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 Casitas Care Center during CMS and state inspections, most recent first.
Noise Disturbance and Dust Buildup in Resident Areas: Two residents reported disruptive noise from staff and hallway activity, including loud voices, music, and conversation that startled or awakened them and interfered with rest. A CNA acknowledged being loud, and the DSD confirmed awareness of complaints. In a separate finding, dust was observed on a facility-provided fan and wall covering at a resident’s bedside; the MS validated the buildup and stated housekeeping should have cleaned those areas as part of routine duties.
A resident with psychotic disorder, depression, anxiety, and severe cognitive impairment was given clonazepam and quetiapine for the same behavior, with both meds monitored for kicking and combative behavior. MAR review and staff interviews showed the orders lacked distinct target behaviors, and the DON acknowledged the duplicate therapy and unclear documentation.
Controlled substance accountability was not maintained for multiple eKITs and one resident’s diazepam dose. Staff found several eKITs in the med room and med carts without shift-change reconciliation logs, an open emergency kit was not replaced within the required 72 hours, and an LVN administered diazepam to a resident but did not immediately sign the controlled drug record, leaving a count discrepancy in the bubble pack.
Medication Error Rate Exceeded Allowed Threshold: Two residents received aspirin chewable tablets instead of the ordered aspirin EC tablets during the morning med pass. The LPNs administering the meds acknowledged the wrong dosage form was given, and the DON stated the orders were not followed. The survey found 2 errors in 25 opportunities, resulting in an 8% med error rate.
Improper Storage of Eye Drops With Oral Medications: An artificial tears eye drop bottle and an atropine eye drop bottle were found stored in the same bin as several oral meds in Medication Cart 1 Station 1. An LPN acknowledged eye drops should be stored separately from oral meds, and the DON confirmed that internal and external meds should be stored separately per facility policy.
Failure to Maintain Resident Dignity During Meal Delivery: A CNA was observed handling meal items without hand hygiene after disposing of tray waste, then entering a resident’s room without knocking and delivering food with bare hands. The resident had major depressive disorder and needed assistance with several ADLs. The CNA acknowledged that hand hygiene and knocking before entry were required, and the facility dignity policy stated staff must knock and request permission before entering residents’ rooms.
Incomplete care plans for skin tear and vaccine refusal: A resident who fell and sustained a skin tear had a CP that lacked specific interventions and a target date, and another resident with DM, acute respiratory failure with hypoxia, and severe cognitive impairment had no CP addressing refusal of updated COVID-19 and influenza vaccines by the representative. The IP noted the vaccine refusal was not reflected in the CP, and the LVN stated the skin tear CP was not resident-centered because it did not identify specific treatment interventions.
Failure to use an ordered PRM occurred when a resident with metabolic encephalopathy, CVA, DM, severe cognitive impairment, and high Braden risk was found with the mattress powered off. The DON confirmed the PRM could not provide the ordered level 3 air flow when off, and the facility's manual stated loss of power requires pump hoses to be disconnected to continue air redistribution.
Inaccurate orthostatic blood pressure documentation was identified for a resident with sepsis, psychotic disorder, acute respiratory failure with hypoxia, and severe cognitive impairment. The OSR directed staff to monitor orthostatic BP while lying and sitting daily, but the MAR showed identical lying and sitting readings on multiple days. An LVN stated the readings were different and that the documented BP was taken while the resident was lying down, and the DON stated the orthostatic BP could not be determined because of the inaccurate documentation.
Failure to Perform Hand Hygiene During Meal Delivery: A CNA handled a soiled meal tray, discarded trash, and then delivered a meal to a resident without performing hand hygiene. The resident had diagnoses including major depressive disorder and HTN, and the facility’s hand hygiene policy stated that hand hygiene is the primary means to prevent the spread of healthcare-associated infection and is indicated immediately after touching the resident’s environment.
Unsealed Double Door Exit Allowed a Large Gap: During an observation and interview, the MSDDE was found with a wide opening when closed, measuring 72 inches long and 1/3 inch wide, with visibility through the double doors. The M-Dir stated the doors must be sealed to prevent insect infestation, and the Medical Director said he would obtain materials to seal the door. The gap was identified as a possible entry point for insects such as flies and mosquitoes, and facility policy called for a clean, sanitary, orderly environment and pest control support.
Surveyors found that staff failed to accurately measure and document PU/I wounds for two residents, instead relying on a photo device’s automatic measurements, including recording a depth of 0 cm. One resident with an unstageable sacrococcygeal ulcer later assessed as a large stage IV PU/I had initial measurements that did not reflect the actual size and depth, and manual measurements were not taken until a surgical consult. Another resident with a sacral PU/I had very small dimensions documented from device-generated readings, while a later surgical consult measured a significantly larger stage II PU/I extending to both buttocks. The treatment nurse acknowledged not manually measuring either resident’s wounds despite knowing the device could be inaccurate, and the DON confirmed that wound sizes and depths were documented incorrectly, contrary to facility policies requiring complete and accurate skin assessment documentation.
A resident with dementia, impaired cognition, and a documented fall risk experienced an unwitnessed fall and was found on the floor. A 72-hour neuro check protocol was initiated, but multiple required Q30-minute and Q1-hour neurological assessments were not completed or documented by the responsible charge nurse. This failure occurred despite facility policies requiring routine neurological assessments and comprehensive documentation of all assessment data and changes in condition.
The facility did not ensure that two residents and their representatives were informed of their right to rescind the arbitration agreement within 30 days of signing, as the Admission Coordinator was unaware of this requirement and did not communicate it during the admission process.
A resident was not informed, nor was the physician notified, when a scheduled dose of levothyroxine was missed due to pharmacy delay. Additionally, the physician was not notified when the same resident refused body weight monitoring for nearly two months, despite orders for weekly weights. Facility staff confirmed the lack of documentation and notification in both cases, contrary to facility policy.
A resident with multiple chronic conditions repeatedly refused body weight monitoring, but staff did not document this refusal in the care plan, notify the physician, or implement interventions as required by facility policy. The lack of communication and care planning was confirmed through record review and staff interviews.
A resident with multiple chronic conditions was admitted without a nutritional assessment being completed by the RD as required by facility policy. Weight records showed inconsistencies and refusals, and the assessment was only performed after a hospital readmission, well past the expected timeframe. Staff interviews confirmed the assessment was missed due to a transition between dietitians.
The facility did not ensure that on-coming nurses signed the narcotic count sheet after counting controlled medications with out-going nurses, resulting in incomplete documentation. Additionally, a resident with multiple health conditions did not receive a scheduled dose of levothyroxine because the medication was not delivered, and there was no documentation of physician notification or administration upon receipt.
A resident's MDS assessment was completed with inaccurate information when the MDS nurse entered an outdated weight from several months prior, rather than using the most recent weight within the required 30-day period or the appropriate 'no information' code. The resident, who had multiple chronic conditions and had refused to be weighed, was incorrectly assessed for weight loss due to this error, contrary to facility policy and CMS guidelines.
A resident with confusion and agitation, admitted with diabetes and asthma, was observed wandering and later left the facility unsupervised at night. A CNA saw the resident exit but did not intervene or identify them, as the resident was in street clothes and appeared normal. Facility policy requiring staff to prevent elopement and notify nursing leadership was not followed, resulting in the resident being found offsite by law enforcement and taken to a hospital.
A resident's family member reported concerns about nursing care to the Social Services Director, but the grievance was not documented or followed up by staff, including the DON and Administrator. The facility's required grievance process was not initiated, and the family member did not receive a response regarding the concerns raised.
A resident with severe cognitive impairment and multiple medical conditions received IV hydration without required monitoring of intake and output or assessment of lung, heart status, and vital signs before administration. Facility staff did not follow policy for documentation and assessment during IV therapy, as confirmed by interviews and record review.
Staff did not assist three residents with severe cognitive impairment and high care needs to get out of bed or participate in activities, despite medical orders allowing participation. CNAs did not routinely offer or provide assistance due to lack of instruction, time constraints, or assumptions about residents' abilities. Facility leadership confirmed that this practice did not align with the facility's policy on promoting quality of life and resident dignity.
The facility did not schedule any outside or evening activities for its residents during two sampled months, contrary to its policy requiring monthly outings and weekly evening events. The Activities Director confirmed that these activities were not planned or provided for 93 residents during this period.
A resident with multiple serious diagnoses experienced hematuria, prompting a physician to order STAT laboratory tests. Despite facility policy and staff expectations that STAT labs be collected within four hours, the tests were not collected until the next day, resulting in a delay of necessary care and services.
The facility failed to ensure call lights were within reach for three residents, potentially delaying services and leaving needs unmet. A resident with acute respiratory failure and another with metabolic encephalopathy were found with call lights on the floor, while a resident with Parkinsonism had the call light hanging behind the bed. Staff acknowledged the oversight, and the facility's policy mandates call lights be within reach.
A facility failed to create comprehensive care plans for four residents, leading to potential inadequate care. One resident with an IV infusion lacked a care plan for site monitoring, another on antibiotics had no plan for administration, a third using an electric kettle was not assessed for safety, and a fourth with a language barrier had no communication plan. These deficiencies were confirmed by staff reviews and interviews.
The facility failed to ensure a safe environment for two residents by not following care plans and safety protocols. A resident at risk for falls did not have a landing mat placed as required, and another resident was allowed to use an electric tea kettle without assessment or care planning. These actions were contrary to the facility's policies on fall risk management and electrical appliance use.
Two residents in an LTC facility did not receive continuous oxygen as ordered by their physicians. One resident with COPD was observed without a nasal cannula multiple times, and staff misunderstood the oxygen order. Another resident with pneumonitis received oxygen at an incorrect flow rate and without a humidifier. The DON confirmed that oxygen should have been administered according to the orders to prevent complications.
A facility failed to ensure proper medication administration practices. A resident was left with medications unattended at the bedside without a self-administration assessment, and another resident experienced a delay in receiving the first dose of an antibiotic for a UTI. The facility's policies for medication administration and timely availability were not followed, leading to these deficiencies.
The facility failed to label leftover food brought by family and visitors with a resident identifier and use-by date in the residents' refrigerator. During an observation, two plastic bags of undetermined food were found without proper labeling. A registered nurse confirmed the requirement for labeling and discarding food older than three days to prevent contamination. The facility's policy mandates labeling and timely disposal of perishable foods.
The facility failed to ensure hospice services for a resident with COPD, as the contracted hospice agency did not provide required staff training, and there was no designated hospice coordinator. Additionally, there was no documentation of hospice staff presence in the facility, leading to a deficiency in hospice care delivery.
The facility failed to maintain proper infection control practices for two residents using nasal cannulas. A resident's oxygen tubing was found on the floor, risking contamination, while another resident's cannula was not labeled with the last change date, contrary to orders. These lapses in protocol could lead to increased infection risk.
A resident's dignity was compromised when their urinary catheter collection bag was left uncovered, contrary to facility policy. The resident, admitted with a urinary catheter infection and bladder neoplasm, had an order for catheter care every shift. A nurse and the DON confirmed the oversight, acknowledging the requirement for privacy bags to promote dignity.
The facility failed to develop baseline care plans within 48 hours for three residents upon admission or readmission, which included addressing antibiotic use for two residents and insulin use for another. This oversight could lead to staff being unaware of necessary monitoring for adverse reactions and the inability to meet residents' immediate care needs.
A facility failed to update a resident's care plan after the discontinuation of Januvia, a diabetes medication. Despite the physician's order to stop the medication, the care plan still indicated its use. The resident, with conditions including dementia and diabetes, had their care plan reviewed by the Infection Preventionist, who noted the discrepancy. The DON confirmed that the care plan was not revised as required by facility policy, potentially leading to confusion in care.
A resident with dementia and limited English proficiency was not provided with a communication board, hindering effective communication with staff. Despite facility policies requiring such support, the board was removed, leaving the resident unable to express needs adequately.
A resident with hypertension and anemia was not provided access to religious services, despite expressing the importance of such activities. The facility's Activity Director confirmed the lack of participation and documentation of religious services for the resident, violating her right to practice her religion.
A facility failed to monitor and document catheter care and UTI symptoms for a resident with an indwelling catheter, as required by the care plan. Despite the resident's conditions and cognitive impairment, there was no evidence of monitoring for pain or infection signs in the Treatment Administration Record. Interviews with staff confirmed the lack of documentation, highlighting a failure to follow the facility's catheter care policy.
The facility did not discard two opened eye drop bottles, Alpheagan and Latanoprost, after 28 days as recommended by the pharmacy. This was observed during a shift, and the RN confirmed the oversight, acknowledging the potential for bacterial growth. The DON stated that licensed nurses should have followed the pharmacy's recommendation to ensure resident safety.
A facility failed to accurately complete an MDS assessment for a resident with type 2 diabetes, omitting the administration of insulin since admission. Despite receiving insulin lispro as ordered, the MDS did not reflect this, potentially affecting the resident's care plan. The MDS Coordinator acknowledged the error, and the Director of Nursing confirmed the inaccuracy, highlighting the importance of accurate assessments for care planning.
Noise Disturbance and Dust Buildup in Resident Areas
Penalty
Summary
The facility failed to maintain comfortable sound levels for two residents who were observed and interviewed about noise in their living areas. One resident, admitted with heart failure and obstructive sleep apnea, stated that a CNA was very loud when entering the room and that the loud voice startled him and disturbed rest. Another resident, admitted with alcohol dependence and depression, reported that early morning noise near the nurses’ station was very loud, including loud music and staff conversation, and that it sometimes awakened residents and made it difficult to go back to sleep. During interview, the DSD acknowledged awareness of complaints about a specific staff member being very loud and stated that the facility should be restful and homelike, with noise levels that do not interrupt sleeping time, especially in the early morning. The DSD also stated that in-service training had been provided regarding maintaining a comfortable noise level. However, the in-service training minutes reviewed for noise level did not include the specific staff member identified by residents. A CNA interviewed separately stated that she was aware she was loud and needed to tone down her voice so as not to disturb residents, especially if they were sleeping. The facility also failed to provide a clean and homelike environment for another resident when dust was observed on the base of the facility-provided fan and on the wall covering with cords behind it at the resident’s bedside. The resident was cognitively intact and required assistance with bathing, dressing, toileting, and personal hygiene. The Maintenance Supervisor observed and validated the dust buildup, stated the fan came from facility storage, and said there should not have been dust in those areas. He stated housekeeping should have cleaned the areas as part of regular duties and that the dust could affect the air quality in the resident’s room.
Duplicate psychotropic medication indications for one resident
Penalty
Summary
The facility failed to ensure one sampled resident was free from unnecessary psychotropic medication use when clonazepam and quetiapine were both ordered and monitored for the same behavior. The resident was admitted with diagnoses including psychotic disorder, depression, and anxiety, and the MDS indicated severe cognitive impairment with routine antipsychotic use. The MAR for March 2026 showed clonazepam 0.25 mg at bedtime for manifested combative behavior and kicking staff, with monitoring each shift for anxiety manifested by combative behavior and kicking staff. The same MAR also showed quetiapine 12.5 mg every 12 hours for manifested agitation, with monitoring each shift for agitation manifested by kicking. During interview and record review, an LVN stated the quetiapine order did not have a specific indication or behavior different from the clonazepam order, and that both medications were used and monitored for the same indication. The DON reviewed the MAR and acknowledged clonazepam was prescribed for combative behavior and kicking staff, while quetiapine was prescribed for kicking staff. The DON also acknowledged clonazepam was monitored for combative behavior and kicking staff without documentation of behaviors in March 2026, and quetiapine was monitored for kicking staff with behaviors documented on two days in March 2026. The DON stated the lack of clear and specific indications and target behaviors created confusion for licensed nurses in documenting behaviors and resulted in duplicate therapy for the resident.
Controlled Substance Reconciliation and Documentation Failures
Penalty
Summary
The facility failed to reconcile multiple medication emergency kits containing controlled substances in the medication room and in medication carts during March 2026. During observation and interview, four eKITs in the medication room were found without accountability logs showing reconciliation at every shift change: two refrigerated kits labeled REF455 and REF587, and two room-temperature kits labeled PO656 and PO738. In addition, two eKITs in medication carts were also found without accountability logs for shift-by-shift reconciliation: one labeled 552 in Medication Cart 1 Station 1 and one labeled 355 in Medication Cart AM Station 1. An open antibiotic and IV medication eKIT was observed in the medication room with documentation showing it had been opened on 3/19/2026 at 1:30 p.m. The DON and RN acknowledged that the kit was open, used, and awaiting replacement from pharmacy. The DON stated the kit should have been replaced with a new one within 72 hours of opening, and acknowledged that it was not replaced within that timeframe. A separate controlled substance discrepancy was identified for Resident 85 in Medication Cart AM Station 2. The resident was prescribed diazepam 5 mg orally twice daily for panicky feelings. The controlled drug record indicated the bubble pack should have contained 9 tablets after the last documented 5 p.m. dose on 3/22/2026, but the bubble pack contained 8 tablets and no other documentation of subsequent administration was present. During interview, the LVN stated one diazepam tablet had been administered at 9 a.m. that morning but had not been signed on the controlled drug accountability log, and the DON acknowledged that the nurse failed to document the dose immediately as required by facility policy.
Medication Error Rate Exceeded Allowed Threshold
Penalty
Summary
The facility failed to ensure that its medication error rate remained below 5 percent. Surveyors identified 2 medication errors out of 25 total opportunities, resulting in an 8% medication error rate and affecting 2 of 4 residents observed during medication administration, Resident 18 and Resident 57. Both residents were prescribed aspirin EC 81 mg once daily for CVA prophylaxis, and both had diagnoses including hypertension. During observation, LVN 3 administered aspirin 81 mg chewable tablet to Resident 57 during the morning medication pass, and Resident 57 swallowed the tablet with water. During interview, LVN 3 stated that the physician order required aspirin 81 mg EC tablet and acknowledged that giving the chewable form instead of the EC form was a medication error because it was the wrong dosage form. LVN 3 also stated that the chewable tablet increased the risk of stomach irritation. During observation, LVN 6 administered aspirin 81 mg chewable tablet to Resident 18 during the morning medication pass, and Resident 18 swallowed the tablet with water. During interview, LVN 6 stated that the physician order required aspirin 81 mg EC tablet and acknowledged that giving the chewable form instead of the EC form was a medication error because it was the wrong dosage form. The DON later stated that both nurses failed to administer aspirin EC as ordered and that licensed nurses should follow facility medication administration guidelines to ensure physician orders are followed and the right medications are administered.
Improper Storage of Eye Drops With Oral Medications
Penalty
Summary
The facility failed to store medications in accordance with manufacturer specifications, professional principles, and facility policy and procedures by not keeping eye drops separate from orally administered medications in one of three inspected medication carts, Medication Cart 1 Station 1. During a concurrent observation and interview on 3/23/2026 at 1:08 p.m., an artificial tears eye drop bottle and an atropine eye drop bottle were observed stored in the same bin/container with several oral medication bottles, including docusate, acetaminophen, vitamin B complex, lactobacillus, oyster shell calcium, and glucosamine. LVN 3 acknowledged that eye drops should be stored separately from oral medications and confirmed that the cart contained both eye drop bottles with oral medications. During an interview on 3/24/2026 at 3:15 p.m., the DON stated that internally administered medications, such as oral medications, and externally administered medications, such as those used for the eyes, should be stored separately to prevent wrong route administration, infections, and contaminations. A review of the facility policy titled "Storage of Medications," last reviewed on 1/5/2026, stated that medications and biologicals are to be stored safely, securely, and properly, following manufacturer recommendations or those of the supplier, and that orally administered medications are kept separate from externally used medications.
Failure to Maintain Resident Dignity During Meal Delivery
Penalty
Summary
The facility failed to provide care in a manner that maintained a resident’s dignity and respect when a CNA entered Resident 26’s room without knocking. Resident 26 was admitted with diagnoses including major depressive disorder and hypertension. The resident’s MDS indicated the resident could understand others and be understood and required varying levels of assistance with activities such as toileting hygiene, showers, dressing, eating, oral hygiene, and personal hygiene. During a dining observation, a CNA was seen disposing of items from a finished meal tray without gloves and without sanitizing her hands afterward. She then wheeled an open meal cart with new meal trays and a container of food to Resident 26’s room, handled the food container with bare hands, entered the room without knocking, and delivered the food to the resident’s overbed table. When interviewed, the CNA stated she should have performed hand hygiene before delivering the food and should have knocked and asked permission before entering the resident’s room. The facility’s dignity policy stated that staff are expected to knock and request permission before entering residents’ rooms.
Incomplete care plans for skin tear and vaccine refusal
Penalty
Summary
The facility failed to develop a comprehensive care plan for a skin tear sustained by a resident after a fall. The resident was admitted with diagnoses including depression and hypertension, and the MDS showed impaired cognitive skills for daily decision making along with substantial/maximal assistance needed for several ADLs and partial/moderate assistance for others. A Change of Condition documented that the resident had a fall and sustained a 3 cm by 1 cm skin tear to the right antecubital area, and the care plan for the actual fall with skin tear listed an objective that the injured areas would resolve without complication. During review, the LVN stated the care plan was not resident-centered because it did not include specific interventions to address the skin tear or a target date to evaluate the effectiveness of treatment. The LVN stated that without specific interventions identified in the care plan, licensed nurses may not be able to provide the necessary care and services to promote healing of the skin tear sustained after the fall. The facility policy on comprehensive person-centered care plans stated that care plans include measurable objectives and timeframes and describe the services to be furnished to attain or maintain the resident’s highest practicable physical, mental, and psychosocial well-being. The facility also failed to develop a care plan regarding refusal of the 2025/2026 COVID-19 and influenza vaccinations for another resident. That resident had diagnoses including DM and acute respiratory failure with hypoxia, and the MDS indicated severely impaired cognitive skills for daily decision making and dependence for all ADLs. The Immunization Report showed the resident had not received the updated COVID-19 or influenza vaccines, and the IP stated the resident was not capable of making her own decisions and her representative had refused the vaccines. The care plan did not indicate the resident had not received these vaccinations or include any interventions related to the representative’s refusal.
Failure to Use Ordered Pressure Redistribution Mattress
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not met when the facility failed to properly use the air redistribution mattress for one resident. Resident 54 was admitted with diagnoses including metabolic encephalopathy, cerebral infarction, and diabetes mellitus. The physician's order dated 1/25/2025 directed that a PRM set at level three be used for skin integrity management. The resident's Braden Scale dated 2/4/2026 indicated high risk for pressure-related skin damage, and the MDS dated 2/5/2026 showed severely impaired cognitive skills for daily decision making and that the resident required a helper to do all the effort for ADLs. During interview and observation on 3/26/2026, LVN 2 stated the facility had started using a new PRM for residents with pressure ulcers and those who were bed bound. At 11:15 a.m., the DON observed that the PRM was turned off and stated the power was off on the mattress, meaning it could not control air flow at the ordered level 3. The DON further stated that when the PRM is turned off, it places Resident 54 at risk of developing pressure-related skin damage and skin that will not be maintained. The facility's PRM user-service manual stated that loss of power requires pump hoses to be disconnected from the mattress to continue air redistribution, and the facility's Support Surface Guidelines stated that any individual at risk for developing pressure ulcers should be placed on a redistribution support surface.
Inaccurate Orthostatic Blood Pressure Documentation
Penalty
Summary
The facility failed to accurately document orthostatic blood pressure measurements for one sampled resident. Resident 4 was admitted with diagnoses including sepsis, psychotic disorder, and acute respiratory failure with hypoxia. The MDS dated 1/12/2026 indicated the resident had severely impaired cognitive skills for daily decision making and required extensive assistance with several activities, including toileting hygiene, bathing, dressing, sit to lying, and lying to sitting on the side of the bed. The resident’s OSR for March 2026 directed staff to monitor orthostatic blood pressure while lying and sitting daily and report any drop in blood pressure to the physician. The MAR for March 2026 showed the same blood pressure recorded while the resident was lying and sitting on eight different days. During interview and record review, an LVN stated the lying and sitting blood pressure readings were different and that the documented blood pressure was taken while the resident was lying down. The DON reviewed the Weights and Vitals Summary and stated orthostatic blood pressure could not be determined due to inaccurate documentation, and that inaccurate documentation would not show whether orthostatic blood pressure was taken and could cause miscommunication with the interdisciplinary team. The facility policy required documentation to be objective, complete, and accurate.
Failure to Perform Hand Hygiene During Meal Delivery
Penalty
Summary
The facility failed to implement appropriate infection control practices for one resident during an infection control observation. Resident 26 was admitted with diagnoses including major depressive disorder and hypertension. The resident’s MDS dated 3/02/2026 indicated the resident could make self-understood and understand others, and required supervision or touching assistance with toileting hygiene, showering, and lower body dressing, along with setup or clean-up assistance with eating, oral hygiene, upper body dressing, putting on/taking off footwear, and personal hygiene. During a concurrent observation and interview on 3/28/2026 at 12:15 p.m., CNA 1 received a finished meal tray containing a cup of ice cream and crumpled plastic shrink wrap, discarded the items into a trash bin, and did not perform hand hygiene afterward. CNA 1 then went to an open meal cart with three new meal trays and a container of soup, removed the soup container using bare hands, entered Resident 26’s room, placed the food on the overbed table, and removed the lid without performing hand hygiene before delivering the meal. CNA 1 stated that hand hygiene should have been performed after discarding items from a soiled tray and prior to delivering food to Resident 26 to prevent infection and cross contamination. The facility’s Handwashing/Hand Hygiene policy stated that hand hygiene is the primary means to prevent the spread of healthcare-associated infection and is indicated immediately after touching the resident’s environment.
Unsealed Double Door Exit Allowed a Large Gap
Penalty
Summary
The facility failed to ensure that the double door exit in the middle station was fully sealed when closed and free of gaps. During a concurrent observation and interview on 3/25/2026 at 12:54 p.m. with the Maintenance Director, the exit doors were inspected and found to have a wide opening with visibility of cars passing through the gaps in the double door. The opening measured 72 inches in length and 1/3 of an inch in width, and the Maintenance Director stated that the exit doors must always be closed and sealed to prevent insect infestation in the facility. The Medical Director stated that he would immediately go to Home Depot to obtain materials to seal the door. During the same interview, the Maintenance Director stated that the gap could serve as an entry point for insects, such as flies and mosquitoes, which could potentially increase the risk of infection for residents in the facility. A review of the facility's policy titled Homelike Environment indicated that staff and management are to maximize a clean, sanitary, and orderly environment, and the Pest Control policy indicated that maintenance services assist in providing pest control services when appropriate and necessary.
Inaccurate Pressure Ulcer Measurement and Documentation for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to accurately measure and document pressure ulcer/injury (PU/I) wound dimensions for two residents, relying instead on automatically generated measurements from a photo device. One resident was admitted with an unstageable pressure ulcer on the sacrococcyx and diagnoses including osteomyelitis, spina bifida, and abnormal posture. An early progress note documented the sacrococcyx wound as 7.66 cm in length, 10.87 cm in width, 0 cm in depth, and 67.66 sq. cm in area, based on a photo taken by the treatment nurse. However, a subsequent surgical consult described the same wound, now characterized as a stage IV PU/I extending to bilateral buttocks, as 11.5 cm in length, 15.0 cm in width, 2.5 cm in depth, and 172.50 sq. cm in area, indicating that the earlier measurements did not reflect the actual wound size and depth. In interviews, the treatment nurse acknowledged that on the date of the initial photo for this resident, she did not manually measure the wound and instead accepted the device’s automatic readings, including a depth of 0 cm. She further stated that actual wound measurements were not obtained until the surgical consult several days later and that she relied on serial photos taken upon admission or the following day and then weekly to assess wound progress. The DON later confirmed that the treatment nurse documented this resident’s wound measurements incorrectly and did not manually verify or correct the automatically generated measurements. A second resident was admitted with diagnoses including acute kidney failure and a disorder of the skin and subcutaneous tissue and was identified on the MDS as having one or more unhealed PU/Is and being at risk for pressure ulcers. A progress note documented a sacral PU/I present on admission with measurements of 1.14 cm in length, 0.57 cm in width, 0 cm in depth, and 0.43 sq. cm in area, again based on a photo taken by the treatment nurse. A later surgical consult described a coccyx wound extending to the right and left buttock, staged as a stage II PU/I, with measurements of 7.0 cm in length, 3.0 cm in width, 0.1 cm in depth, and 21 sq. cm in area. The treatment nurse stated that the admitting nurse had only marked skin sites without measurements on arrival, and that she took photos and obtained measurements the following day using the device’s automatic readings, without manual measurement, despite knowing that the device’s measurements were sometimes inaccurate. The DON confirmed that the treatment nurse did not manually measure these PU/I sizes to correct the automatically generated measurements, contrary to facility policies requiring complete and accurate documentation of skin condition, including size and location of affected areas.
Failure to Complete and Document 72-Hour Neuro Checks After Unwitnessed Fall
Penalty
Summary
The facility failed to complete ordered 72-hour neurological checks following an unwitnessed fall for one resident. The resident was admitted with diagnoses including type 2 diabetes, abnormal posture, unspecified fall, and vascular dementia, and had moderately impaired cognition per the MDS. The resident required assistance with activities of daily living and was care planned as being at risk for falls with injury due to limited mobility, dementia, history of falls, unsteady gait, and weakness. On the date of the incident, a Change in Condition Evaluation documented that the resident experienced a fall and was found sitting on the floor. Following this unwitnessed fall, a 72-hour neuro check protocol was initiated, but the corresponding neuro check flowsheets showed that multiple required assessments were not completed. Specifically, the Infection Preventionist confirmed that several Q30-minute and Q1-hour neurological checks were missing and that the charge nurse responsible for the resident’s care was responsible for performing and documenting these assessments. Facility policies on neurological assessment required routine neuro exams to evaluate for small changes over time and mandated documentation of the date and time of the procedure, the person performing it, all assessment data, how the resident tolerated the procedure, any refusals and reasons, and the signature and title of the recorder. The facility’s charting and documentation policy further required that all services provided and any changes in the resident’s condition be documented in the medical record to facilitate communication among the interdisciplinary team, but this was not done for the missed neuro checks.
Failure to Inform Residents of Right to Rescind Arbitration Agreement
Penalty
Summary
The facility failed to ensure that the Admission Coordinator (AC) was aware that residents and their representatives have the right to rescind the facility's arbitration agreement within 30 days of signing. This deficiency was identified for two of three sampled residents. For one resident, the admission record showed the resident had the capacity to understand and make decisions, and the arbitration agreement was signed by the resident's representative. For the second resident, records indicated severe cognitive impairment, and the arbitration agreement was also signed by a representative. During interviews, the AC stated she was unaware that residents or their representatives could rescind their signature on the arbitration agreement after signing. The Administrator confirmed that residents and their representatives do have this right and that the AC is responsible for informing them. Review of the facility's policy and procedure confirmed that residents and their representatives must be advised of their right to rescind the agreement within 30 days, but this was not communicated by the AC as required.
Failure to Notify Physician and Resident of Missed Medication Dose and Refusal of Weight Monitoring
Penalty
Summary
The facility failed to notify a resident and the resident's physician regarding a missed dose of levothyroxine, a medication prescribed for hypothyroidism. The medication was scheduled to be administered in the morning, but was not available due to a delay in pharmacy delivery. Documentation showed that the dose was not given as scheduled, and there was no evidence that the physician or the resident was informed of the missed dose. Interviews with the Director of Nursing and the Director of Staff Development confirmed that the physician should have been notified and that this was not documented in the clinical record. The resident also stated she was not informed about the missed dose. Additionally, the facility failed to notify the physician when a resident refused body weight monitoring for an extended period of 58 days. Physician orders required weekly weights, but after the last recorded weight, the resident declined further monitoring. There was no documentation of the resident's refusal or of any notification to the physician regarding this ongoing refusal. Staff interviews confirmed that there was no record of the refusals or physician notification in the progress notes or care plans. The facility's policies required prompt notification of the resident, physician, and representative of changes in the resident's condition or status, including refusals of care. Despite these policies, the required notifications and documentation were not completed in both instances involving the missed medication dose and the refusal of weight monitoring.
Failure to Develop and Implement Care Plan for Refusal of Weight Monitoring
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan to address a resident's ongoing refusal to allow body weight monitoring. Despite physician orders for weekly weights and documentation in the nutrition/dietary progress notes that the resident was refusing to be weighed, there was no evidence in the resident's care plan or progress notes that this refusal was addressed. The resident had multiple diagnoses, including hypothyroidism, diabetes mellitus, hypertension, and morbid obesity, and required varying levels of staff assistance for daily activities, but was cognitively intact. Interviews with nursing staff revealed that the refusal to be weighed was not communicated among the care team, and the physician was not notified of the resident's ongoing refusals. Facility policy required that a care plan be developed and revised as resident conditions changed, but no such care plan or interventions were documented for the resident's refusal to allow body weight monitoring. The lack of documentation and care planning had the potential to negatively affect the delivery of care and services for the resident.
Failure to Complete Timely Nutritional Assessment on Admission
Penalty
Summary
The facility failed to conduct a nutritional assessment upon admission for one of four sampled residents, as required by its own policy and procedure. The resident in question was originally admitted with multiple diagnoses, including hypothyroidism, diabetes mellitus, hypertension, and morbid obesity. Despite these significant health conditions, there was no documented evidence that a nutritional assessment was completed by the dietitian at the time of admission. Record reviews showed that the resident's weight was documented at various points, both in the hospital and at the facility, but there were inconsistencies and strikethrough entries in the weight records. The resident had been refusing to be weighed since January, and the last recorded weight was from that time. The dietitian only completed the nutritional assessment after the resident returned from a hospital stay in April, well beyond the required timeframe for an initial assessment. Interviews with facility staff confirmed that the initial nutritional assessment was not completed as required. The Director of Staff Development acknowledged the absence of documentation for the assessment at admission, and the Registered Dietitian stated she was unaware that the assessment had not been done, attributing the oversight to a transition between dietitians. The facility's policy clearly states that a nutritional assessment should be conducted upon admission, but this was not followed in this case.
Failure to Document Controlled Medication Counts and Missed Medication Administration
Penalty
Summary
The facility failed to ensure proper documentation and procedures were followed regarding the handling of controlled medications. On two separate occasions, the on-coming nurses did not sign the Narcotic Count Sheet (NCS) after counting controlled medications with the out-going nurses. Specifically, one nurse forgot to sign the NCS after the count, and another instance showed a blank NCS, making it unclear if the count was performed according to facility protocol. The Director of Nursing confirmed that both nurses should have signed the NCS immediately after the count, as per facility policy, to confirm the accuracy of the controlled medication inventory. Additionally, the facility did not administer a prescribed dose of levothyroxine to a resident with hypothyroidism, diabetes mellitus, hypertension, and morbid obesity. The medication was scheduled to be given in the morning, but documentation showed it was not administered because the medication had not yet been delivered from the pharmacy. There was no evidence that the medication was given upon receipt, nor was there documentation that the resident's physician was notified about the missed dose. The facility's policies require that controlled medications be counted and documented by both the on-coming and out-going nurses at each shift change, and that medications be administered as prescribed, with proper documentation if a dose is missed or delayed. In these instances, the required procedures were not followed, resulting in incomplete records and a missed medication dose for a resident.
Inaccurate MDS Assessment Due to Incorrect Weight Documentation
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessment for a resident by entering incorrect information in Section K0200 (weight) and Section K0300 (weight loss). The MDS nurse used a weight measurement of 265 lbs. from January, which was not within the required 30-day window of the assessment reference date in April. This led to an inaccurate entry for the resident's current weight and, subsequently, an incorrect assessment of weight loss status. The resident in question had a medical history that included hypothyroidism, diabetes mellitus, hypertension, and morbid obesity. The resident had been refusing to be weighed, and the last recorded weight was from January, as noted in the dietary progress notes. Despite this, the MDS nurse did not use the appropriate 'no information' code as instructed by the facility's policy and the CMS Resident Assessment Instrument (RAI) manual. Instead, the nurse entered the outdated weight to proceed with the MDS process, resulting in inaccurate data being recorded. Interviews and record reviews revealed that the MDS nurse was unaware of the resident's refusal to be weighed and acknowledged confusion regarding which weight to use. The nurse admitted to entering the outdated weight and recognized that this led to an inaccurate assessment of the resident's nutritional status. Facility policy and the RAI manual both require the use of the most recent weight within 30 days or, if unavailable, the use of a specific code with documentation, which was not followed in this case.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Policy Implementation
Penalty
Summary
The facility failed to implement its policy and procedure regarding wandering and elopement, resulting in a resident with a history of confusion and agitation leaving the premises unsupervised. The resident, who had been admitted with diagnoses including type 2 diabetes mellitus and asthma, was observed wandering and entering other resident rooms earlier in the evening. Despite these behaviors, a Certified Nursing Assistant (CNA) observed the resident leaving the facility late at night but did not intervene or attempt to identify the individual, as the resident was wearing street clothes and appeared to be walking normally. The CNA later acknowledged that he did not recognize the person leaving and did not stop to verify their identity or purpose for leaving, only realizing after being informed that a resident was missing that the individual was likely the resident in question. The facility's policy required staff to attempt to prevent residents from leaving, seek assistance from other staff, and notify nursing leadership if a resident was observed leaving the premises. These steps were not followed in this instance. The resident was subsequently found by local law enforcement and taken to a hospital for evaluation. Interviews with facility staff, including the Director of Nursing, confirmed that the CNA should have stopped and identified the individual leaving the building, especially given the time of night and the resident's lack of reflective clothing. The failure to follow established procedures resulted in the resident leaving the facility unsupervised.
Failure to Promptly Address and Document Resident Grievance
Penalty
Summary
The facility failed to promptly address and resolve a grievance raised by the family member of a resident with severely impaired cognition and multiple medical conditions, including pneumonitis, UTI, and gastrostomy status. The family member contacted the Social Services Director (SSD) to express concerns about the nursing care provided to the resident. Although the SSD informed the Administrator (ADM) of these concerns, there was no documentation of the grievance in the facility's Concern/Grievance Log for the relevant months, and no formal grievance process was initiated. Interviews with facility staff revealed that both the SSD and the Director of Nursing (DON) did not follow up with the family member regarding the reported concerns. The SSD admitted to being too busy to follow up or complete the necessary grievance documentation, and the DON stated she forgot to address the concerns after being informed. The facility's policy requires prompt investigation and written response to grievances, but this process was not followed, resulting in the resident's grievance not being addressed as required.
Failure to Monitor and Assess Resident During IV Fluid Administration
Penalty
Summary
The facility failed to implement its intravenous (IV) administration policy for a resident receiving IV hydration therapy. Specifically, staff did not monitor or document the resident's intake and output (I&O) as required by facility policy, despite an active physician's order for IV fluids. Interviews with nursing and medical records staff confirmed that there was no evidence of I&O monitoring for the resident, and the nurse stated that monitoring was discontinued after 30 days, even though the resident continued to receive IV hydration. The facility's policy required documentation of I&O in the medical record for residents receiving IV fluids. Additionally, the nurse did not assess the resident's lung and heart status or vital signs prior to administering IV fluids, contrary to facility policy, which mandates such assessments before and during IV therapy to monitor for complications like fluid overload. The nurse acknowledged the importance of these assessments but stated they were not performed because there was no specific physician order for them. The resident involved had severely impaired cognition, was dependent on staff for personal care, and had multiple diagnoses including pneumonitis, UTI, and gastrostomy status.
Failure to Assist Residents with Participation in Activities
Penalty
Summary
Facility staff failed to implement the policy on quality of life by not assisting three out of four sampled residents to participate in activities. These residents had significant cognitive impairments and were dependent on staff for daily care, including oral hygiene, toileting, and personal hygiene. Medical records indicated that each resident was permitted to participate in activities as long as it did not conflict with their treatment plan. Despite this, repeated observations throughout the day showed that these residents remained in bed and were not offered the opportunity to get out of bed or attend activities. Interviews with staff revealed that certified nursing assistants (CNAs) did not routinely offer or assist these residents to get out of bed or participate in activities. Reasons given included lack of instruction from licensed nursing staff, time constraints, and assumptions about the residents' ability to participate due to medical devices or communication barriers. For example, one CNA stated that a resident with a gastrostomy tube was not brought to activities because of the tube, and another CNA indicated that a nonverbal resident was not offered the opportunity to get out of bed because of her communication limitations. Further interviews with the registered nurse, activities director, director of staff development, director of nursing, and administrator confirmed that the facility's policy required staff to assist residents in getting out of bed and participating in activities to promote quality of life. These staff members acknowledged that the policy was not being followed and that residents were not being provided with opportunities for stimulation and social interaction as required.
Failure to Provide Required Outings and Evening Activities
Penalty
Summary
The facility failed to implement its policy and procedure regarding activity programs by not incorporating at least one activity per month held away from the facility and not offering at least one evening activity per week for 93 residents during two of the three sampled months (January and February 2025). During an interview and record review with the Activities Director, it was confirmed that no outside activities or evening activities were scheduled for these months, despite the facility's policy requiring such activities. The activity calendar for the specified months lacked both outings and evening events, and the Activities Director acknowledged responsibility for scheduling these activities and confirmed their absence.
Delay in STAT Laboratory Testing for Resident with Change in Condition
Penalty
Summary
The facility failed to provide timely laboratory services for a resident who was admitted with diagnoses including acute respiratory failure with hypoxia, urinary tract infection, and chronic obstructive pulmonary disease. The resident experienced a change in condition, specifically hematuria, and the physician ordered STAT laboratory tests, including a CBC with differential and a comprehensive metabolic panel. According to facility staff, STAT labs are expected to be collected within four hours of the order. However, the laboratory tests were not collected until the following day, well beyond the expected timeframe for STAT orders. Record review and staff interviews confirmed that the delay in obtaining the STAT laboratory tests was due to the laboratory company not arriving within the required four-hour window. The facility's policy states that clinical laboratory services should be provided to meet the needs of residents, but in this instance, the delay resulted in a failure to provide necessary and timely care and services for the resident.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for three residents, potentially delaying the provision of services and leaving residents' needs unmet. Resident 5, who was readmitted with acute respiratory failure, hemiplegia, and moderately impaired cognitive skills, was observed with the call light on the floor, out of reach. The MDS Nurse confirmed this observation and repositioned the call light within reach. Similarly, Resident 44, admitted with metabolic encephalopathy and severely impaired cognitive skills, was found with the call light on the floor, not within reach, during an observation. Certified Nursing Assistant 2 acknowledged the oversight and the importance of having the call light within reach for safety. Resident 45, who was readmitted with Parkinsonism and severely impaired cognitive skills, was observed with the call light hanging behind the head of the bed, out of reach. Certified Nursing Assistant 3 admitted to forgetting to place the call light back within reach after providing care. The Director of Nursing confirmed that call lights should always be within reach for resident safety. The facility's policy, reviewed in January 2025, mandates that residents have a means to call staff for assistance, and the call light should be within reach upon admission and as needed.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for four residents, leading to potential inadequate care. Resident 287, who was readmitted with several diagnoses including pneumonitis and type 2 diabetes, had a physician order for IV infusion of D5W. However, the facility did not create a care plan with specific interventions for monitoring the IV site, which could result in inadequate care of the IV site. This oversight was confirmed during a review and interview with the MDS Coordinator. Resident 36, who was readmitted with diagnoses such as dislocation of an internal joint prosthesis and essential hypertension, was receiving Ceftriaxone Sodium intravenously for a urinary tract infection. Despite this, the facility did not develop a care plan with person-centered interventions for the antibiotic administration, potentially leading to complications from the antibiotic use. This deficiency was acknowledged by the MDS Coordinator during a review of the resident's physician orders and care plans. Resident 37, who had intact cognition and was capable of making decisions, was using an electric kettle in his room without a care plan assessing his ability to do so safely. The Director of Nursing admitted that the resident should have been assessed and a care plan developed to ensure safety. Additionally, Resident 20, who primarily spoke Korean and had severely impaired cognitive skills, did not have a care plan addressing the language barrier, which could hinder effective communication and care. The Infection Preventionist confirmed the absence of a care plan for communication needs during a review of the resident's records.
Failure to Ensure Resident Safety and Adherence to Care Plans
Penalty
Summary
The facility failed to provide a safe environment for Resident 70 by not placing a landing mat on the right side of the bed as indicated in the care plan and physician's order. Resident 70, who was admitted with diagnoses including chronic obstructive pulmonary disease, palliative care needs, and cerebral infarction, was identified as being at risk for falls. Despite the physician's order and care plan intervention specifying the use of a right-side landing mat to minimize injury from falls, the mat was found under the bed during an observation. The Registered Nurse confirmed that the mat should have been placed on the right side, and the Director of Nursing acknowledged the oversight. The facility also failed to ensure the safety of Resident 37 by allowing the resident to keep an electric tea kettle in the room without proper assessment or care planning. Resident 37, who had intact cognition and was capable of making decisions, was observed using the kettle to boil water. The Director of Nursing admitted that there was no assessment or care plan addressing the use of the kettle, which posed a potential risk for accidents. The Maintenance Director was unaware of the kettle's presence and stated that electrical appliances should not be in resident rooms without approval. The facility's policies on falls and fall risk management, as well as safety and supervision of residents, were not adhered to in these cases. The policy required interventions to prevent falls and minimize complications, and the electrical appliances policy mandated written approval for such items in resident rooms. These deficiencies highlight lapses in following established protocols to ensure resident safety.
Failure to Administer Continuous Oxygen as Ordered
Penalty
Summary
The facility failed to ensure that two residents received continuous oxygen as ordered by their physicians. Resident 70, who was admitted with chronic obstructive pulmonary disease (COPD) and was dependent on supplemental oxygen, was observed multiple times without wearing the nasal cannula despite the oxygen concentrator being on. Registered Nurse 2 incorrectly stated that the oxygen order was as needed, not continuous, and Licensed Vocational Nurse 2 acknowledged that the resident often removed the nasal cannula but did not ensure it was worn continuously as ordered. Resident 287, who was readmitted with diagnoses including pneumonitis and had a care plan indicating the need for continuous oxygen, was observed receiving oxygen at a higher flow rate than ordered and without a humidifier. Licensed Vocational Nurse 1 confirmed that the oxygen was not administered according to the physician's order, which specified a lower flow rate and the use of a humidifier. The Director of Nursing acknowledged that both residents should have received oxygen as per their physician's orders to prevent complications. The facility's policies on oxygen administration and physician services were not adhered to, leading to the deficiencies observed in the care of these residents.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to ensure that licensed nurses did not leave medications unattended at a resident's bedside. Resident 57, who was readmitted with chronic hematogenous osteomyelitis, type 2 diabetes mellitus with a foot ulcer, and a non-pressure chronic ulcer, was observed with two pills in an unlabeled medication cup on his bedside table. The resident stated that the nurse left the medications for him to take later, a practice that was confirmed by Registered Nurse 2. The nurse justified this by stating that the medications were only vitamins and that the resident was trustworthy. However, there was no documented evidence of a Medication Self Administration Assessment, which is required to ensure the resident can safely self-administer medications. Additionally, the facility failed to administer the first dose of an antibiotic timely to Resident 60, who was readmitted with a urinary tract infection. The physician's order for Cipro was received at 3:22 a.m., but the first dose was not administered until 9:00 a.m., exceeding the four-hour window for timely administration. The MDS Nurse confirmed that the antibiotic was available in the facility's pharmacy e-kit, and the Director of Nursing acknowledged that the delay was inexcusable. The facility's policies and procedures for medication administration and provider pharmacy requirements were not followed in these instances. Medications are to be administered as prescribed and promptly available, especially anti-infectives, which should be available within four hours. The failure to adhere to these guidelines resulted in deficiencies in the pharmaceutical services provided to the residents.
Improper Labeling of Leftover Food in Resident Refrigerator
Penalty
Summary
The facility failed to ensure that leftover food brought by residents' family and visitors was properly labeled with a resident identifier and use-by date in the residents' refrigerator. During an observation and interview with a registered nurse, it was noted that two plastic bags containing undetermined leftover food were found in the refrigerator. One bag had a room number but no name or date, while the other had no resident's name or date. The registered nurse acknowledged that the refrigerator is used to store residents' food and confirmed that all items should be labeled with an identifier and date. The nurse also stated that any leftover food older than three days should be discarded to prevent contamination and potential foodborne illness. The facility's policy, last reviewed in January 2025, requires perishable foods to be stored in re-sealable containers with tightly fitting lids and labeled with the resident's name, item, and use-by date. Nursing staff are responsible for discarding perishable foods on or before the use-by date. The failure to adhere to this policy had the potential to result in foodborne illness for the residents.
Failure to Ensure Provision of Hospice Services
Penalty
Summary
The facility failed to ensure the provision of hospice services for Resident 70, who was admitted with chronic obstructive pulmonary disease and was dependent on supplemental oxygen. The facility did not ensure that the contracted hospice agency provided training programs to the facility staff as per the contractual agreement. Interviews with various staff members, including a registered nurse, a certified nursing assistant, and the MDS nurse, revealed that none had received in-service training from the hospice agency. The facility's administrator and director of nursing were unaware of the training requirements outlined in the hospice contract. Additionally, the facility did not have a designated staff member to coordinate care and services provided by hospice and the facility. Interviews with the MDS nurse, registered nurse, social services director, administrator, and director of nursing indicated confusion and lack of clarity regarding who was responsible for coordinating hospice care. The facility's policy and procedure required a designated coordinator, but this role was not filled, leading to a lack of coordination in hospice care services. Furthermore, there was no documented evidence that hospice staff was physically present in the facility to provide hospice-related services to Resident 70. The MDS nurse and the director of staff development confirmed the absence of a sign-in sheet for hospice staff, which was necessary to document their presence and services provided. The facility's policy required documentation of all services provided to residents, but this was not adhered to, resulting in a deficiency in ensuring hospice care was delivered as required.
Infection Control Lapses in Oxygen Therapy Management
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices for two residents using nasal cannulas for oxygen therapy. For Resident 137, the nasal cannula oxygen tubing was observed touching the floor, which the Director of Nursing (DON) acknowledged as contaminated and a potential source of infection. The facility's infection control policy, as well as CDC guidelines, emphasize the importance of maintaining a sanitary environment to prevent the transmission of infections, which was not adhered to in this instance. For Resident 287, the nasal cannula was not labeled with the date it was last changed, contrary to the physician's orders and facility policy that require weekly changes and proper labeling to prevent respiratory infections. The Licensed Vocational Nurse (LVN) and the DON confirmed the oversight, and the Infection Preventionist reiterated the importance of labeling to prevent infection. Both deficiencies highlight lapses in following established infection control protocols, potentially increasing the risk of infection for the residents involved.
Failure to Cover Urinary Catheter Bag Compromises Resident Dignity
Penalty
Summary
The facility failed to maintain the dignity of a resident by not ensuring that the resident's indwelling urinary catheter collection bag was covered with a privacy bag. This oversight was observed during a room visit, where the urinary catheter bag was found uncovered. The resident, who was admitted with diagnoses including an infection due to a urinary catheter and a malignant neoplasm of the bladder, had an order for catheter care every shift. However, the staff did not adhere to the facility's policy requiring catheter bags to be covered to promote dignity. During an interview, a registered nurse confirmed the absence of a privacy bag on the resident's catheter collection bag and acknowledged the requirement for such a cover to promote dignity. The Director of Nursing also confirmed that the catheter bags should be covered and admitted that the staff had forgotten to do so for this resident. The facility's policy clearly states that residents should be treated with dignity and respect, and that practices compromising dignity, such as leaving catheter bags uncovered, are prohibited.
Failure to Develop Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to develop baseline care plans within 48 hours of admission or readmission for three residents, which is a requirement to ensure that residents' immediate needs are met. Resident 21 was readmitted with diagnoses including chronic obstructive pulmonary disease and gastro-esophageal reflux disease, and had a physician order for ertapenem sodium injection for a urinary tract infection. However, a baseline care plan addressing the antibiotic use was not created, which could lead to staff being unaware of what to monitor for potential adverse reactions. Similarly, Resident 59, who was readmitted with a diagnosis of urinary tract infection and gastro-esophageal reflux disease, had physician orders for antibiotics cefdinir and sulfamethoxazole-trimethoprim to treat G-tube site cellulitis. Despite these orders, a baseline care plan was not developed to monitor the resident during antibiotic therapy, potentially preventing staff from identifying adverse reactions and intervening promptly. Resident 62 was admitted with diagnoses including benign prostatic hypertension, a history of falling, and type 2 diabetes mellitus. The resident had an order for insulin lispro to be administered per sliding scale, but the baseline care plan did not reflect the insulin use. This oversight was acknowledged by the MDS Coordinator, who admitted the mistake. The lack of a thorough baseline care plan could result in the inability to meet the resident's immediate care needs and deliver necessary services.
Failure to Update Resident's Care Plan After Medication Discontinuation
Penalty
Summary
The facility failed to update and revise a resident's care plan after the resident's physician discontinued the administration of Januvia, a medication for controlling blood sugar levels. This oversight involved a resident who was originally admitted on October 25, 2024, and readmitted on November 19, 2024, with diagnoses including unspecified dementia, major depressive disorder, type two diabetes mellitus, and cerebral infarction. Despite the physician's order to discontinue Januvia on October 25, 2024, the resident's care plan, initiated on October 26, 2024, still indicated that the resident was taking Januvia. This discrepancy was identified during a review of the resident's care plan and physician orders by the Infection Preventionist on March 8, 2025. The Director of Nursing confirmed that the licensed nurses did not review or revise the resident's care plan following the discontinuation of Januvia. The facility's policy requires that care plans be reviewed and revised when there are changes in a resident's medication. The failure to update the care plan could lead to confusion regarding the care and services provided to the resident. The facility's policy on comprehensive person-centered care plans emphasizes the importance of revising care plans as information about residents and their conditions change.
Failure to Provide Communication Board for Non-English Speaking Resident
Penalty
Summary
The facility failed to provide a communication board for a resident whose primary language was Korean, which hindered the resident's ability to communicate effectively with staff. The resident, who was admitted and readmitted with diagnoses including unspecified dementia, major depressive disorder, type two diabetes mellitus, and cerebral infarction, had severely impaired cognitive skills and required assistance with activities of daily living. Despite the resident's need for a communication board to express needs, it was not available at the bedside, as observed during an interaction with a Certified Nursing Assistant (CNA) who relied on hand gestures to communicate. Interviews with the Director of Social Services (DSS) and the Director of Nursing (DON) revealed that the facility's policy required the provision of communication devices for residents who do not speak English. The DSS confirmed that a communication board was initially placed but was later removed for unknown reasons. The absence of the communication board was acknowledged by the DON, who stated that it was necessary for accurate communication and understanding of the resident's needs. The facility's policies on translation and activities of daily living support emphasized the importance of providing appropriate communication support for residents with limited English proficiency.
Failure to Provide Religious Services to a Resident
Penalty
Summary
The facility failed to provide religious services to a resident, identified as Resident 10, which violated the resident's right to access and receive religious services. Resident 10 was admitted to the facility with diagnoses of hypertension and anemia. The resident's Annual Minimum Data Set (MDS) indicated that participating in religious services was somewhat important to her. However, during an observation and interview, Resident 10 expressed that she had not attended a church service in a long time and that the facility did not offer any religious services. She also mentioned that no pastor or priest had visited her room, and she resorted to conducting her own bible study. The Activity Director (AD) confirmed that Resident 10 had not participated in any religious activities for the months reviewed and there was no documentation of her being offered or invited to attend any religious service. The AD acknowledged the importance of addressing the spiritual needs of residents and recognized the resident's right to practice their religion. Despite the facility's policy indicating that activity goals should be individualized to match residents' preferences, there was a lack of documented attendance or invitation for Resident 10 to participate in religious services, leading to the deficiency.
Failure to Monitor Catheter Care and UTI Symptoms
Penalty
Summary
The facility failed to provide proper care and monitoring for a resident with an indwelling catheter, as outlined in the resident's care plan. The resident, who was admitted with conditions such as benign prostatic hypertension, obstructive uropathy, and reflux uropathy, required substantial assistance with daily activities and had a moderately impaired cognitive function. The care plan specified that the resident should be monitored for signs and symptoms of urinary tract infections (UTIs) and pain associated with the catheter, but there was no documented evidence of such monitoring in the Treatment Administration Record for the specified period. Interviews with the MDS Coordinator and the Director of Nursing revealed that the licensed staff did not document the required monitoring for pain and signs of infection as per the care plan. The MDS Coordinator confirmed the absence of documentation regarding the monitoring of the resident's indwelling catheter, which was a necessary intervention to provide appropriate care. The Director of Nursing reiterated the requirement for licensed staff to monitor and document any complications associated with urinary catheters, including signs of UTIs and catheter-related pain. The facility's policy on catheter care emphasized the importance of preventing catheter-associated UTIs and required staff to observe residents for complications and report any issues to a physician or supervisor. However, the lack of documentation and monitoring for the resident's catheter care indicated a failure to adhere to these procedures, potentially leading to inadequate care and monitoring for the resident.
Failure to Discard Eye Drops After 28 Days
Penalty
Summary
The facility failed to adhere to the pharmacy's medication recommendation label by not discarding two opened eye drop bottles after 28 days of opening. This was observed during a concurrent observation and interview with a registered nurse, who confirmed that the eye drops, Alpheagan and Latanoprost, should have been discarded on specific dates to prevent bacterial growth. The eye drops were found on a medication cart used during the 3-11 shift, and the registered nurse acknowledged the oversight, stating that the eye drops should have been discarded to ensure resident safety. The Pharmacist Consultant clarified that the discard label on the eye drops is a pharmacy recommendation rather than a regulation. However, the Director of Nursing emphasized that licensed nurses are responsible for reading medication labels before administration and should have discarded the eye drops as per the pharmacy's recommendation. The facility's policy on medication procedures, reviewed earlier in the year, also indicated the importance of administering medications safely and effectively, which includes reading medication labels before administration.
Inaccurate MDS Assessment for Insulin Administration
Penalty
Summary
The facility failed to conduct an accurate Minimum Data Set (MDS) assessment for a resident, identified as Resident 62, by not indicating that the resident was receiving insulin since his admission. Resident 62 was admitted with diagnoses including benign prostatic hypertension, a history of falling, and type 2 diabetes mellitus. Despite having an order for insulin lispro to be administered per sliding scale and receiving it from February 13 to February 17, 2025, the MDS dated [DATE] did not reflect this insulin administration. This oversight was acknowledged by the MDS Coordinator, who admitted to the mistake and recognized the need for correction. The Director of Nursing confirmed that the MDS assessment did not accurately reflect the resident's status, as it failed to indicate insulin use. The facility's policy requires the MDS Coordinator to ensure accurate completion of the MDS assessment, which is used to develop the resident's care plan. The inaccurate MDS assessment had the potential to negatively affect the resident's plan of care and the delivery of necessary services. The facility's policy emphasizes the importance of accurate assessments to inform the resident's comprehensive care plan.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 3,502 citations issued within 25 miles in the last 12 months — including the 27 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Granada Hills
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Granada Hills Convalescent | 1.1 mi | ★★★★★ | 19 | 0 |
| The Gardens Healthcare Center | 1.2 mi | ★★★★★ | 1 | 0 |
| Rinaldi Convalescent Hospital | 1.2 mi | ★★★★★ | 42 | 0 |
| Magnolia Gardens Convalescent Hospital | 1.3 mi | ★★★★★ | 28 | 0 |
| The Rehabilitation Center Of North Hills | 2.1 mi | ★★★★★ | 8 | 0 |
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