Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Century Villa, Inc during CMS and state inspections, most recent first.
An LPN gave medication cups to four residents without explaining what medications were being administered, and each resident swallowed the pills. The residents had diagnoses including DM, COPD, schizophrenia, bipolar disorder, anxiety, dementia, and HTN, and records showed varying capacity to understand and make decisions. During interview, the LPN stated residents should be told what medication they are receiving if they ask, and that they need to know in case they want to refuse.
Missing discharge notice and summary: A resident with cataract, HTN, and COPD was discharged to a lower level of care, but the medical record did not contain a Notice of Proposed Transfer or a discharge summary. The SSD stated the notice was used to inform the resident of the appeal process and to notify the Ombudsman, and the DON confirmed the discharge summary was absent. The facility P&P required written transfer/discharge notice with appeal rights and a discharge summary for community discharge.
A resident with unspecified dementia, schizophrenia, and depression did not have care plans for the mental health diagnoses. During record review, an LVN confirmed the care plans were missing and stated they should be in place so staff would know the interventions if behavioral issues occurred. The MDS nurse stated care plan initiation was a team effort and should be checked during quarterly MDS updates; the facility policy required care plans to include measurable objectives and timeframes.
A resident with bipolar disorder, schizophrenia, and suicidal ideations had intact cognition and capacity to make decisions, but the facility failed to carry out physician orders for stool for occult blood, chest x-ray, abdominal ultrasound, colonoscopy, and a dental referral after an ENT note identified a right jaw lymph node. The SSD stated the dental referral was missed, and the DSD stated the ordered tests were not transcribed into the physician orders, so the resident did not receive the ordered lab work or testing.
A facility arbitration agreement incorrectly stated that it could not be rescinded within 30 days of signature, and this version was used for three residents. The residents had psychiatric diagnoses and varying documentation of capacity/cognition, and the SSD confirmed the same erroneous agreement had been signed over the past 3 years. The ADM stated the error had the potential to violate resident rights by not providing the 30-day rescission period.
The facility failed to ensure that a resident was protected from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, due to inadequate protective measures and oversight.
A resident with multiple psychiatric diagnoses was prescribed Depakote, an anticonvulsant, which was not properly coded as such in the MDS assessment under high-risk drug classes. The MDS nurse confirmed the medication should have been classified based on its pharmacological category, but this was not done, resulting in inaccurate data being reported to CMS.
A resident with significant medical needs and a POA had their personal funds retained by the facility after discharge due to the facility's failure to respond to a request for the account balance. The Business Office Manager did not provide the required information to the resident's representative, despite facility policy mandating timely written statements upon request.
The facility failed to implement care plan interventions for two residents, leading to deficiencies in their care. One resident with an ankle monitor lacked a care plan for skin care, while another resident had no care plan for temporary leave with family, despite having orders for such absences. The absence of these care plans was acknowledged by staff, highlighting a failure to follow facility policies.
The facility failed to adhere to infection control protocols for two residents, leading to potential infection risks. One resident's nasal cannula and humidifier were not changed as per policy, and another resident's enteral nutrition container was not replaced within the recommended timeframe. These oversights could lead to microbial growth and respiratory or gastrointestinal infections.
A resident with COPD, depression, and schizophrenia had their call light placed out of reach, potentially delaying necessary care. Staff confirmed the call light should be within reach, as per facility policy.
A resident's privacy was compromised when a sign disclosing the need to keep a law enforcement device charged was posted above their bed. The resident, with conditions including COPD, epilepsy, and schizophrenia, was unable to express or understand ideas and was fully dependent on staff. Facility staff acknowledged the privacy breach, which violated the policy requiring discreet display of confidential information.
A facility failed to revise a resident's care plan to include specific instructions for oxygen therapy, despite the resident's diagnoses of COPD, respiratory failure, and chronic heart failure. The care plan lacked details on the frequency, route, and conditions for administering oxygen, which was necessary for managing the resident's shortness of breath. The MDS Nurse acknowledged the oversight, noting that the care plan should have been updated to guide staff on when to administer oxygen and change equipment.
The facility failed to correctly obtain orthostatic blood pressure readings for two residents, potentially delaying interventions for orthostatic hypotension. Blood pressure readings were taken in the wrong order and without sufficient time between position changes, contrary to facility policy.
A resident with a history of cerebrovascular accident, schizophrenia, and bipolar disorder was not properly supervised or equipped with a smoking apron during a smoking break, contrary to her care plan and smoking assessment. The resident was observed on the smoking patio without the required protective gear and with her back to the supervising staff, posing a safety hazard. Facility staff acknowledged the oversight, which was inconsistent with the facility's smoking policy.
A resident with cervicalgia and neuropathy did not receive prescribed tramadol for severe pain on two occasions, despite the medication being removed from the narcotic cart. The discrepancy between the controlled drug record and the eMAR was confirmed by staff, leading to increased pain and frustration for the resident.
A facility failed to assess and obtain a physician's order for siderail use for a resident with diagnoses of failure to thrive and encephalopathy. The resident was observed with siderails up, but no assessment or order was documented. Staff interviews confirmed the lack of an Interdisciplinary Team meeting to determine the appropriateness of siderail use, contrary to facility policy.
The facility failed to manage medications properly, as an expired cranberry extract and an unlabeled docusate sodium liquid were found in a medication cart. The Treatment Nurse confirmed the expired extract should have been disposed of, and the lack of an open date on the docusate liquid could lead to uncertainty about its effectiveness. This was contrary to the facility's policy on medication storage.
A facility failed to date and label food items stored in a resident's room, as required by their policy. Observations revealed that a liter of Coca-Cola, a bag of Ruffles potato chips, and a jar of Cheez Whiz were not dated or labeled. Staff interviews confirmed that the policy mandates dating and labeling of food items, which should be consumed within three days to prevent potential health issues. The resident involved was independent and had the capacity to make decisions.
A facility failed to maintain accurate medical records for a resident during a transfer to another facility. The transfer form contained outdated vital signs and incorrect transfer details, which were not updated to reflect the resident's condition on the day of transfer. The resident had chronic kidney disease, schizophrenia, and anxiety disorder. Staff acknowledged the error, and the importance of accurate documentation was emphasized by the DON.
The facility failed to meet the minimum room size requirement of 80 square feet per resident in six rooms, each occupied by three residents. Despite having a waiver, the limited space potentially affected resident safety and environment, as confirmed by the Maintenance Supervisor and Administrator.
A facility failed to document medication administration within the ordered time for four residents with conditions like bipolar disorder and schizophrenia. Medications scheduled for 9:00 am were administered late by an LVN, who cited issues with a new electronic record system. Despite training, the LVN needed more support, which was not communicated to management. The facility's policy requires timely medication administration, which was not followed, potentially affecting therapeutic outcomes.
The facility did not complete annual competency checklists for the IP, two LVNs, and a CNA, as required by their policy. This was discovered during a review of employee files by the DSD, who could not provide evidence of completed evaluations. The DON confirmed that these evaluations are necessary to ensure staff competency and identify training needs.
Residents Were Not Informed of Medications Before Administration
Penalty
Summary
The facility failed to ensure licensed nursing staff informed four sampled residents of the medications before administering them. During observations on 4/9/2026, LVN 1 and LVN 3 were seen giving medication cups to Residents 11, 22, 23, and 51 without explaining what medications were being administered, and each resident then swallowed the pills. During an interview later that morning, LVN 1 stated that if residents ask what medication is being given, staff should tell them, and that residents need to know what medication they are receiving in case they want to refuse. Resident 11 had diagnoses including type 2 DM, HTN, and dementia, and records noted fluctuating capacity to understand and make decisions, though the MDS indicated the resident was usually able to understand and be understood by others. Resident 22 had COPD, schizophrenia, and bipolar disorder; the H&P stated the resident did not have the capacity to understand and make decisions, while the MDS indicated the resident was usually able to understand and be understood by others. Resident 23 had HTN, schizophrenia, and anxiety, and the H&P stated the resident had the capacity to understand and make decisions. Resident 51 had COPD, paranoid schizophrenia, and anxiety, and the H&P stated the resident had fluctuating capacity to understand and make decisions; the MDS indicated the resident was usually able to understand and be understood by others.
Missing discharge notice and summary
Penalty
Summary
The facility failed to complete discharge documents for one sampled resident before discharge. Resident 84 was admitted with diagnoses including unspecified complicated cataract, hypertension, and COPD. The resident’s H&P dated 7/10/2025 indicated fluctuating capacity to understand and make decisions. On 3/19/2026, the MDS showed the resident was discharged to the home/community and would not return to the facility, and a physician order indicated the resident may discharge to an assisted living facility for lower-level care. Progress notes from the same date stated the resident was alert, oriented, stable for transfer to a lower level of care, and discharged at 10:20 a.m. with current medications, personal belongings, and necessary documents. During a concurrent interview and record review on 4/9/2026, the Social Services Director stated there was no Notice of Proposed Transfer or discharge summary in the medical record. The SSD stated nurses fill out the Notice of Proposed Transfer and oversee faxing the notice to the Ombudsman, and that the notice included information regarding the appeal process and informed the ombudsman of the transfer. During a concurrent interview and record review, the Director of Nursing also stated there was no discharge summary and that it was very important to document the discharge summary. The facility policy for Transfer and Discharge (Including AMA), dated 01/2026, stated that for non-emergency discharges initiated by the facility, the resident and representative must receive written notice at least 30 days before transfer or discharge, including the reason, effective date, location, and appeal rights, and that for a community discharge, a discharge summary and plan of care should be prepared.
Missing Care Plans for Schizophrenia and Depression
Penalty
Summary
The facility failed to ensure that Resident 9 had comprehensive care plans for schizophrenia and depression. Resident 9’s admission record showed an initial admission and a readmission to the facility, and the resident’s diagnoses included unspecified dementia, schizophrenia, and depression. The resident’s H&P dated 10/9/2025 indicated fluctuating capacity to understand and make decisions. The MDS dated 1/13/2026 indicated the resident was usually understood, could usually understand others, had moderately impaired cognition, and was independent with eating and oral hygiene. During a concurrent interview and record review on 4/9/2026, LVN 1 reviewed Resident 9’s care plans and stated there were no care plans for schizophrenia or depression, adding that such care plans should be present so staff would know the interventions if behavioral issues occurred. During an interview on 4/10/2026, the MDS Nurse stated that initiation of care plans was a team effort and should be checked during quarterly MDS updates, and that the purpose of the care plan was to ensure the resident’s goals and interventions were being met. The facility policy titled Comprehensive Care Plans stated the care plan would describe services to be furnished to attain or maintain the resident’s highest practicable physical, mental, and psychosocial well-being and include measurable objectives and timeframes.
Missed Physician Orders for Testing and Dental Referral
Penalty
Summary
The facility failed to ensure physician orders for lab work, medical procedures, a chest x-ray, and a dental referral were carried out for one sampled resident. Resident 26 was admitted and later readmitted to the facility with diagnoses including bipolar disorder, schizophrenia, and suicidal ideations. The resident’s MDS dated 1/29/2026 indicated cognition was intact and unimpaired, and the H&P dated 3/3/2026 indicated the resident had the capacity to understand and make decisions. An ENT consultation note dated 3/26/2026 identified a right jaw lymph node and included a referral to a dentist for further evaluation. During interview, the SSD stated the dental referral order was missed and the ENT note was placed in the logbook without alerting the dentist. A physician progress note dated 4/3/2026 documented the resident’s request for testing for pancreatic, colon cancer, and other cancers, and included orders for stool for occult blood, chest x-ray, abdominal ultrasound, and colonoscopy. The DSD stated these orders were not carried over into the resident’s physician orders, were missed and not transcribed, and the resident did not receive the lab work or testing ordered.
Arbitration Agreement Misstated Residents’ 30-Day Right to Rescind
Penalty
Summary
The facility failed to ensure its arbitration agreement accurately reflected residents’ right to rescind the agreement within 30 days for three sampled residents. The facility’s undated Resident-Facility Arbitration Agreement stated, “This agreement may not be rescinded by written notice within thirty (30) days of signature,” which conflicted with the residents’ right to refuse or withdraw from the agreement. During interview, the Social Services Director stated this typographical error had been in the agreement used for the last 3 years and that the agreements containing the error were signed by Resident 15, Resident 26, and Resident 41. Resident 15 had diagnoses including schizoaffective disorder bipolar type, DM, and COPD, with documentation showing fluctuating capacity in the H&P and intact cognition on the MDS. Resident 26 had diagnoses including bipolar disorder, schizophrenia, and suicidal ideations, with intact cognition on the MDS and capacity to understand and make decisions documented in the H&P. Resident 41 had diagnoses including schizophrenia, anxiety disorder, and depression, with fluctuating capacity in the H&P and intact cognition on the MDS. The Administrator stated the typographical error had the potential to violate resident rights by not providing the 30-day time period to rescind the agreement.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report documents that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's protective measures and oversight.
Failure to Accurately Code Anticonvulsant Medication in MDS Assessment
Penalty
Summary
The facility failed to ensure an accurate Minimum Data Set (MDS) assessment for one resident by not properly coding Depakote, an anticonvulsant medication, under Section N0415 (High-Risk Drug Classes) as required. The resident in question had diagnoses including paranoid schizophrenia, bipolar disorder, and anxiety disorder, and was prescribed Depakote for bipolar disorder. Despite the medication's pharmacological classification as an anticonvulsant, it was not marked as such in the MDS assessment. The Minimum Data Set Nurse (MDSN) acknowledged during interview and record review that Depakote should have been coded as an anticonvulsant regardless of the reason for its prescription, as per the Resident Assessment Instrument (RAI) manual. The MDSN admitted to not coding Depakote as an anticonvulsant in previous assessments and stated that this error was not previously flagged. The facility's policy and procedure on conducting accurate resident assessments requires that all assessments reflect the resident's status at the time and be completed by qualified staff. The inaccurate MDS assessment resulted in incorrect data being transmitted to CMS, specifically related to medication classification and care screening.
Failure to Respond to Request for Resident Personal Funds Account Balance
Penalty
Summary
The facility failed to respond to a request for the account balance of personal funds for one resident after discharge, resulting in the facility retaining the resident's funds. The resident in question had a Durable Unlimited Power of Attorney (POA) appointing her son to act on her behalf for financial matters. The resident was admitted with multiple diagnoses, including anemia, chronic kidney disease, and gastrostomy status, and was dependent on staff for all activities of daily living. The Minimum Data Set (MDS) indicated the resident rarely had the ability to make herself understood or understand others. The POA requested the account balance while the Business Office Manager (BOM) was away from the facility, but as of the survey date, the BOM had not responded to the request. A review of the resident's Trust Transaction History showed a closing balance of $1,504.04. The facility's policy and procedures require that quarterly statements be provided in writing to the resident or their representative within 30 days after the end of the quarter and upon request. Despite this policy, the BOM confirmed that no response had been given to the POA regarding the resident's personal funds account balance, resulting in the facility retaining the funds after the resident's discharge.
Failure to Implement Care Plans for Residents
Penalty
Summary
The facility failed to implement care plan interventions for two residents, leading to deficiencies in their care. Resident 44, who was admitted with an ankle monitor, did not have a care plan addressing skin care related to the device. Observations revealed that the ankle monitor was not properly managed, as there was no material between the device and the skin to prevent breakdown. The Director of Nursing acknowledged the absence of a care plan and the need for one to prevent skin issues, although no skin problems had been reported at the time. Resident 90, who had orders allowing temporary leave with family, also lacked a care plan addressing safety and documentation for such absences. The LVN and MDS Nurse confirmed the absence of a care plan for temporary leave, which would typically include goals and interventions to ensure the resident's safety while outside the facility. The facility's policy on temporary passes was not followed, as it required proper documentation and safety measures, which were not in place for Resident 90.
Infection Control Deficiencies in Oxygen and Enteral Nutrition Management
Penalty
Summary
The facility failed to ensure proper infection prevention and control measures for two residents, leading to potential risks of infection. For one resident, the nasal cannula and humidifier used for oxygen therapy were not dated or labeled correctly. The humidifier was observed to be dated over a month prior, and the nasal cannula lacked any date or label. According to the facility's policy, these items should be changed weekly to prevent respiratory infections. Interviews with staff revealed inconsistencies in the understanding of the required frequency for changing these items, with some staff indicating a two-week interval and others stating a weekly change was necessary. Another resident was observed with an enteral nutrition container that had been hanging for more than 24 hours, contrary to the manufacturer's guidelines and the facility's policy, which require the formula to be changed daily. The container was dated two days prior, and there was no nurse's signature or initials to confirm it had been changed as per the physician's orders. This oversight in changing the enteral nutrition could lead to microbial growth, posing a risk of gastrointestinal issues for the resident. The facility's policies and procedures for oxygen administration and enteral nutrition were found to be lacking in specific infection control guidelines. The failure to adhere to these policies and ensure proper labeling and timely changes of medical equipment and nutrition containers could potentially lead to the transmission of infectious microorganisms and increase the risk of infection among residents.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light device was placed within reach for a resident, identified as Resident 56, which could result in a delay or inability to obtain necessary care and services. Resident 56 was admitted with diagnoses including chronic obstructive pulmonary disease (COPD), depression, and schizophrenia, and had fluctuating capacity to understand and make decisions. The Minimum Data Set (MDS) assessment indicated that Resident 56 required supervision or assistance for activities of daily living. During an observation, the call light was found hanging on the overhead light above the resident's bed, out of reach, which was confirmed by Certified Nursing Assistant (CNA) 1. Interviews with facility staff, including the Director of Staff Development (DSD) and the Director of Nursing (DON), confirmed that the call light should always be within reach of the resident to ensure they can call for help in an emergency. The facility's policy and procedure on answering the call light also indicated that the call light should be within easy reach when the resident is in bed or confined to a chair. The failure to adhere to this policy was identified as a deficiency during the survey.
Violation of Resident Privacy Due to Inappropriate Signage
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's personal and medical information by posting a sign above the resident's bed. The sign disclosed that a law enforcement device needed to be plugged in, which was visible to anyone entering the room. This action violated the resident's right to privacy, as the sign contained sensitive information indicating the resident's involvement with law enforcement. The resident, who was admitted to the facility with chronic obstructive pulmonary disease, epilepsy, and schizophrenia, was dependent on staff for all functional abilities and had limited ability to express ideas or understand others. During observations and interviews, staff members, including a CNA and an LVN, acknowledged the inappropriate placement of the sign and its implications for the resident's privacy. The Director of Nursing also recognized the privacy violation but noted that the sign had been in place since before her tenure and was believed to be court-ordered. The facility's policy on posting signs requires that confidential information be displayed discreetly or in restricted areas, which was not adhered to in this case.
Failure to Revise Care Plan for Oxygen Therapy
Penalty
Summary
The facility failed to ensure that a resident's care plan was revised to include specific instructions for oxygen therapy. The resident, who was diagnosed with chronic obstructive pulmonary disease, respiratory failure, and chronic heart failure, required continuous oxygen at two liters per minute for shortness of breath and wheezing. However, the care plan, dated several months prior, only indicated that oxygen should be available if ordered or as needed, without specifying the frequency, route, or conditions under which the oxygen should be administered. This lack of detailed instructions placed the resident at risk of not meeting the care plan goal of avoiding shortness of breath. During an interview and record review, the MDS Nurse acknowledged that the care plan should have been updated to include specific interventions such as when to administer oxygen based on the resident's oxygen saturation levels, and when to change the nasal cannula and humidifier. The facility's policy on reviewing and revising care plans stated that care plans should be updated with new or modified interventions when a resident experiences a status change. The failure to revise the care plan with complete interventions could affect the resident's ability to meet their care plan goals.
Improper Orthostatic Blood Pressure Monitoring
Penalty
Summary
The facility failed to properly obtain orthostatic blood pressure readings for two residents, which could potentially delay necessary interventions for orthostatic hypotension. Resident 3, who has a history of bipolar disorder, schizophrenia, and hypertension, had an order to monitor orthostatic blood pressure weekly. However, the blood pressure readings were not taken correctly, as the times recorded were only one minute apart, and the readings were taken in the wrong order, with sitting measurements taken before lying measurements. This incorrect method of obtaining orthostatic blood pressure readings was confirmed during an interview with a registered nurse. Similarly, Resident 52, who also has a diagnosis of schizophrenia and hypertension, had an order to monitor orthostatic blood pressure weekly. The blood pressure documentation for Resident 52 showed similar issues, with readings taken only one minute apart and in the incorrect order. The facility's policy on orthostatic hypotension requires blood pressure to be measured in three positions: lying, sitting, and standing, with adequate time between position changes. The failure to adhere to this policy and the incorrect method of obtaining readings were identified as deficiencies during the survey.
Failure to Supervise Resident During Smoking Break
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 32, was adequately supervised and wore a smoking apron during a smoking break. Resident 32, who has a history of cerebrovascular accident, schizophrenia, and bipolar disorder, was observed sitting in a wheelchair on the smoking patio without a smoking apron and with her back to the sliding glass door, contrary to her care plan and smoking assessment requirements. The Assistant Activities Director (AAD) and Activities Director (AD) both acknowledged that Resident 32 needed supervision and a smoking apron for safety, and that the resident's positioning and lack of protective gear posed a safety hazard. Interviews with the Director of Nursing (DON) and a review of the facility's policy on resident smoking confirmed that the facility's procedures were not followed. The DON stated that smoking assessments are used to determine if residents require supervision and protective gear while smoking. The facility's policy mandates supervision and the use of smoking aprons for residents who need them, as indicated in their care plans. The failure to adhere to these protocols resulted in a potential safety risk for Resident 32, as she was not properly supervised and did not have the necessary protective equipment while smoking.
Failure to Administer Pain Medication as Prescribed
Penalty
Summary
The facility failed to administer pain medication as needed to one of the sampled residents, identified as Resident 84. Resident 84 was admitted with diagnoses including cervicalgia, idiopathic neuropathy, and anxiety, and was capable of understanding and making decisions. The Minimum Data Set (MDS) assessment indicated that Resident 84 experienced significant pain, rated seven out of ten, which had the potential to interfere with daily activities. Despite the physician's order to administer tramadol 50mg every six hours for severe pain, the medication was not given at the scheduled times on two occasions, as documented in the Electronic Medication Administration Record (eMAR). Interviews with Resident 84 and facility staff revealed that the medication was removed from the narcotic cart but not administered, leading to increased pain and frustration for the resident. The Licensed Vocational Nurse (LVN) and the Minimum Data Set (MDS) Nurse confirmed the discrepancy between the controlled drug record and the eMAR, indicating a failure to follow the facility's medication administration policy. This oversight resulted in Resident 84 experiencing worsened pain and emotional distress due to the delay in receiving her prescribed pain medication.
Failure to Assess and Order Siderails for a Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 39, had an assessment and physician's order for the use of siderails. During an observation, it was noted that Resident 39 was resting in bed with one siderail up on each side, yet there was no documented order for their use in the resident's records. The resident had been admitted with diagnoses including failure to thrive and encephalopathy, conditions that could affect their ability to safely use siderails. Interviews with facility staff, including a Registered Nurse and the Minimum Data Set Nurse, revealed that an Interdisciplinary Team (IDT) meeting is required to assess the appropriateness of siderail use for residents. It was confirmed that Resident 39 did not undergo such an assessment, nor was there an order for siderails. The facility's policy mandates an assessment and documentation of the need for siderails before their use, which was not adhered to in this case.
Medication Management Deficiency
Penalty
Summary
The facility failed to properly manage medications in accordance with accepted professional principles, as observed during a survey. Specifically, a bottle of expired cranberry extract was found in medication cart #3 at nurses station #3, and a bottle of opened docusate sodium liquid lacked an open date label. During an interview, the Treatment Nurse acknowledged that the expired cranberry extract should have been disposed of to prevent residents from receiving ineffective medication. Additionally, the absence of an open date on the docusate liquid could lead to uncertainty about its effectiveness. The facility's policy on medication storage, which requires the disposal of outdated drugs and maintaining medication areas in a clean and safe manner, was not adhered to, contributing to this deficiency.
Failure to Date and Label Food Items in Resident's Room
Penalty
Summary
The facility failed to ensure that food items stored in a resident's room were properly dated and labeled, as required by their policy. During an observation, it was noted that a liter of Coca-Cola, a large bag of opened Ruffles potato chips, and an open jar of Cheez Whiz in the resident's room were not dated or labeled. Interviews with facility staff, including a Licensed Vocational Nurse (LVN) and a Certified Nursing Assistant (CNA), confirmed that the facility's policy mandates that all food items brought in by family or visitors must be dated and labeled, and consumed within three days. The staff acknowledged that failing to adhere to this policy could potentially lead to stomach issues for the resident. The resident involved, identified as Resident 84, was admitted to the facility with diagnoses including cervicalgia, idiopathic neuropathy, and anxiety. The resident was assessed to have the capacity to understand and make decisions, and was independent with personal hygiene, dressing, and eating. The facility's policy on the use and storage of food brought in by family or visitors emphasizes the importance of labeling and dating food items to ensure resident safety. However, the failure to comply with this policy in the case of Resident 84 represents a deficiency in the facility's adherence to its own procedures.
Inaccurate Documentation During Resident Transfer
Penalty
Summary
The facility failed to maintain complete and accurate medical records for Resident 22, which is not in accordance with accepted professional standards. Specifically, the facility did not document the correct information regarding the resident's transfer to a different facility. The transfer form for Resident 22, dated 2/3/25, contained outdated vital signs and incorrect transfer details, which were not updated to reflect the resident's condition on the day of transfer. This discrepancy was acknowledged by the Director of Staff Development (DSD) and Registered Nurse (RN) 2, who admitted to not updating the transfer form with the correct information. Resident 22, who had diagnoses including chronic kidney disease, schizophrenia, and anxiety disorder, was transferred to another facility on 2/3/25. The Director of Nursing (DON) emphasized the importance of accurate documentation to ensure the resident's condition is known and to facilitate proper care during transfers. The facility's policy on charting and documentation requires that all services and changes in a resident's condition be documented in the medical record, which was not adhered to in this case.
Deficiency in Room Size Requirements
Penalty
Summary
The facility failed to ensure that six out of forty-seven rooms met the minimum requirement of 80 square feet per resident in multiple occupancy rooms. During observations and interviews, it was confirmed that rooms 22, 24, 26, 27, 28, and 29 did not meet this requirement, as they were each occupied by three residents but only provided approximately 225 to 229 square feet in total. This deficiency was acknowledged by the Maintenance Supervisor and the Administrator, who confirmed the room measurements and the occupancy levels. The Administrator stated that the facility had a room waiver for these rooms, which allowed for the variance in square footage. However, the waiver did not negate the fact that the residents in these rooms had less space, potentially affecting their safety and environment. The facility's policy and procedure indicated that shared rooms must provide at least 80 square feet per resident, which was not adhered to in these cases. The Administrator acknowledged that the limited space could increase the risk of accidents for the residents occupying these rooms.
Medication Administration Timing Deficiency
Penalty
Summary
The facility failed to document medication administration within the ordered time for four sampled residents. Each resident had specific diagnoses, including bipolar disorder, schizophrenia, dementia, epilepsy, and neuropathy, which required timely medication administration to manage their conditions effectively. The medications for these residents were scheduled for 9:00 am on November 22, 2024, but were administered and documented at varying times outside the prescribed window by LVN 3. LVN 3, responsible for administering the medications, stated that the facility had recently transitioned to an electronic medical record system on October 8, 2024. Despite receiving training, LVN 3 admitted to being slow in documenting medication times and expressed a need for additional training, which was not communicated to management. The facility's policy requires medication to be administered within 60 minutes before or after the scheduled time, a guideline that was not adhered to in these instances. The Director of Nursing (DON) confirmed the transition to the electronic system and mentioned that staff had access to training resources. However, the DON could not provide documentation of these training sessions. The facility's documentation policy emphasizes timely entries after care is provided, which was not followed, leading to potential risks in therapeutic outcomes for the residents involved.
Failure to Complete Annual Competency Checklists for Nursing Staff
Penalty
Summary
The facility failed to ensure that the Infection Preventionist (IP), two Licensed Vocational Nurses (LVN1 and LVN2), and one Certified Nursing Assistant (CNA2) had their annual competency checklists completed. This deficiency was identified during a review of employee files conducted by the Director of Staff Development (DSD) on August 13, 2024. The DSD was unable to provide evidence that the required annual competencies were completed for these staff members. The purpose of these annual competencies is to assess the nursing skills of the staff and ensure they are capable of performing their duties effectively. The Director of Nursing (DON) confirmed that the facility's policy requires staff to complete a competency checklist upon hire and annually thereafter. These checklists are intended to verify staff competency and identify any need for additional training. The facility's policy and procedure document, titled 'Competency Evaluation,' outlines that these evaluations are necessary to ensure staff have the appropriate skills to meet the needs of the residents. The failure to complete these evaluations could potentially result in staff providing substandard care due to a lack of verified competencies.
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Illustrative
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 Inglewood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Primrose Post-acute | 0.2 mi | ★★★★★ | 7 | 0 |
| Inglewood Health Care Center | 0.5 mi | ★★★★★ | 32 | 0 |
| Hyde Park Healthcare Center | 0.9 mi | ★★★★★ | 33 | 1 |
| Lotus Care Center | 1.2 mi | ★★★★★ | 14 | 0 |
| Centinela Skilled Nursing & Wellness Centre West | 1.3 mi | ★★★★★ | 18 | 0 |
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