversight. The medication order was dated but not administered until a week later, resulting in a delay of care. Interviews with staff confirmed the oversight, and the facility's policy on medication administration was not followed.
Failure to Clarify Skin Inspection Order for Knee Immobilizer
Penalty
Summary
The facility failed to clarify the physician’s order regarding inspection of the skin under a knee immobilizer for a resident with a right tibia and fibula fracture. The resident was admitted and later readmitted with diagnoses including encephalopathy, UTI, and the right leg fracture. Her MDS indicated she could make her needs known but was dependent on staff for rolling in bed. Hospital records showed the knee immobilizer was applied to the right knee and was intended to be worn for 6 weeks due to the fracture and non-weight bearing status. The resident’s order summary dated 3/24/26 directed staff to monitor the right knee immobilizer for discoloration, edema, odor, or skin breakdown and notify the MD. On 4/22/26, the resident was transferred to the hospital for altered mental status and returned on 4/26/26. Hospital discharge documentation noted a Stage 3 pressure ulcer at the edge of the right lower extremity splint, and a skin check on 4/27/26 documented an unstageable pressure ulcer on the right lateral calf measuring 6 cm by 4 cm with 90% eschar and 10% slough. During interview, the LVN stated staff monitored the skin around the immobilizer but did not inspect inside it because there was no physician order to do so. The DON stated there was no order to always wear the immobilizer for 6 weeks and no order to remove it for skin inspection, and that nursing staff should have called the PCP to clarify whether it could be removed for skin inspection. The facility policy required weekly skin assessment for residents with casts or splints and communication of skin changes to the physician.
Failure to Assess and Document Resident Condition Before and After Out-on-Pass Leave
Penalty
Summary
The facility failed to complete and document required nursing assessments before and after an approved out-on-pass (OOP) leave for one resident. The resident had diagnoses including muscle weakness, bone density disorder, and lack of coordination, and her history and physical noted that her capacity for medical decision-making waxed and waned due to mental incapacitation. A recent MDS documented that her cognition was severely impaired and that she was dependent on staff for toileting hygiene, showering, and dressing. Facility records showed she left the facility on OOP in the morning and returned in the afternoon on the same day, but there were no nursing progress notes or assessments documenting her condition at the time of departure or upon return, despite facility policy requiring continuous nurse’s notes and documentation when a resident returns from OOP. The omission was confirmed through review of the resident’s progress notes and Weights and Vitals Summary, which showed no vital signs or assessments completed around the time of the OOP leave. On the following day, nursing documentation noted swelling and skin discoloration of the resident’s left lower extremity, and the resident’s daughter reported that the resident had hit her left leg while in the vehicle during the OOP. An SBAR completed that day described the swelling and discoloration and led to an X-ray order, which subsequently showed a nondisplaced fracture of the left ankle and foot. During interviews, an LVN and the DON both acknowledged that no assessment or vital signs were documented before the resident left or when she returned from OOP, and both stated it was important to assess the resident at those times to identify any possible medical changes in condition. Facility policies on charting, documentation, and residents out on pass required documentation of treatment, care, and events while out on pass, which was not done in this case.
Failure to Inform Residents During Medication Administration
Penalty
Summary
Licensed nursing staff failed to inform Residents 13 and 91 of the medications being administered before giving them their medications, and the residents were not given an opportunity to participate during medication administration. Resident 13 was admitted and readmitted with diagnoses including type 2 DM, HF, and age-related osteoporosis. Resident 13's H&P stated the resident did not have the capacity to understand and make decisions, while the MDS indicated the resident usually could make self understood and understand others and was dependent on staff for toileting, bathing, lower body dressing, and personal hygiene. Resident 91 was admitted with diagnoses including hemiplegia and hemiparesis, facial weakness, and type 2 DM. Resident 91's H&P stated the resident did not have the capacity to understand and make decisions, while the MDS indicated the resident could make self understood and understand others and required maximal assistance for toileting, bathing, and lower body dressing. During observation, LVN 3 gave Resident 13 six medicine cups and Resident 91 nine medicine cups without explaining what medications were in the cups. Both residents swallowed the pills, and Resident 91 also swallowed liquid medications. During interview, LVN 3 stated she was taught to inform residents of the names of medications before administering them. The DON stated nurses are trained to explain medications to residents prior to administration and that it is important to inform residents because they have the right to refuse. The facility's P&P titled Administration of Drugs, revised 5/2020, did not identify the federally required content element that licensed nurses must explain the type of medication being administered and the procedure.
Dialysis E-Kit Not Kept in Resident Room
Penalty
Summary
The facility failed to ensure that Resident 72 had a care plan for the resident's dialysis emergency kit not being kept in the resident's room. Resident 72 was admitted with diagnoses including ESRD, dependence on renal dialysis, and type 2 DM with diabetic chronic kidney disease. The history and physical noted the resident's capacity for medical decision making was waxing and waning, and the MDS indicated the resident usually could make self understood and understand others, was independent with eating, lower body dressing, footwear, and personal hygiene, and received dialysis as a special treatment. The order summary indicated dialysis treatments every Tuesday, Thursday, and Saturday, with assessment of the dialysis site every shift for tenderness, redness, and bleeding. During an observation in the resident's room, there was no dialysis e-kit present. An LVN stated he did not know why the e-kit was not in the room, that it should be available for emergencies, and he did not know where it was located. The DSD stated the e-kit should be kept at the bedside, but because the resident threw out the contents because he did not want the bag there, the e-kit was kept at nursing station 2 so it would remain intact and ready in case of emergency. The facility's policy on comprehensive person-centered care planning stated that if a resident refuses services posing a risk to health and safety, the comprehensive care plan will identify the declined care or service, the associated risks, the IDT's efforts to educate the resident and resident representative, and any alternate means to address risk.
Care Plans Not Updated to Match Current Physician Orders
Penalty
Summary
The facility failed to revise and update person-centered care plans to match current physician orders for two residents. One resident had diagnoses including respiratory failure with hypoxia, CHF, asthma with acute exacerbation, pulmonary hypertension, and acute pulmonary edema, and the MDS showed moderate cognitive impairment with extensive assistance needed for ADLs. A physician order dated 1/16/2026 directed oxygen at 2 L/min continuously via nasal cannula, but during review with an LVN on 3/11/2026, the altered respiratory status care plan still listed oxygen at 4 L/min via nasal cannula. The LVN confirmed the care plan should have been revised when the order was implemented. Another resident had diagnoses including Parkinson's disease, Alzheimer's Disease, and gastrostomy, and the H&P stated the resident did not have the capacity to understand and make decisions. The MDS showed moderate cognitive impairment and total staff assistance needed for multiple ADLs. A physician order dated 2/25/2026 directed continuous g-tube feeding at 60 mL/hour for 20 hours, but during review with the MDS Coordinator on 3/12/2026, the altered nutrition/hydration care plan still documented g-tube feeding at 70 mL/hour for 20 hours. The MDS Coordinator confirmed the care plan should have been revised to reflect the current physician order. The DON stated nursing staff were responsible for ensuring care plans reflected current physician orders and that care plans were expected to be revised when changes occurred, including new physician orders.
Failure to Report Sediment in Indwelling Catheter Tubing
Penalty
Summary
Failure to provide appropriate catheter care and monitor for urinary tract infection was identified for one resident with an indwelling catheter. The resident had diagnoses including COPD, pressure ulcers, and paraplegia, and the record showed fluctuating decision-making capacity in the H&P, while the MDS indicated intact cognition and dependence on staff for toileting hygiene, showering, and dressing. The resident was admitted and later readmitted to the facility, and the care plan identified the resident as high risk with an indwelling catheter and directed staff to monitor, record, and report signs and symptoms of UTI to the physician. During observation, the resident was seen with sediment in the indwelling catheter tubing on two occasions. The DSD stated there was a large amount of sediment and that the catheter should have been assessed during nursing rounds, and the physician should have been notified immediately because sediment could indicate possible UTI or infection. An LVN also stated the sediment should have been reported to the physician and that nursing was responsible for monitoring for signs and symptoms of possible infection. The facility policy on significant change of condition indicated the licensed nurse or nurse supervisor should be aware of recognized changes, including signs or symptoms of infection.
Oxygen Administration and Storage Deficiencies
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was deficient for two residents. Resident 30 had diagnoses including respiratory failure with hypoxia, CHF, asthma with acute exacerbation, pulmonary hypertension, and acute pulmonary edema, and the MDS indicated moderate cognitive impairment and dependence on staff for multiple ADLs. During observation, Resident 30 was receiving oxygen via nasal cannula at 3.5 L/min, while the physician order reviewed at the same time specified oxygen at 2 L/min continuously. The LVN present confirmed the setting did not match the order and stated staff were expected to follow physician orders when administering oxygen. The DON later stated nursing staff were responsible for administering treatments in accordance with physician orders and verifying the correct treatment prior to administration. Resident 34 had diagnoses including COPD, dependence on supplemental oxygen, and dementia, and the H&P indicated fluctuated capacity to understand and make decisions; the MDS indicated severely impaired cognition and dependence on staff for personal hygiene, showering, and dressing. During observations in the resident's room, an oxygen tank was found standing upright without a holder to support it. The DSD stated the oxygen tank needed to be secured and, when not in use, placed in the oxygen storage room, and stated that if the tank fell it could burst and explode. An LVN also stated the tank was not secured and could combust and harm Resident 34. The facility policy on oxygen handling and storage stated oxygen tanks must be secured to a wall within a chain or heavy cable and that safety cups will be installed on all tanks not in use.
Delayed Foot Care After Podiatry Orders
Penalty
Summary
The facility failed to ensure that a physician’s recommended foot care treatments were followed for one sampled resident. Resident 7 was admitted and later readmitted to the facility with diagnoses including COPD, pressure ulcers, and paraplegia. The resident’s H&P dated 5/6/2025 noted fluctuating capacity to understand and make decisions, while the MDS dated 1/4/20206 indicated cognition was intact and that the resident was dependent on staff for toileting hygiene, showering, and dressing. A podiatry evaluation and treatment record dated 3/6/2026 documented physician recommendations for Clotrimazole 1% cream to be applied daily to the affected area and A&D ointment to be applied daily. During interviews and record review on 3/11/2026, the DSD and SSD stated these physician recommendations were not followed and that treatment should have started after the resident was seen by the physician. The SSD stated the recommendations should have been brought to nursing so the medical treatment could begin, and the DSD stated the delay in care and treatment could make the resident’s condition worse. The facility’s policy stated drugs and treatments must be received and recorded immediately in the resident’s chart by the person receiving the order.
Opened Medication Bottle Not Dated
Penalty
Summary
A deficiency was cited for failure to ensure that an opened medication container was labeled with the date it was opened. During an observation on 3/12/2026 at 08:15 AM, an LVN administered Ferrous Sulfate from an opened bottle that did not have an open date on the label. During an interview later that day, the LVN stated the bottle should have been labeled with the date it was first opened so it could be removed from the cart after 30 days and noted that without knowing how long ago it was opened, there was no way to know if it would still be effective. The facility policy titled Medication Storage in the Facility, dated May 2022, stated that when the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated.
Food Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to dispose of an unlabeled and undated bag of spinach in the kitchen refrigerator, where it was observed next to tomatoes with a milky white substance in the bag. During the observation, Dietary Staff 1 stated the spinach should have been labeled with a date and could cause a resident to complain or become ill if served. The Dietary Manager later stated the spinach should have had a date showing when it was placed in the refrigerator and should have been discarded because it did not have a date and the milky substance could make residents sick. The facility also failed to keep food and storage areas in accordance with professional standards when an uncovered oatmeal bin was observed in the dry goods storage room, cardboard boxes were stored under the kitchen hand washing sink, two bottles of Gatorade were stored in the meat freezer, and a bottle labeled Spice did not have a list of ingredients or a use-by date. Dietary Staff 1 and the Director of Staff Development stated the oatmeal should be covered to prevent bugs, dust, and dirty material from contaminating it, and the Dietary Manager stated empty cardboard boxes could harbor pests and bugs and should not be stored in the kitchen. The Director of Staff Development stated the Gatorade should not be in the meat freezer because residents' food should be stored separately from staff food, and the Dietary Manager stated the Spice container should have a use-by date and ingredient list or residents could have an allergic reaction to unknown ingredients.
Improperly Covered Outdoor Trash Bins
Penalty
Summary
The facility failed to ensure that two of three outside trash bins were properly contained with covers that were completely closed. During a concurrent observation and interview on 3/10/2026 at 8:53 a.m. with the DSD, two large trash bins in the trash bin storage area were observed to be overfilled and partially covered. The DSD stated the trash bins should be covered because rodents and other animals can get into the trash. During a later interview on 3/13/2026 at 11:49 p.m., the DSD stated the facility did not have policies for the disposal of cardboard boxes and outdoor trash bin disposal. A review of the State Operations Manual-Appendix PP dated 7/23/2025 indicated the facility must properly contain refuse and dispose of it properly.
Missing EBP Signage for Resident with Wound Infection
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when the facility failed to ensure an Enhanced Barrier Precautions sign was displayed in Resident 104’s room. Resident 104’s admission record indicated cellulitis of the right lower limb, MRSA infection, and hemiplegia/hemiparesis affecting the left non-dominant side. The H&P stated Resident 104 had capacity for medical decisions and had been discharged from a hospital to the facility for care of a nonhealing right lower extremity wound initially caused by a burn. The MDS indicated Resident 104 received OT and PT and had a BIMS score of 15, showing intact cognition. The care plan stated Resident 104 had a right lower extremity infection, was on antibiotic therapy for a right leg wound infection, and was on enhanced barrier precautions requiring staff and visitors to use gowns and gloves for personal care. During observation in Resident 104’s room, an isolation cart was present at the entry wall, but there was no isolation sign on the door or inside the room. CNA1 stated that if there was no sign, staff would not know what isolation items to wear before entering the room. The Infection Preventionist later stated the EBP sign had been found on the floor near the head of Resident 104’s bed and was placed on the wall at the head of the bed, and that if the sign was not available for visitors to see, they would not know what to do to protect themselves from organisms and could spread it to others. The facility policy stated EBP is used with standard precautions and includes gown and glove use during high-contact resident care activities for residents with wounds and/or indwelling medical devices.
Failure to Perform Hand Hygiene Before Direct Resident Contact
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a CNA entered a resident’s room and touched the resident’s forehead without performing hand hygiene. The resident had been admitted on 4/9/2022 and had diagnoses including dementia, Alzheimer’s disease, and dysphagia following a nontraumatic intracerebral hemorrhage, and a history and physical dated 1/2/2025 documented that the resident did not have the capacity to understand and make decisions. The resident’s orders included a fortified puree diet, pain assessments with pain management, and monitoring of both lower extremities every shift for redness, discoloration, swelling, and pain related to immobilizer use. During observation on 2/17/2026 at 11:19 a.m., the CNA touched the resident’s forehead without first cleaning their hands, and in a concurrent interview acknowledged they were supposed to perform hand hygiene before touching residents because not doing so could cause an infection. The facility’s hand hygiene policy dated 12/2023 required use of alcohol-based hand rub or soap and water before and after direct contact with residents. This failure to perform hand hygiene before direct contact with the resident constituted noncompliance with the facility’s infection prevention and control program and its written hand hygiene policy.
Failure to Perform Hand Hygiene and Change Gloves Before Wound Treatment
Penalty
Summary
Failure to implement infection prevention and control measures occurred during wound treatment for one resident with a stage 4 sacral pressure ulcer. The resident’s admission record showed diagnoses including acute respiratory failure with hypoxia, acute pulmonary edema, and a stage 4 pressure ulcer of the sacral region. The Minimum Data Set indicated the resident had clear speech, some difficulty communicating, and was dependent on staff for oral hygiene, toileting hygiene, and showering/bathing. During a concurrent observation and interview at the resident’s bedside, an OT was observed wearing gloves, pulling the privacy curtain, and proceeding to administer Ultramist wound treatment without changing gloves or performing hand hygiene. The OT stated that failing to change gloves and wash hands before administering the wound treatment could spread germs and increase the risk of infection for the resident. The resident’s physician order directed daily Ultramist Therapy on Monday, Wednesday, and Friday for management of the stage 4 pressure injury, and the OT encounter note documented that mist therapy was performed to the sacrococcyx pressure ulcer. The facility’s hand hygiene policy stated that healthcare workers are to perform hand hygiene before non-surgical invasive procedures and after removing PPE.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which resulted in the presence of accident hazards and insufficient oversight to prevent potential incidents. No additional details regarding the specific hazards, the individuals involved, or their medical conditions at the time of the deficiency are provided in the report.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt notification and communication regarding an incident that required reporting, as well as the failure to provide investigation outcomes to the appropriate external agencies as required.
Failure to Document and Reconcile Discharge Medications
Penalty
Summary
The facility failed to ensure that the Post Discharge Plan of Care for a resident discharged to a board and care facility was completed according to its own policy and professional standards. The discharge documentation did not include the names, dosages, or amounts of post-discharge medications, specifically omitting details about a controlled substance, Norco, which was dispensed in significant quantity. The medication section of the discharge plan was left blank, and there was no indication of the interdisciplinary team member responsible for completing the document, nor was there a signature from the party accepting the plan. The resident in question had a history of Alzheimer’s disease, cardiomegaly, difficulty walking, and a history of falls, and required supervision or assistance with daily activities. The resident was discharged with a large quantity of Norco, a narcotic pain medication, but the physician order did not specify which medications or amounts were to be provided upon discharge. The discharge summary and transfer/discharge report also failed to document the specific medications and quantities given to the resident or their family. Interviews with facility staff revealed that the normal process for discharging a resident with narcotics was not followed, and the documentation was incomplete due to the nurse being in a hurry. Further, the attending physician was not informed about the medications being sent with the resident and stated that he would not have approved the discharge of Norco due to its risks. The facility’s policy required a reconciliation of all pre-discharge and post-discharge medications, but this was not completed. The lack of proper documentation and communication regarding the controlled medication placed the resident at risk, as noted in the report.
Failure to Document Controlled Medication Administration in e-MAR
Penalty
Summary
The facility failed to ensure that the administration of Norco, a controlled pain medication, was properly documented in the electronic Medication Administration Record (e-MAR) for a resident. Specifically, the Controlled Medication Count Sheet indicated that Norco tablets were removed from inventory on several occasions, but these administrations were not recorded in the e-MAR. This discrepancy was confirmed during a review of both the count sheet and the e-MAR, as well as through an interview with a Licensed Vocational Nurse, who acknowledged that the e-MAR was not signed to reflect the removal and administration of the medication. The resident involved had a history of Alzheimer’s disease, cardiomegaly, difficulty walking, and a history of falls, and was under a physician’s order to receive Norco as needed for pain management. Facility policy required that all administrations of controlled medications be immediately documented with the date, time, amount administered, and the nurse’s signature. The failure to document these administrations in the e-MAR constituted a breach of this policy and created a risk of miscommunication among healthcare personnel regarding the resident’s medication administration.
Failure to Disinfect Blood Pressure Monitor Between Uses
Penalty
Summary
A deficiency occurred when a Licensed Vocational Nurse (LVN) failed to disinfect a wrist blood pressure monitor before and after use on a resident. The LVN was observed attempting to take the resident's blood pressure multiple times without success, then placing the monitor back into the medication cart drawer without cleaning it. The LVN acknowledged not disinfecting the device, and another LVN confirmed that this failure could spread germs and increase infection risk. The Infection Preventionist Nurse also stated that not cleaning the monitor before and after use increases the risk of spreading communicable diseases among residents. The resident involved had a history of dementia, chronic obstructive pulmonary disease (COPD), and muscle weakness, and was dependent on staff for assistance with daily activities. The resident's care plan included interventions to prevent skin injury and infection, as the resident had an actual impairment to skin integrity related to a left hip wound infection. The facility's infection control policy required that supplies and equipment be cleaned immediately after use, but this procedure was not followed in this instance.
Failure to Individualize Care Plans and Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to provide an environment free from accident hazards and did not ensure adequate supervision to prevent accidents for two residents. For one resident with muscle weakness and cognitive communication deficits, the care plan was not individualized after a witnessed fall. The care plan, revised after the fall, only included checking range of motion and reporting mental changes, but did not address the specific cause of the fall, such as sliding from the wheelchair. Additionally, there was no Interdisciplinary Team (IDT) meeting conducted to discuss safety interventions following the incident. For another resident with difficulty walking and low back pain, the facility did not conduct an accurate fall risk assessment after a fall, as the assessment did not reflect the incident or the resident's poor balance and medication use, which could increase fall risk. The resident was incorrectly assessed as medium risk instead of high risk. Furthermore, after a subsequent fall, recommendations from rehabilitation services to apply bed railings and cushion pads along the bedside were not implemented. There was also no care plan created to address the new fall risk factors. Observations confirmed that recommended safety interventions, such as bed railings and cushion pads, were not present in the resident's room. The facility's own policies required appropriate assessments and interventions to prevent and minimize falls, as well as IDT review and care plan updates, but these procedures were not followed for the residents involved.
Failure to Enforce Smoking Policy and Update Resident Smoking Evaluation
Penalty
Summary
The facility failed to maintain a safe and hazard-free environment for a resident by not implementing its own Smoking Policy, which prohibits residents from keeping cigarette or tobacco products in their possession. During an observation, a pack of approximately 18 cigarettes was found at the resident's bedside, and there was no metal lock box present. The Registered Nurse confirmed that the resident should not have had cigarettes in their possession, as it was against facility policy and could jeopardize safety. The resident's care plan included an outdated intervention to provide a lock box for smoking materials, which conflicted with the current facility policy. Additionally, the facility did not review, update, or document the resident's Smoking Evaluation at least quarterly, as required by policy. The last documented Smoking Evaluation was several months prior, and the Director of Nursing acknowledged that the evaluation should have been completed quarterly to assess the resident's safety to smoke. The resident had a history of nicotine dependence, COPD, and chest pain, and was assessed as requiring partial/moderate assistance with dressing but was independent with eating and able to understand and express needs. The lack of updated assessments and conflicting care plan interventions contributed to the deficiency.
Failure to Notify Physician of Resident's Skin Condition Change
Penalty
Summary
The facility failed to notify a resident's physician regarding the presence of scratch marks on the resident's left hand. The resident, who had a history of cerebral infarction, bipolar disorder, and aphasia, was observed to have two scratch marks during a room observation. Documentation indicated that the resident had difficulty communicating but was able to comprehend most conversations with prompting. The resident required substantial assistance with activities of daily living such as toileting hygiene, showering, and dressing. Interviews with facility staff, including the Director of Staff Development (DSD), Director of Nursing (DON), and Administrator (ADM), confirmed that a skin assessment had not been performed and the physician had not been notified about the scratches. The facility's policy required that all changes in a resident's condition be communicated to the physician, but this protocol was not followed in this instance. The deficiency was identified through observation, interview, and record review.
Failure to Complete Physician-Ordered Urinalysis Following Change in Condition
Penalty
Summary
The facility failed to ensure that a physician-ordered urinalysis (UA) with culture and sensitivity was completed and sent to the laboratory for one resident. The resident, who had a history of cerebral infarction, bipolar disorder, and aphasia, was admitted with cognitive impairment and required substantial assistance with activities of daily living. On a documented change of condition, the resident exhibited physical aggressive behavior and confusion, prompting the physician to order a UA to check for a possible urinary tract infection (UTI). Despite the physician's order and the facility's policy requiring prompt implementation of new orders following a change in condition, the UA was not performed. The Director of Staff Development confirmed that the test was not completed, acknowledging that the resident's symptoms could have indicated a UTI. The facility's policy emphasized the need for timely response to changes in resident condition, but the failure to carry out the ordered laboratory test constituted a deficiency in providing timely and quality laboratory services.
Facility Fails to Maintain Cleanliness and Adequate Room Temperatures
Penalty
Summary
The facility failed to maintain a clean and safe environment for its residents, as evidenced by the presence of dust on the air vent above a resident's bed and inadequate room temperatures. During an initial tour, it was observed that the air vent above the head of a resident's bed was covered with dust. The resident, who had been admitted with diagnoses including breast cancer, muscle weakness, and difficulty walking, reported that the dust appeared to be moving like bugs. The Maintenance Supervisor confirmed that the vent was dirty despite a log indicating that vents were clean. The supervisor explained that the vent was a return vent meant to recycle air and should not affect the resident. Additionally, the facility failed to maintain room temperatures within the required range of 71 to 81 degrees Fahrenheit. One resident was observed under multiple blankets and expressed feeling cold, while another resident reported being freezing at night despite using an extra blanket. A third resident, who preferred to keep her window open, had a room temperature of 69 degrees Fahrenheit, which was confirmed by the Maintenance Supervisor. The thermostat controlling multiple rooms was set to maintain 76 degrees, but it could be adjusted by anyone, affecting the temperature in several rooms. The facility's policy required a safe and comfortable environment, which was not upheld in these instances.
Failure to Replace Full Sharps Containers
Penalty
Summary
The facility failed to ensure that two sharps containers on Medication Cart #2 and Medication Cart #4 were replaced when they reached the Full line, posing a potential risk of injury to staff or residents. During an observation, it was noted that the sharps container on Medication Cart #4 was full, with objects protruding from the lid. Similarly, the sharps container on Medication Cart #2 contained objects past the Full line. During a concurrent observation and interview, an LVN confirmed that both containers were overfilled and acknowledged that they should have been replaced once the Full line was reached. The LVN also recognized the potential for injury due to the overfilled sharps containers.
Inaccurate MDS Completion for Resident
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was completed accurately for a resident, which had the potential to negatively affect the plan of care and delivery of services. The resident was admitted with diagnoses including End Stage Renal Disease, heart failure, and cirrhosis of the liver. The resident's cognitive skills for daily decision-making were intact, and they required set-up assistance for Activities of Daily Living such as oral and personal hygiene. During a review of the resident's MDS assessment, it was found that the section regarding the Influenza Vaccine was inaccurately completed. The MDS was coded to indicate that the resident had received the vaccine, but there was no documentation to support this, as the resident last received the vaccine the previous year. The facility's policy requires that each individual who completes a portion of the assessment certifies its accuracy, and that accurate MDS data is transmitted to the CMS system.
Failure to Complete PASRR Level II Assessment for Resident
Penalty
Summary
The facility failed to ensure that a resident received a Pre-Admission Screening and Resident Review (PASRR) level II assessment, which is a federal requirement for individuals with mental disorders or intellectual disabilities. The resident in question was admitted with diagnoses of depression, schizophrenia, and anxiety, and the care plan indicated that staff should follow PASRR level II recommendations. However, the PASRR level II assessment was not completed, despite the resident's PASRR level I being positive, indicating the need for further evaluation. During a review of the resident's records, it was found that the resident had fluctuating capacity to understand and make decisions, and was dependent on staff for activities of daily living. The MDS nurse confirmed that the PASRR level II assessment was necessary to determine the appropriate mental health services and care for the resident, but it was not conducted. This oversight had the potential to result in the resident not receiving the required services for their mental health condition, as per the facility's policy and procedure on PASRR.
Failure to Implement Care Plan for Fluid Restriction
Penalty
Summary
The facility failed to initiate a comprehensive care plan for a resident who was non-compliant with a physician-ordered fluid restriction. The resident, diagnosed with End Stage Renal Disease, heart failure, and dependent on renal dialysis, was observed with large quantities of fluids in his room, including soda, water, and orange juice. Despite having the cognitive ability to understand and make decisions, the resident stated that staff had not informed him about the risks of excessive fluid intake. The Licensed Vocational Nurse was unaware of the specific fluid restriction amounts, and the Director of Nursing confirmed that no care plan was in place to address the resident's non-compliance. The facility's policy required the interdisciplinary team to develop a comprehensive person-centered care plan for each resident, including measurable objectives and timeframes to meet their needs. However, the resident's electronic clinical records did not indicate any care plan addressing the non-compliance with fluid restriction. The Director of Nursing acknowledged the resident's risk for fluid overload due to non-compliance and the importance of developing a comprehensive care plan for continuity of care.
Failure to Provide Nail Care for Resident with Diabetes
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 16, received proper grooming for his long fingernails. Resident 16 was admitted with diagnoses including diabetes, hypertension, and dementia, and was noted to have severe cognitive impairment, making him dependent on staff for all activities of daily living. The care plan for Resident 16 indicated that staff should refer him to podiatry if he had thick nails. However, during an observation, it was noted that Resident 16 had long, thick nails with debris underneath, which had not been addressed. Licensed Vocational Nurse (LVN) 1 acknowledged the need for nail cutting for infection control but admitted to not notifying the Social Services Director (SSD) about the resident's condition. The SSD confirmed that she had not been informed of the need for podiatry services for Resident 16. The facility's policy and procedure documents indicated that residents should be well-groomed and that a podiatrist should provide nail care for residents with diabetes, but these procedures were not followed in this case.
Failure to Report Significant Weight Loss
Penalty
Summary
The facility failed to ensure that a resident, who experienced a significant weight loss of 10 pounds within 30 days, was reported to the physician in a timely manner. The resident, who was admitted with diagnoses including diabetes, hypertension, and dementia, was dependent on staff for all activities of daily living and had severe cognitive impairment. Despite the facility's policy requiring physician notification for weight changes exceeding 5% or 5 pounds in 30 days, the necessary communication and intervention were delayed. The deficiency was identified during a review of the resident's clinical records, which showed a weight drop from 147 pounds to 137 pounds over a month. The Licensed Vocational Nurse acknowledged that a change of condition form should have been completed earlier, and the physician should have been notified to obtain new care orders. Additionally, the Director of Staff Development confirmed that an Interdisciplinary Team meeting, crucial for planning the resident's care, was not conducted as required by the facility's policy.
Failure to Remove IV Line After Completion of Antibiotic Therapy
Penalty
Summary
The facility failed to ensure the timely removal of a peripheral intravenous (IV) line for a resident after the completion of IV antibiotic therapy. Resident 75, who was admitted with diagnoses including End Stage Renal Disease, sepsis, and anemia, had an IV line inserted for the administration of Meropenem, an antibiotic, which was scheduled to be discontinued on December 14, 2024. However, during an observation on December 17, 2024, it was noted that the IV line was still in place, with the dressing dated November 26, 2024, indicating that the line had not been removed as per the facility's policy once the therapy was completed. The resident's cognitive skills were severely impaired, and they were dependent on staff for daily activities, including medical decision-making. During an interview, a registered nurse confirmed that the IV antibiotic treatment had been completed the previous week and acknowledged that the nursing staff should have removed the IV line immediately to prevent potential infection at the insertion site. The facility's policy, dated May 2022, clearly stated that the IV line should be removed when the therapy is discontinued, which was not adhered to in this instance.
Inadequate Monitoring of Oxygen Saturation Levels
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 39, had her oxygen saturation levels checked frequently enough to maintain them above 90% as per the physician's orders and care plan. During an observation, it was noted that Resident 39 had an oxygen concentrator and nasal cannula by her bedside, but the equipment was not in use. The resident was admitted with diagnoses including cerebral infarction and heart failure, conditions that necessitate careful monitoring of oxygen levels. The physician's orders from October and November 2024 specified that oxygen should be applied via nasal cannula at 2 liters per minute to keep oxygen saturation at or above 90% as needed for shortness of breath. However, a review of the resident's Weights and Vitals Summary revealed that her oxygen saturation was only checked once in October and November, and twice in December, which was insufficient to ensure compliance with the physician's orders. During an interview, an LVN confirmed that vital signs, including oxygen saturation, should be taken at least once a day or as ordered. The LVN acknowledged that the staff should have clarified with the doctor how frequently the oxygen saturation should be checked, as the current practice did not allow them to determine when to administer oxygen to maintain the required saturation levels.
Deficiencies in Dialysis Care and Communication
Penalty
Summary
The facility failed to implement Resident 20's fluid restriction order accurately, which placed the resident at risk for swelling, discomfort, and shortness of breath. Despite having a fluid restriction order of 1200 cc per 24 hours, the resident's meal ticket did not indicate this restriction, and the care plan lacked details on managing and monitoring fluid intake. Observations revealed that Resident 20 had a significant amount of fluids, such as water bottles and orange juice, in his room, and staff were unaware of the fluid restriction. The Director of Nursing acknowledged the lack of consistent monitoring of the resident's fluid intake. The facility also failed to collaborate and communicate with the dialysis center regarding which hypertensive medications were to be held for Resident 20 before dialysis treatment. The resident was scheduled for hemodialysis three times a week, and certain medications were held on dialysis days without documentation of coordination with the dialysis center. The Minimum Data Set Nurse confirmed the absence of documentation indicating whether the hypertensive medications should be administered, adjusted, or withheld prior to dialysis. Additionally, the facility did not ensure that Resident 75's dialysis emergency kit was readily available at the bedside. The absence of the emergency kit, which should contain essential supplies to manage excessive bleeding from the dialysis site, was confirmed by both a Registered Nurse and the Director of Nursing. The lack of an accessible emergency kit posed a risk of complications in the event of excessive bleeding, as the facility's policy indicated that any problems with a resident's access should be addressed immediately.
Failure to Provide Necessary Behavioral Health Care
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 60, received necessary behavioral health care services. Despite having a physician order for a psychiatric evaluation dated 11/11/2024, the facility did not notify a psychiatrist when Resident 60 exhibited episodes of refusal of care, such as showering, bathing, and changing clothes. The Social Service Director (SSD) was responsible for referring residents to a psychiatrist but was not informed by the licensed nursing staff about the physician's order for Resident 60's psychiatric referral. This lack of communication resulted in the resident not being evaluated by a psychiatrist, which could have addressed his refusal of care behavior. Resident 60 was admitted to the facility with diagnoses including multiple myeloma, anemia, and hypertension. The resident had the capacity to understand and make decisions, as indicated in the Minimum Data Set (MDS) dated 9/28/2024. The Director of Nursing (DON) confirmed that the psychiatric referral was not followed through by the facility staff, acknowledging that a psychiatrist could have helped manage the resident's behavior and develop a treatment plan. The facility's policy and procedure on Behavioral Health Services emphasized the importance of providing necessary behavioral health care to maintain residents' well-being, but this was not adhered to in Resident 60's case.
Failure to Schedule Urology Follow-Up for Resident
Penalty
Summary
The facility failed to ensure a follow-up appointment for a urology evaluation was completed for a resident diagnosed with urinary retention, obstructive uropathy, and acute cystitis. The resident, who had an indwelling urinary catheter, expressed a desire to see a medical doctor to address his condition and remove the catheter due to recurring urine infections. Despite having a physician order for a urology consult, there was no documentation indicating that the facility staff scheduled the necessary appointment. The Director of Nursing confirmed that Social Services was responsible for arranging transportation and medical appointments, but acknowledged the absence of documentation for the urology consult. The Social Service Director admitted to not following up with the resident's primary physician for the referral and failing to schedule the appointment. The facility's policy required Social Services to provide medically related social services, including scheduling appointments, to maintain the residents' well-being. This oversight had the potential to delay necessary care and services for the resident.
Medication Management Deficiencies in LTC Facility
Penalty
Summary
The facility failed to provide appropriate pharmaceutical services for two residents, leading to deficiencies in medication management. For one resident, several critical medications, including Jardiance, Apixiban, Breo Ellipta, Metoprolol Tartrate, and Sitagliptin, were not ordered in a timely manner, resulting in missed doses. This resident, who has severe cognitive impairment and is dependent on staff for all activities of daily living, was at risk due to the unavailability of these medications. The Licensed Vocational Nurse (LVN) and the Director of Staff Development (DSD) acknowledged that medications should be reordered when there are three remaining to prevent outages, as per the facility's policy. Another resident was at risk of receiving a duplicate dose of Carvedilol due to the LVN's failure to document the administration of the medication immediately after it was given. This resident, who has intact cognition and requires moderate assistance with activities of daily living, was administered Carvedilol without timely documentation, which could lead to confusion and potential medication errors. The Assistant Director of Nursing (ADON) confirmed that medications should be documented as soon as they are administered to ensure safety and accuracy, in line with the facility's policy.
Missed Medication Dose for Resident with Diabetes
Penalty
Summary
The facility failed to ensure that a resident received her prescribed dose of Jardiance, a medication used to control high blood sugar. The resident, who was admitted with diagnoses including diabetes, hypertension, and dementia, was dependent on staff for all activities of daily living due to severe cognitive impairment. The care plan for the resident indicated that staff were responsible for administering diabetes medication as ordered by the doctor. During a medication administration observation, an LVN stated that the resident's Jardiance was not available and confirmed that the resident had missed a dose the previous day. The facility's policy on medication administration required that medications be administered within prescribed time frames, and the policy on medication errors defined a medication error as doses that are ordered but not administered. The LVN's job description also required administering medications as ordered by the physician. This oversight put the resident's health at risk due to the potential for elevated blood sugar levels.
Expired Medications Found in Storage
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored according to professional principles, as observed in the medication storage room. During an observation and interview with the Assistant Director of Nursing (ADON), it was found that the medication refrigerator contained an emergency kit and three bags of ertapenem, all of which were past their discard dates. The emergency kit was labeled to be discarded after September 2024, while the ertapenem bags were to be discarded on 12/13/2024, 12/14/2024, and 12/16/2024. The ADON acknowledged that these items should not have been present and stated that their use could potentially harm a resident. A review of the facility's policy and procedure titled 'Medication Storage in the Facility,' dated May 2022, indicated that outdated medications should be immediately removed from inventory. This oversight in medication management had the potential to result in harm to residents if the expired medications were administered.
Failure to Conduct Ordered Laboratory Tests for a Resident
Penalty
Summary
The facility failed to ensure that a resident received necessary laboratory tests as ordered by a physician. The resident, who was admitted with diagnoses including diabetes, hypertension, and dementia, was supposed to have a Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), Hemoglobin A1C (HgA1c), Thyroid Synthesizing Hormone (TSH), and Lipid panel completed on a specified date. However, these tests were not conducted as per the physician's order, which was confirmed during an interview with a Licensed Vocational Nurse (LVN). The LVN acknowledged that the tests were not completed and could not provide a reason for the oversight. The resident's medical records indicated severe cognitive impairment and dependency on staff for all activities of daily living. The care plan for the resident included obtaining and monitoring lab work as ordered, with results to be reported to the physician. Despite this, the facility did not adhere to its policy and procedure for obtaining laboratory services and notifying providers of test results, as outlined in their policy titled 'Diagnostic Test Results Notification.' This failure had the potential to result in a lack of required monitoring of the resident's health conditions.
Failure to Include Hospice in Care Planning
Penalty
Summary
The facility failed to ensure that hospice services met professional standards for a resident by not having a hospice representative participate in the interdisciplinary team (IDT) care conference meeting. Resident 71, who was admitted with diagnoses including protein calorie malnutrition, chronic obstructive pulmonary disease, and adult failure to thrive, was on hospice care. The Minimum Data Set indicated that the resident's cognitive skills for daily decision-making were severely impaired. Despite the requirement for hospice staff to be actively involved in the care plan meetings, the Social Service Director (SSD) confirmed that no hospice representative attended the IDT care plan meeting in October 2024. The SSD acknowledged the responsibility of coordinating with the hospice representative for the IDT care plan meeting and stated that the absence of documentation indicated the meeting did not occur. The facility's policy and procedure on End of Life, Hospice, and/or Palliative Care emphasized the integration of hospice services into the individualized care plan and required collaboration with hospice staff. The SSD confirmed that IDT care plan meetings should be conducted every three months per state and federal requirements, and the hospice representative's participation was mandatory to ensure continuity in the care provided to the resident.
Improper LAL Mattress Setting for Resident with Stage 4 Ulcer
Penalty
Summary
The facility failed to ensure that a resident's low air loss (LAL) mattress was set to the appropriate setting, which is crucial for the management of a Stage 4 sacral ulcer. The resident, who was admitted with a diagnosis of schizophrenia and had no cognitive impairment, required assistance with activities of daily living and had a documented weight of 141 pounds. However, during an observation, the LAL mattress was found to be set at a firm setting of 350, rather than matching the resident's weight of 141 pounds as required. Interviews with the nursing staff, including Licensed Vocational Nurses (LVN) and the Director of Nursing (DON), confirmed that the mattress setting should correspond to the resident's weight to prevent further skin breakdown and promote wound healing. The facility's manual and policy on skin and wound management also indicated the importance of setting the mattress to the appropriate weight setting. The incorrect setting of the LAL mattress had the potential to delay the wound healing process and increase the risk of further skin breakdown for the resident.
Infection Control Breach: Urinal Placement Next to Meal Tray
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices were followed when a urinal containing urine was placed on a resident's bedside table alongside a meal tray. This incident involved a resident who was admitted with a diagnosis of schizophrenia and required assistance with activities of daily living, including toileting hygiene. The resident's care plan noted a preference for placing the urinal on the bedside table, with an intervention to monitor its placement every shift. During an observation, a CNA placed a meal tray on the bedside table next to the urinal containing urine, which was acknowledged as inappropriate by the CNA. Interviews with the CNA, an LVN, and the DON confirmed that the urinal should have been removed and the table cleaned before placing the meal tray to prevent potential food cross-contamination. The facility's infection prevention and control policy emphasized minimizing the spread of infection, which was not adhered to in this instance.
Failure to Enter Medication Order in EMR
Penalty
Summary
The facility failed to ensure that a resident had telephone orders for Hydroxyzine entered into the electronic medical record (EMR). This oversight was identified during a review of the resident's admission record and Minimum Data Set (MDS), which indicated the resident was cognitively intact and had diagnoses including osteoarthritis, muscle weakness, and hip pain. The resident was admitted to the facility with these conditions, and the deficiency was noted when a registered nurse (RN) reviewed the resident's EMR and Order Summary Report. During an interview and record review, the RN revealed that a text message from the resident's psychiatric provider had ordered Hydroxyzine for anxiety, but this order was not entered into the system. As a result, the medication could not be ordered or administered if requested by the resident. The facility's policy and procedure for medication administration require that all medications be recorded on the resident's medication administration record (MAR), which was not adhered to in this case.
Failure to Administer Continuous Oxygen and Label Equipment
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident by not administering continuous oxygen as per the physician's orders. The resident, who had diagnoses including pneumonitis and chronic obstructive pulmonary disease (COPD), was observed without the nasal cannula and oxygen turned off, contrary to the physician's order for continuous oxygen at 2 liters per minute. Licensed Vocational Nurse (LVN) 2 incorrectly stated that the oxygen was to be given as needed, which was not in line with the physician's continuous oxygen order. This oversight was confirmed by both LVN 2 and Registered Nurse (RN) 1 during interviews and record reviews. Additionally, the facility did not ensure that the resident's oxygen equipment was labeled and dated according to the facility's policy and procedure. The nasal cannula tubing was found unlabeled and placed on top of the oxygen concentrator. The Director of Nursing (DON) acknowledged that the continuous oxygen order was not followed and emphasized the importance of adhering to physician's orders. The facility's policy required oxygen equipment to be labeled and dated, which was not adhered to in this case.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to report an abuse allegation involving a resident in a timely manner to the State Survey Agency. The resident, who was admitted with chronic kidney disease, urinary tract infection, osteoarthritis, and Type 2 diabetes, reported to the Social Services Director (SSD) that someone had hit her arm. The SSD documented the resident's statement but did not report the allegation to any facility staff or the Administrator, who is the abuse coordinator. The SSD later re-interviewed the resident, who then denied being struck, but the initial allegation was not communicated as required by the facility's policy. The Director of Nursing (DON) and the Administrator both confirmed that any abuse allegation should be reported within two hours, and the failure to do so could result in further abuse or the resident not feeling safe. The facility's policy, revised in April 2019, mandates that all allegations of abuse, neglect, misappropriation of resident property, or exploitation be reported to the Administrator immediately. The lack of timely reporting of the abuse allegation was identified as a deficiency with the potential to result in further abuse to the resident.
Failure to Administer Bethanechol Timely
Penalty
Summary
The facility failed to ensure that a new prescription order for Bethanechol, a medication used to relieve urinary muscle spasms, was carried out for a resident. The resident was admitted with diagnoses including osteoarthritis, benign prostatic hyperplasia, alcohol dependence, and anemia. The physician's order for Bethanechol was dated 6/21/2024, but the medication was not administered until 6/28/2024. This delay was due to a licensed staff member not carrying out the physician's order, resulting in a delay of care. Interviews with the Licensed Vocational Nurse (LVN), Assistant Director of Nursing (ADON), and Director of Staff Development (DSD) confirmed the oversight. The ADON discovered the incomplete order after the resident complained about not receiving the medication. The ADON then ensured the order was carried out on 6/28/2024. The facility's policy requires medications to be administered according to the physician's written orders, which was not followed in this case, leading to a delay in care and potential complications for the resident.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Hawthorne
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Las Flores Convalescent Hospital | 0.6 mi | ★★★★★ | 18 | 0 |
| Lawndale Healthcare & Wellness Centre Llc | 0.9 mi | ★★★★★ | 31 | 0 |
| Memorial Hospital Of Gardena D/p Snf | 1.9 mi | ★★★★★ | 13 | 0 |
| Hawthorne Healthcare & Wellness Centre, Lp | 2 mi | ★★★★★ | 17 | 0 |
| Clear View Convalescent Center | 2.1 mi | ★★★★★ | 4 | 0 |
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