Below average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Chatsworth Park Health Care Center during CMS and state inspections, most recent first.
Missing Annual Water Outage Response Training: The facility failed to provide documented evidence that staff completed the required annual training on water outage response. RNs and an LVN stated they did not receive the training, and the DSD confirmed the facility does not conduct water outage response training as part of annual compliance training. The DON, ADON, and ADM acknowledged the importance of the training, but the ADM could not produce documentation showing it was completed.
Resident room temperature was found above the acceptable 71 F to 81 F range, with a reading of 82.4 F during an observation. The resident, who had CHF, anemia, DM, and anxiety and required max assist for toileting hygiene and bed mobility, reported that the room felt hot and that a nurse did not adjust the A/C because other roommates did not want it changed. A maintenance consultant also noted that several hallway vents were not blowing air.
Lack of Written Procedures for Temperature and HVAC Monitoring: The facility failed to develop and implement written P&P for monitoring room air temperatures and HVAC units. Staff described a process of checking resident room temperatures, averaging readings by station, and documenting HVAC filter changes, but the logs did not identify the inspection components or the staff performing the work, and the facility had no written guidance for the process.
HVAC Failure Left Resident Room Too Hot: A resident with CHF, anemia, DM, anxiety, and impaired mobility reported that the room felt like roasting in my own skin. Staff measured the room at 82.4 F, above the stated acceptable range of 71 F to 81 F, and a maintenance consultant found multiple hallway vents not blowing air. An HVAC tech later determined the ductwork serving the hallway had become disconnected due to age and deterioration, leaving the area without proper airflow.
Failure to notify the physician of repeated medication refusals for two residents. One resident with HTN, thyrotoxicosis, malnutrition, and impaired decision-making repeatedly refused ordered meds, and the record did not show physician notification before a later COC. Another resident with dysphagia, anxiety, and anemia repeatedly refused losartan, vitamins B12 and D3, and multivitamins, but the MAR/progress notes did not show the physician was notified. Facility policy required physician notification after 3 days of refusal.
Failure to document rationale for continued antipsychotic use: A resident with psychosis was maintained on olanzapine 2.5 mg nightly, but the record showed no documented GDR attempt and no clear clinical rationale or contraindication for continuing the medication. MDS assessments noted severe cognitive impairment, no documented behavioral symptoms, and ongoing antipsychotic use, while the DON acknowledged the facility did not complete the required annual GDR review.
Inaccurate MDS and Assessment Coding The facility failed to accurately code MDS and related assessments for three residents. One resident’s MDS did not reflect restorative nursing/PROM services that were documented as provided, another resident’s fall risk evaluation incorrectly marked no predisposing disease despite a CVA diagnosis, and a third resident’s MDS and Face Sheet omitted depression even though the neurobehavioral exam, OSR, and MAR documented active depression and trazodone use for depression.
The facility failed to develop complete care plans for several residents with identified needs. A resident had a bed positioned against the wall without a care plan, another resident on oxygen therapy had no plan identifying treatment goals or interventions, and a resident with repeated medication refusals had no care plan or IDT documentation addressing the refusals. The facility also lacked a care plan for a resident receiving PRN Zofran, failed to include turning and repositioning interventions for a bedbound resident with a stage 4 sacral PU, and did not include measurable sleep goals for a resident receiving trazodone for insomnia.
A resident had hydrocortisone cream at the bedside without a physician order or self-administration authorization, another resident’s PRN ondansetron use was not accurately documented in the eMAR, a resident with schizoaffective disorder missed a scheduled Depakote dose because it was not available, and eight eKITs containing CSs were not reconciled at each shift change as required by policy.
Expired Novolog Flexpens for two residents were left in a med cart after their 28-day use period had passed, and an LPN confirmed they should have been removed and discarded. In a separate med cart, dorzolamide eye drops were stored in the same bin as oral meds, and the LPN and DON stated eye meds should be kept separate from oral medications to prevent wrong-route use and contamination.
A resident with CKD and a renal diet received double portions on the tray ticket before a physician order was in place. The DSS added the double portions because the resident wanted more food, but did not notify the RD right away. The RD later learned of the change, contacted the MD, and obtained an order for renal diet with double portions. The DON stated communication between nursing and dietary was important to ensure the resident had the proper diet.
A resident with severe cognitive impairment, frequent incontinence, and a prior resolved pressure injury waited ten minutes for help to the restroom after a CNA knew of the request but delayed assistance while helping another resident. The CNA did not seek help from other staff, and other staff reported they were not notified. The DON stated a three- to five-minute wait was acceptable, and the facility’s call light policy required staff to respond or notify the charge nurse if unable to assist.
A facility failed to keep a copy of the AD acknowledgment form or AD readily available in the medical records for two residents. One resident had DM, dysphagia, repeated falls, and lacked capacity to make decisions; the other had DM, dysphagia, dementia, and also lacked capacity. RN could not locate the AD documentation for either resident, and the DON stated the AD or acknowledgment form should be maintained in the active chart.
A resident’s diet ticket containing PHI was discarded in a dining room trash can instead of being secured for shredding, and two treatment nurses performed sacral wound care for another resident without fully closing the room’s curtains. The residents had significant cognitive and medical impairments, and the facility’s policies required PHI protection and privacy during treatment.
Failure to Obtain Required Documentation Before Using a Physical Restraint: A resident with dementia, DM2, and difficulty walking was observed asleep in bed with one side of the bed against the wall. The MDSN confirmed there was no physician order, informed consent, or entrapment risk assessment for the bed placement, and the DON stated these were expected before restraint use. The facility policy identified a bed against the wall as a physical restraint and required an order, consent, and entrapment assessment.
Failure to turn and reposition a bedbound resident with a Stage 4 sacral PU. A resident with Parkinson’s disease, dysphagia, severe cognitive impairment, and a Braden score of 7 had a sacral PU and other pressure injuries. The care plan and physician orders did not include individualized q2h turning/repositioning, and the task record showed the resident was turned once per shift instead of every 2 hours. Staff and the resident’s RP stated the resident should be repositioned q2h, and the wound was observed with full-thickness tissue loss, exposed muscle, and undermining.
A resident with CKD and intact cognition had Halobetasol ordered PRN for itching, but staff repeatedly failed to bring the cream when requested. During observation, an LPN/TN searched treatment carts before finding the medication, and the DON and ADON later found hydrocortisone 1% cream in the resident’s bedside drawer and on top of the drawers even though there was no physician order for it. The resident said he bought the hydrocortisone online because his Halobetasol was not being brought to him.
Failure to monitor a resident on Levofloxacin for black box warning adverse reactions. A resident with UTI and significant ADL dependence received Levofloxacin 250 mg daily, but the ADON confirmed the care plan did not document the FDA black box warning or the required monitoring for serious reactions such as tendon rupture, peripheral neuropathy, and CNS effects.
A facility failed to provide ordered respiratory care for two residents. One resident with acute respiratory failure and cognitive impairment was observed without oxygen even though the order required continuous O2 at 2 L/min via NC, and staff confirmed the oxygen was not being given. Another resident with COPD and acute respiratory failure with hypoxia was observed on an oxygen concentrator set at 3 L/min despite an order for 2 L/min PRN. Staff and the DON acknowledged the orders were not followed.
A resident with ESRD and dependence on HD had a left upper chest permacath, but the post-dialysis assessment had no documentation that the access site was checked for bleeding, swelling, redness, or signs of infection. The ADON stated nurses should assess the access site after dialysis, and the facility P&P required access assessment upon return from dialysis.
Infection control practices were not followed for two residents when a urinal was left unlabeled and a resident’s oxygen cannula tubing was observed touching the floor. The IPN stated the urinal needed a label to identify the resident, and an RN and the DON stated the oxygen tubing should not touch the floor for infection control reasons. One resident had anemia and anxiety disorder, and the other had COPD and acute respiratory failure with hypoxia and was receiving oxygen therapy.
Failure to Provide Physician Choice Form: A resident with stroke, dementia, dysphagia, DM2, and bipolar disorder was found to lack decision-making capacity and have severely impaired cognition. The RP emailed the administrator requesting that the resident’s PCP continue as the attending physician, but the ADON confirmed the RP was not given the facility’s Resident’s Right to Choose a Physician form. The ADON stated residents have the right to choose their physician and that staff should have helped contact the requested physician.
Failure to Report Ongoing Low Fluid Intake: A resident with MI, dysphagia, acute kidney failure, and stage 4 CKD had fluid intake that stayed below RD-estimated needs during I&O monitoring. The ADON stated staff did not notify the MD even though the resident’s average daily intake remained below the estimated requirement for about a month, despite facility policy requiring low intake or fluid imbalance to be reported.
Failure to Include Fish Dislikes in Care Plans: The facility did not develop or implement individualized, person-centered care plans for two residents to address their dislike of fish. Both residents had intact cognition, required assistance with ADLs, and had diet slips listing fish as a dislike, yet fish continued to be served as a main entree. The DS and ADON confirmed there were no nutritional care plans addressing the fish dislike, and the facility policy required the IDT to develop comprehensive care plans with measurable objectives and timeframes.
Failure to Honor Documented Food Dislikes: Two residents with intact cognition had fish listed as a food dislike on their diet slips, yet fish continued to be served as a main entree. One resident with DM, anemia, ESRD, and dialysis dependence said kitchen staff repeatedly served fish despite being told not to, while another resident with DM, malnutrition, and depression said staff and family had already communicated that fish should not be served. Dietary staff confirmed fish was listed as a dislike for both residents, and the DS stated there were no care plans addressing the fish dislike.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
Two residents with severely impaired cognition and dependence on staff for personal hygiene were observed with long, untrimmed fingernails that extended past the fingertips, with one resident's nails noted as brown and dirty underneath and the other's described by the ADON as dry, long, uneven, and sharp. An LVN and the ADON acknowledged the condition of the nails during observations and interviews, and the ADON stated that nail care should be provided weekly and nails kept short to prevent injury. The facility's nail care policy, which calls for promoting cleanliness, safety, and a neat appearance, was not followed for these residents.
A resident with severe cognitive impairment and multiple neurological diagnoses developed redness on the right lateral abdomen that was reported by a CNA to the treatment nurse as a change in condition. Although a physician’s order was obtained to apply triple antibiotic ointment to the area, the treatment nurse did not measure the redness, despite acknowledging that treatment nurses are responsible for assessing and measuring skin changes. A later change-in-condition note stated the irritation had increased in size, but no measurements were documented, and the nurse could not explain how the increase was determined. The ADON confirmed the absence of measurements and that facility policy requires licensed nurses to measure and describe all skin injuries as part of the skin and wound assessment.
Surveyors found that direct care staff did not comply with the facility’s infection control and employee handbook requirements for fingernail length. A CNA and an LVN providing hands-on care were observed with long fingernails extending beyond their fingertips, despite the LVN acknowledging awareness of the policy. The ADON and IP both confirmed that staff who provide direct resident care are required to keep fingernails short and trimmed as part of the facility’s infection prevention and control program and as specified in the employee handbook.
A resident with impaired cognition and high care needs reported being physically and verbally abused by multiple staff members. Although the ADON promptly notified leadership, the ADM did not ensure the allegation was immediately reported to authorities as required by policy and regulations, instead relying on a prior investigation and failing to meet mandated reporting timelines.
Surveyors found that the facility did not develop or implement appropriate person-centered care plans for three residents. One resident on antibiotic therapy lacked a care plan for monitoring complications, another had an oxygen therapy care plan that did not match physician orders, and a third resident with a language barrier did not have a timely communication care plan. These deficiencies were confirmed by facility staff and documented in resident records.
Eight medication emergency kits containing controlled medications were not reconciled at each shift change in a medication room, as required by facility policy and regulations. Both nursing staff and the DON confirmed that accountability logs were not maintained for these kits, resulting in a lack of proper documentation and control over the inventory of controlled substances.
A resident with limited mobility and multiple health conditions did not have heel protectors applied while in bed as ordered by the physician. Staff observed the resident's heels in direct contact with the mattress, and both a CNA and the DON confirmed that the physician's order for heel protectors was not followed, contrary to facility policy for pressure injury prevention.
A resident with severe cognitive impairment and a medium fall risk was found in bed with the bed brake lock not engaged after ADL care, contrary to facility policy. The bed was observed unlocked by maintenance staff and subsequently locked. Facility policy requires staff to ensure beds are locked after care to promote safety.
A resident dependent on staff for care and with a history of UTIs was found with an indwelling catheter tubing that was looped and nearly kinked, contrary to facility policy and staff expectations. Both the TN and DON confirmed the tubing should be kept straight to prevent backflow and potential infection.
A resident with multiple complex medical conditions received an IV antibiotic at a faster rate than ordered by the physician, as a nurse manually set the flow regulator above the prescribed rate. The nurse acknowledged the error, and the DON confirmed that this was a medication administration error and not in accordance with facility policy.
A resident with end stage renal disease did not have proper post-dialysis assessments documented, as the facility failed to follow up with the dialysis center when post-dialysis weights were missing or when weights did not decrease after treatment. Staff interviews confirmed that required communication and documentation with the dialysis center did not occur, despite facility policy and care plan requirements.
A resident with complex medical needs received an IV antibiotic at a faster rate than ordered due to a nurse setting the flow regulator incorrectly. The nurse admitted to the error, and the DON confirmed that staff must follow physician orders for medication administration, including the rate.
An open vial of Aplisol used for TB testing was found in a medication room refrigerator without a label indicating the date it was opened. Both an RN and the DON confirmed the vial was not labeled as required by manufacturer instructions and facility policy, making it impossible to determine if the medication was still within its safe usage period. Facility policy mandates that multi-dose vials be labeled with the date opened and discarded after 28 or 30 days, but this was not followed, resulting in the vial being considered expired.
A resident receiving oxygen therapy was found with their nasal cannula tubing lying on the floor, which was confirmed by the ADON to be contaminated and in need of replacement. Facility policy and CDC guidelines note that floors can quickly become contaminated, posing an infection risk when care equipment touches them.
A resident with severe cognitive impairment and a diagnosis of osteomyelitis was prescribed IV Vancomycin for an infection, but the required infection surveillance form was not completed within the facility's specified timeframe. The infection control nurse confirmed the delay, which did not align with the facility's antibiotic stewardship policy requiring timely assessment and documentation when antibiotics are initiated.
Six multiple-resident rooms were found to be below the required 80 square feet per resident, with measurements ranging from 73.2 to 79.2 square feet. Despite the shortfall, residents did not report concerns and were observed to have adequate space for movement and care equipment.
The facility failed to ensure timely documentation of the History and Physical (H&P) by the attending physician for three residents, as required by facility policy. The H&Ps were completed beyond the 72-hour window, potentially affecting care coordination. The ADON confirmed the delays, which involved residents with conditions such as fractures, respiratory failure, and chronic kidney disease.
A resident with major depressive disorder and hypertension reported missing jewelry, but the facility failed to document the loss as required by its theft and loss policy. The Social Services Assistant did not inform the Administrator or document the incident, citing the resident's forgetfulness as a reason. The facility's policy requires documentation and reporting of losses over $25, which was not followed in this case.
A resident's Discharge Summary was found to be incomplete and inaccurate, failing to reflect the resident's request for discharge and missing contact information for the Home Health agency. The resident, admitted with a fracture and other conditions, insisted on being discharged home, but the summary incorrectly cited health improvement as the reason for discharge.
A resident with a fracture and other conditions was overmedicated due to the facility's failure to follow physician's orders for pain management. Despite reporting mild pain, the resident received a dosage intended for moderate pain, as confirmed by the ADON. This discrepancy highlights a failure to adhere to the facility's medication administration policies.
A resident did not receive a prescribed antibiotic in a timely manner due to a failure to check the emergency medication kit and a lack of awareness of the medication's delivery. The resident, admitted with conditions including a fracture and pneumonitis, was prescribed amoxicillin-pot clavulanate for aspiration pneumonia. The medication was available in the facility's emergency kit, but the LVN did not administer it as required by the physician's order.
A resident did not receive their daily probiotic as prescribed due to an error in transcription by an LVN, who entered the order for 30 days instead of daily. The resident, with conditions including Parkinson's disease and bipolar disorder, was affected by this oversight. The DON confirmed the error and noted that the facility's policy for order transcription was not followed.
A resident's representative requested clinical records, including medication administration records and blood pressure readings, but the LTC facility failed to provide them within the required timeframe. The Medical Records Director misunderstood the request, leading to a delay in fulfilling the request, which violated the facility's policy and the resident's rights.
A resident with severe cognitive impairment and dependency on staff was found with their call light out of reach, contrary to the facility's policy. The resident confirmed the need for the call light in emergencies, and staff acknowledged the oversight.
Missing Annual Water Outage Response Training
Penalty
Summary
The facility failed to implement its policy titled, Water Shut Off and Water Supply Interruption, by not providing documented evidence that staff completed annual training on water outage response. During interviews, RN 2, RN 3, and LVN 1 each stated that they did not receive training on water outage response. The DSD reviewed the policy and confirmed that it called for annual training, but stated that the facility does not conduct training specific to water outage response and that it is not part of the annual compliance training. During a concurrent interview and record review, the DON stated that annual water outage response training should be conducted so nurses will know what to do during an emergency water outage. The ADON stated that such training should be conducted because if staff are not trained, residents may be placed in danger and at risk for harm. The ADM reviewed the all staff in-service training report and was unable to provide documented evidence that annual training on water outage response was conducted. The facility assessment also stated that the facility makes a good faith effort to provide staff training, education, and competencies necessary to provide the level and types of support and care needed for the resident population.
Resident Room Temperature Exceeded Acceptable Range
Penalty
Summary
The facility failed to maintain a resident room temperature within the required range of 71 F to 81 F for one of five sampled residents. Resident 1 was originally admitted on 3/22/2026 and re-admitted on 4/20/2026 with diagnoses including CHF, anemia, DM, and anxiety. The resident’s MDS dated 4/24/2026 indicated adequate hearing and vision, clear speech, the ability to understand and be understood, cognitive intactness, impaired range of motion in one lower limb, and a need for maximum assistance with toileting hygiene and bed mobility. During a concurrent observation and interview on 7/13/2026 at 2:51 p.m., Maintenance Assistant 1 measured the room temperature in Resident 1’s room with an infrared thermometer and obtained a reading of 82.4 F. Resident 1 stated during interview that the room had felt hot in the afternoon a few days earlier and that a nurse had been asked to increase the air conditioning, but the nurse said the other roommates did not want the temperature changed and did not adjust it. Resident 1 stated that it felt like roasting in the resident’s own skin. Maintenance Consultant 1 later stated that 71 F to 81 F was the acceptable range and that 82.4 F was too hot, and also observed that three hallway vents were not blowing air.
Lack of Written Procedures for Temperature and HVAC Monitoring
Penalty
Summary
The facility failed to develop and implement written policies and procedures for monitoring room air temperatures and HVAC units. During record review, the Weekly Air Temperature Record showed temperatures documented for Station 1 through Station 4, the Lobby, and Offices on multiple dates, with outside temperatures ranging from 81 F to 96 F and indoor readings recorded in the low to mid-70s. During interviews, Maintenance Consultant 1 stated that room temperatures were checked daily, should be taken at knee level, and that the weekly process was to randomly check several resident rooms at each station and document the average temperature for each station. MC 1 also stated that the Weekly Air Temperature Log reflected the facility's process. A review of the Change of Air Filters on Air Conditioner Units log showed entries for multiple dates that consisted only of a downward arrow mark extending from Unit 1 through Unit 16. MC 1 stated that the log did not identify what HVAC components were checked beyond air filter replacement and did not identify who performed the inspection or maintenance, and also stated that the facility did not have written P&P addressing room temperature monitoring. The Administrator stated that the current process for weekly room temperature monitoring involved MA 1 obtaining temperatures in all resident rooms, documenting the readings on paper, and then the Administrator calculating and documenting the average temperature for each nursing station. The Administrator further stated that the facility did not have written P&P for room temperature monitoring or HVAC inspections that specified the inspection process, required inspection components, documentation requirements, or staff responsibilities.
HVAC Failure Left Resident Room Too Hot
Penalty
Summary
The facility failed to maintain the HVAC unit in functioning condition to provide a comfortable environment for one of five sampled residents. Resident 1’s face sheet showed admission on 3/22/2026 and re-admission on 4/20/2026 with diagnoses including CHF, anemia, DM, and anxiety. The MDS dated 4/24/2026 indicated the resident had adequate hearing and vision, clear speech, was cognitively intact, had impaired range of motion in one lower limb, and required maximum assistance for toileting hygiene and bed mobility. During a concurrent observation and interview on 7/13/2026, Maintenance Assistant 1 measured the temperature in Resident 1’s room at 82.4 degrees Fahrenheit. Resident 1 stated the room had felt hot in the afternoon a few days earlier and that a nurse had been asked to increase the air conditioning, but the nurse said the other roommates did not want the temperature changed and did not adjust it. Resident 1 also stated that it felt like roasting in my own skin. Maintenance Consultant 1 stated that the acceptable room temperature range was 71 F to 81 F and that the room temperature was too hot, and observed that three vents in the hallway outside the room were not blowing air. The consultant later stated that an HVAC technician found the vents serving the hallway had become disconnected from the HVAC unit, and the service invoice stated the ductwork had become disconnected due to age and deterioration. The facility policy on Homelike Environment stated the environment would be designed and maintained to promote comfort and provide a safe, welcoming, and comfortable living environment for residents.
Failure to Notify Physician of Repeated Medication Refusals
Penalty
Summary
The facility failed to notify the physician when two residents repeatedly refused prescribed medications. One resident was admitted with diagnoses including hypertension, thyrotoxicosis with thyrotoxic crisis, and severe protein-calorie malnutrition. The resident’s H&P stated the resident could make needs known but could not make medical decisions, and the MDS indicated severely impaired cognition for daily decision making. The resident had active orders for methimazole, multiple vitamins-minerals, trazodone, lubiprostone, and propranolol, and staff stated the resident tended to refuse medications. For this resident, the MDSN stated licensed nurses should notify the physician after three refusals and document the refusals in a progress note or create a COC. During record review, the COC dated 6/11/2026 indicated the resident refused medication and staff paged the physician and waited for a reply, but it did not show whether the physician was reached. The MDSN and DON stated there was no documentation that the physician was notified prior to 6/11/2026, and there was no documentation that the physician gave instructions regarding the repeated refusals throughout June 2026. The facility policy required physician notification after a pattern of refusal for 3 days and documentation in the progress note. A second resident was admitted and readmitted with diagnoses including dysphagia, anxiety disorder, and anemia, and the MDS indicated intact cognitive skills for daily decision making. The resident had orders for losartan potassium, vitamin B12, vitamin D3, and multivitamins with minerals. Review of the MAR showed repeated refusals of these medications across multiple date ranges in May 2026. The ADON stated the progress notes did not document that licensed nurses notified the physician about the refusals, and stated the physician should have been reported to so alternative therapies or medications could be prescribed. The facility’s Resident Rights policy stated the attending physician would be notified of refusals of care, treatments, or procedures and that physician notification would be documented in the progress notes.
Failure to Document Rationale for Continued Antipsychotic Use
Penalty
Summary
The facility failed to ensure that Resident 69’s medication regimen was free from unnecessary psychotropic medication use. Resident 69 was admitted with a diagnosis including psychosis and was prescribed olanzapine 2.5 mg at bedtime beginning 2/25/2025 for psychosis from calm to hostile behavior. The resident’s MDS assessments dated 5/27/2025, 8/22/2025, 11/19/2025, and 2/16/2026 indicated severe cognitive impairment, no documented physical or verbal behavioral symptoms, use of antipsychotics, and no GDR attempt. The resident’s care plan, revised 9/4/2025, identified olanzapine use for psychosis from calm to hostile behavior with a goal of decreased episodes of signs and symptoms of the diagnosis. The MARs from May 2025 through June 2026 showed the resident received olanzapine 2.5 mg nightly and was monitored every shift for psychotic behavior manifested by mood swings from calm to hostile behavior. The MARs documented zero behaviors during May 2025 and June 2025, and the record review indicated no documented GDR attempt during the reviewed period. During interview, the DON stated the facility failed to attempt a GDR annually for olanzapine and/or to document a clinical rationale for continuing the medication or specific contraindications preventing a GDR. The DON stated the resident was placed at risk of continuing unnecessary psychotropic medication that could result in adverse consequences and side effects, negatively impacting the resident’s well-being. A facility progress note dated 7/1/2026 documented a telehealth encounter with the responsible party to discuss the clinical rationale for a new GDR attempt and a plan to initiate a GDR of olanzapine.
Inaccurate MDS and related assessments
Penalty
Summary
The facility failed to conduct accurate MDS assessments for three sampled residents by not reflecting each resident’s status at the time of assessment. For Resident 8, the MDS dated 5/26/2026 indicated severe cognitive impairment and substantial/maximal assistance with several ADLs, but Section O stated the resident had not performed passive or active range of motion exercises. The resident’s OSR showed restorative nursing program orders entered on 6/20/2026 for PROM exercises to the right upper and right lower extremities, and the Restorative Nursing Record for May 2026 was signed off as provided. During interview, the ADON stated the MDS did not reflect the resident’s status because it coded that no restorative nursing program was provided when the restorative record showed it was provided. For Resident 30, the Face Sheet listed diagnoses including nontraumatic subarachnoid hemorrhage and type 2 diabetes, and the H&P dated 6/8/2026 stated the resident did not have the capacity to understand and make decisions. The MDS dated 6/9/2026 indicated the resident usually understood others and was usually understood by others, and was dependent on staff for toileting hygiene, lower body dressing, and putting on/taking off footwear. During review of the fall risk evaluation dated 6/5/2026, the MDSN stated the section for predisposing disease was filled out incorrectly because “none present” was selected even though the resident had a listed predisposing disease, CVA. The DON stated the fall risk evaluation should have included the resident’s predisposing diseases. For Resident 117, the Face Sheet listed heart failure and hypertension, and the Neurobehavioral Status Exam dated 4/28/2026 documented depressed mood, impaired judgment, moderate to severe cognitive impairment, significant major depression, and an active diagnosis of depression. The MDS dated [DATE] indicated severe cognitive impairment and antidepressant use, but did not list depression under Active Diagnoses. The OSR and MAR showed trazodone 50 mg at bedtime for depression manifested by inability to sleep. During interview, the DON and ADON acknowledged that the Face Sheet and MDS did not include depression under Active Diagnoses despite the Neurobehavioral Status Exam and medication record showing depression, and the MDSN stated she overlooked including depression in the MDS and Face Sheet.
Incomplete care plans for oxygen therapy, medication refusals, PRN antiemetic use, bed positioning, pressure ulcer care, and insomnia goals
Penalty
Summary
The facility failed to develop comprehensive care plans for multiple residents with identified needs. For one resident with dementia, type 2 diabetes, and difficulty walking, staff observed the bed positioned with the right side against the wall, and the Minimum Data Set nurse confirmed there was no care plan addressing the bed against the wall, although the Director of Nursing stated licensed nurses were expected to complete such a care plan before placing the bed that way. The facility policy required the interdisciplinary team to develop a comprehensive care plan with measurable objectives and timeframes for each resident's identified needs. For another resident receiving oxygen therapy for acute respiratory failure with hypoxia, the record showed an order for oxygen at 2 LPM as needed via nasal cannula to keep oxygen saturation above 90% for shortness of breath. The Assistant Director of Nursing stated there was no care plan for the oxygen therapy, and that a care plan should identify the goals of treatment and the interventions needed to achieve them, including infection prevention measures such as changing tubing when soiled and keeping tubing above the floor. The facility policy likewise required a comprehensive person-centered care plan with measurable objectives and timeframes. A third resident had repeated medication refusals in June, including refusals of methimazole, vitamins, lubiprostone, propranolol, and trazodone. The MDS nurse stated staff should notify the physician, document the refusal, and create a care plan, but the active care plans did not include a resident-centered plan for medication refusal, and the DON stated there was no care plan or IDT meeting regarding the refusals. Another resident had PRN Zofran ordered for nausea and received it multiple times over several days, but the MDS nurse and DON both stated no care plan had been created for the medication. A separate resident with Parkinson's disease, cellulitis, dysphagia, and a stage 4 sacral pressure ulcer was bedbound and severely cognitively impaired, yet the care plan did not include individualized turning and repositioning interventions every two hours, and staff interviews confirmed there was no physician order or documentation showing that turning and repositioning was included in the plan of care.
Medication Storage, Documentation, and Controlled Substance Accountability Failures
Penalty
Summary
Pharmaceutical services were not provided as required for multiple residents. For one resident with chronic kidney disease and intact cognitive skills for daily decision making, hydrocortisone 1% cream was found at the bedside even though there was no physician order for the medication and no documentation that the resident was authorized to self-administer it. The resident’s self-administration assessment and care plan addressed halobetasol lotion, but not hydrocortisone. The cream was observed in the top bedside drawer and on the exterior top of the drawers, and the DON and ADON stated it should have been secured and that there should have been an order for it. For another resident with hypertension, major depressive disorder, anemia, and moderate cognitive impairment, the eMAR did not accurately reflect administration of PRN ondansetron. The pharmacy dispensed 10 tablets, and only five administrations were documented even though seven tablets had been removed from the bubble pack. During interview, the LVN stated two doses were not documented, including one dose given earlier that day that had not yet been entered into the eMAR. The DON and ADON confirmed the documentation was inaccurate, and the facility policy required medications to be documented directly after administration, including the symptoms, results, and time the effects were noted. For a resident with schizoaffective disorder, the scheduled morning dose of Depakote was not administered because the medication was not available in the medication cart or in the facility at the time of the scheduled dose. The LVN stated the dose was missed because the medication had not been obtained in advance. In addition, eight emergency medication kits containing controlled substances in the medication room did not have accountability logs showing reconciliation at every shift change for June 2026. The RN and DON stated these controlled substances were not reconciled at each shift change as required by facility policy.
Expired Insulin Left in Cart and Eye Drops Stored with Oral Medications
Penalty
Summary
The facility failed to remove and discard two expired open Novolog Flexpens for two residents from Medication Cart Station 2 Middle. During a concurrent observation and interview, one open Novolog Flexpen for Resident 88 was found stored at room temperature with a handwritten label showing it had been opened on 5/30/2026 and expired on 6/27/2026. A second open Novolog Flexpen for Resident 105 was found stored at room temperature with a handwritten label showing it had been opened on 5/28/2026 and expired on 6/27/2026. The LVN present stated the pens were considered expired based on the handwritten dates, but they had not been removed from the cart and were still available for use. The LVN also stated expired medications should be removed from the cart and placed in the expired medication bin so they would not be accidentally used. The DON later acknowledged that several LVNs failed to remove the two expired Novolog Flexpens from the medication cart. The facility also failed to store an eye drop medication separately from oral medications in Medication Cart Station 1 Middle. During observation, dorzolamide eye drop solution was stored in the same bin with coenzyme Q10 oral tablets and sodium chloride oral capsules. The LVN stated oral medications and eye drops should be stored separately in their own sections or bins to prevent wrong route administration and possible contaminations and infections, and the DON stated the facility failed to store the eye drops separately from oral medications.
Missing Physician Order for Double Portions on Renal Diet
Penalty
Summary
The facility failed to ensure there was a physician’s order for double portions for a resident on a renal diet. Resident 60 was admitted with chronic kidney disease, was cognitively intact, and required setup or clean-up assistance with eating. The resident’s physician orders included a renal diet, easy to chew texture, thin liquids, and double portions for all meals excluding liquids, but the diet ticket showed double portions before the physician order was obtained. The resident’s care plan for nutritional problems, initiated earlier in the year, included an intervention for double portions, and the dietary services supervisor added double portions to the resident’s diet ticket because the resident wanted more food. The dietary services supervisor stated he entered double portions onto the diet ticket and did not notify the registered dietitian immediately after making the change. The registered dietitian stated she did not know about the double portions on the diet ticket until later, and that the physician was not notified until 6/30/2026, when an order for renal diet with double portions was obtained. During interviews, the dietary services supervisor stated he was honoring the resident’s wishes when he added double portions, and the registered dietitian stated double portions on a renal diet could double the calories and protein a resident normally receives. The director of nursing stated communication between nursing and dietary was important to ensure the resident had the proper diet. The facility policy stated diet orders prescribed by the physician are to be provided by food and nutrition services, and any discrepancy is to be clarified by the FNS director or designee with nursing.
Delayed Assistance to Restroom Request
Penalty
Summary
A resident with a history of a fracture of the first lumbar vertebra and severe cognitive impairment was frequently incontinent and had previously had an unstageable pressure injury that had resolved. During an observation, two call lights were seen at the station four area, including the resident’s room call light. Staff answered the other room’s call light, and the resident stated she needed help to go to the restroom and had been waiting ten minutes. CNA 1 stated she knew the resident had requested help to go to the restroom but told her she would have to wait until the CNA finished assisting the resident’s roommate with her meal. CNA 1 stated the resident waited ten minutes before being helped and that she did not notify other staff for assistance. Other staff stated they had not heard the call light or been notified. The DON stated a three- to five-minute wait was acceptable and later stated that waiting ten minutes could create a problem with urination, maybe UTI or incontinence. The facility’s call light policy stated staff are to respond to a resident’s request and, if unable to assist, explain to the resident and notify the charge nurse for further instructions.
Missing Advance Directive Documentation in Resident Records
Penalty
Summary
The facility failed to ensure that a copy of the resident's Advance Directive acknowledgment form was maintained in the medical record and readily retrievable for two sampled residents. For Resident 30, the face sheet showed admission with diagnoses including type 2 DM, dysphagia, and repeated falls. The H&P stated the resident did not have the capacity to understand and make decisions, and the MDS indicated the resident usually understood others and was usually understood by others, while also showing dependence on staff for toileting hygiene, lower body dressing, and putting on/taking off footwear. During interview and record review, RN 1 could not locate an Advance Directive acknowledgment form or an advance directive in the resident's electronic or paper record. For Resident 63, the face sheet showed admission with diagnoses including type 2 DM, dysphagia, and dementia. The H&P stated the resident did not have the capacity to understand and make decisions, and the MDS indicated the resident usually understood others and was usually understood by others, with supervision needed for eating, oral hygiene, and upper body dressing. During interview and record review, RN 1 also could not locate an Advance Directive acknowledgment form or an advance directive for this resident. The DON stated that a copy of the resident's AD or the AD acknowledgment form indicating no AD should be maintained in the active chart, and the facility policy stated the AD must be documented in the health record and confirmed in the medical record once a decision is made.
Privacy and Confidentiality Failures
Penalty
Summary
The facility failed to keep personal and medical records confidential when a CNA discarded a resident’s paper diet ticket into a trash can in the dining room instead of securing it for shredding. The resident had severe protein-calorie malnutrition, was severely cognitively impaired, and required setup or clean-up assistance with eating. The diet ticket contained the resident’s dietary order for a no added salt diet with regular texture and thin liquids. During observation, the CNA removed the tray materials and threw the ticket away in a trash can next to the dining room door, where it remained visible until the surveyor observed it. The ADON later removed the ticket from the trash can and stated it should not have been discarded there because it contained personal information and should have been shredded. The facility also failed to provide privacy during wound care for another resident who was bedbound, had a sacral pressure ulcer, and lacked capacity to understand and make decisions. The resident’s H&P and MDS indicated severely impaired cognition and dependence on staff for ADLs. During a concurrent observation, two treatment nurses prepared to perform a sacral pressure ulcer dressing change in the resident’s room, but one window curtain could not be fully closed because of broken plastic hanging hooks, and the resident’s bed privacy curtain was not drawn. The nurses stated the window curtain needed repair or replacement to ensure it could be fully drawn and that leaving the curtains open or not fully drawn did not provide privacy from passers-by. The facility policy titled Dignity and Privacy required staff to provide care with respect and dignity, maintain privacy during exams and treatment, and draw curtains closed to shield residents from passers-by. The policy titled Minimum Necessary Principle for Use and Disclosure of PHI stated that PHI must be protected in accordance with HIPAA. The observations and interviews showed that the resident’s diet ticket was discarded in a public trash can and that wound care was performed without fully closing the curtains to protect the resident’s privacy.
Failure to Obtain Order, Consent, and Entrapment Assessment Before Using Bed Against Wall
Penalty
Summary
The facility failed to ensure Resident 108 was free from the use of a physical restraint when the resident’s bed was placed against the wall. Resident 108 was admitted and later readmitted with diagnoses including dementia, type 2 diabetes, and difficulty walking. The resident’s H&P dated 6/11/2026 stated the resident had the capacity to understand and make decisions, and the MDS dated 6/8/2026 indicated the resident usually understood others and was usually understood by others and did not have a restraint and/or alarm. During observation on 6/29/2026, Resident 108 was asleep in bed and the LVN stated the right side of the bed was against the wall. During record review and interview on 6/30/2026, the MDSN stated there was no order, consent, or assessment for risk of entrapment for the use of the restraint. The MDSN stated these should have been completed prior to using the restraint. The DON later stated licensed nurses are expected to obtain an order, consent, and complete an assessment for risk of entrapment prior to the use of restraints. The facility policy identified a bed against the wall as a physical restraint and stated that an order, informed consent, and entrapment assessment were required before use.
Failure to Turn and Reposition a Bedbound Resident With a Stage 4 Sacral Pressure Ulcer
Penalty
Summary
The facility failed to ensure that Resident 48 was turned and repositioned in accordance with professional standards of care. Resident 48 was admitted and readmitted with diagnoses including Parkinson’s disease, cellulitis of the abdominal wall, and dysphagia. The resident was bedbound, had severely impaired cognition, dependence in ADLs, and a sacral pressure ulcer. The resident’s MDS indicated pressure injuries over a bony prominence, including four Stage 1 pressure injuries and one Stage 4 pressure ulcer present since admission, and the Braden Scale score was 7, indicating severe risk. The physician orders did not include an order for turning and repositioning, and the care plan revisions did not include individualized turning and repositioning interventions. A weekly skin review noted a history of pressure ulcers, immobility, and incontinence, and listed interventions to encourage and assist with turning and repositioning every two hours and as needed, as tolerated. However, the Turned and Repositioned Intervention/Task record for 06/2026 indicated the resident was turned once each shift rather than every two hours, and the ADON stated there was no documentation showing the resident was turned every two hours or as needed. During interviews, the resident’s representative stated it did not seem staff were turning Resident 48 every two hours to promote healing of the sacral pressure ulcer. The treatment nurse stated the sacral wound was healing slowly and that the resident should be turned every two hours. On observation, the sacral wound showed full-thickness skin and tissue loss with exposed muscle and undermining. CNAs stated bedbound residents are repositioned every two hours and that repositioning is charted in the eHR, but they were unable to demonstrate how to document the time the resident was turned. The DSD stated the standard of practice for turning and repositioning is every two hours, especially for residents with pressure ulcers, and that this intervention should be included in the resident’s interventions and tasks.
Unordered topical medication left at bedside
Penalty
Summary
The facility failed to ensure that a resident’s medication was not left unattended at the bedside when there was no physician’s order for the medication that specified the frequency of administration. Resident 60 was admitted and later re-admitted with chronic kidney disease and was cognitively intact, with setup or clean-up assistance needed for eating. The resident’s physician’s orders included Halobetasol Propionate External Cream 0.05% to be applied topically every eight hours as needed for itching, but there was no physician’s order for hydrocortisone 1% cream. The care plan for self-administration stated the resident may self-administer Halobetasol Propionate Lotion and may keep it on the bedside table, but it did not indicate that hydrocortisone could be administered by the resident. During interview, the resident stated he asked for his Halobetasol cream for itching on his arms and abdomen and said staff often forgot to bring it or said they had to get it from the treatment cart and then did not bring it. During observation, the treatment nurse searched both treatment carts before finding the resident’s Halobetasol cream. Later, the DON and ADON observed hydrocortisone 1% cream inside the resident’s top bedside drawer and on the exterior top of the drawers. The resident stated he bought the hydrocortisone cream from an online store because no one was bringing him his Halobetasol cream. The DON and ADON stated the hydrocortisone should be secured and that they did not know it was at bedside, and the ADON stated it was important to have a physician’s order for all of the resident’s medications to ensure a frequency and avoid excessive dosing.
Failure to Monitor Levofloxacin Black Box Warning
Penalty
Summary
The facility failed to ensure that a resident receiving Levofloxacin for a urinary tract infection was monitored for serious adverse reactions associated with the medication’s FDA black box warning. Resident 14 was admitted and later readmitted with diagnoses including abnormal posture and UTI. The resident’s MDS indicated the resident could make self understood and sometimes understand others, but was totally dependent on staff for eating, oral hygiene, toileting hygiene, upper and lower body dressing, footwear, and personal hygiene. During a concurrent interview and record review, the ADON reviewed the physician’s order for Levofloxacin 250 mg by mouth once daily for six days for UTI. The ADON stated that residents on antibiotic therapy, including Levofloxacin, must have the FDA black box warning documented in the care plan, including the serious adverse reactions that require monitoring. The ADON stated that a care plan for a medication with a black box warning would inform staff of the potential adverse reactions and required interventions, and that without ongoing monitoring for the serious adverse reactions associated with Levofloxacin, the resident was placed at risk for harm. The medication package insert reviewed by the facility indicated a black box warning for disabling and potentially irreversible adverse reactions, including tendinopathy and tendon rupture, peripheral neuropathy, and CNS effects.
Failure to Follow Ordered Oxygen Therapy for Two Residents
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents by not ensuring oxygen was administered as ordered by the physician. Resident 104 was admitted with acute respiratory failure with hypoxia, hypertension, and encephalopathy, and the H&P stated the resident did not have the capacity to understand and make decisions. The MDS indicated moderate cognitive impairment and that the resident was receiving continuous oxygen therapy. The physician’s order required continuous oxygen at 2 L/min via nasal cannula to keep oxygen saturation above 92% every shift, and the care plan directed staff to provide oxygen per physician orders and set oxygen at 2 L/min continuously. During observation, Resident 104 was found in bed without oxygen in place. The oxygen concentrator was off, the tubing was wrapped around the concentrator, and it was positioned away from the resident. The LVN stated the resident was not receiving oxygen at that time and should have been receiving oxygen continuously at 2 L/min per the physician order. The DON later reviewed the order and stated the physician order was not followed. Resident 56 had diagnoses including COPD and acute respiratory failure with hypoxia. The MDS indicated the resident was cognitively intact and received oxygen therapy. The physician’s order required oxygen at 2 L/min via nasal cannula as needed for respiratory failure with hypoxia and COPD management, and the care plan directed staff to provide oxygen therapy as ordered or needed. During observation, Resident 56 was wearing a nasal cannula connected to an oxygen concentrator set at 3 L/min. RN 2 reviewed the order and stated licensed nurses should have followed it, and the DON stated Resident 56 should have been on oxygen at 2 L/min.
Failure to Assess Dialysis Access Site After Hemodialysis
Penalty
Summary
The facility failed to assess Resident 8’s dialysis access site after hemodialysis for signs and symptoms of infection. Resident 8 was admitted with diagnoses including end stage renal disease and dependence on renal dialysis, and the resident’s MDS indicated severely impaired cognitive skills for daily decision making and substantial to maximal assistance needs for several activities of daily living. A physician order directed hemodialysis every Tuesday, Thursday, and Saturday through a left upper chest permacath. During interview and record review, the Nursing Facility Post-Dialysis Assessment dated 6/23/2026 showed no documentation that the access site was assessed after dialysis. The ADON stated that after a resident returns from dialysis, nurses should check the access site for bleeding, swelling, redness, and signs and symptoms of infection, and stated that failure to assess timely could delay care and result in serious complications such as bleeding. The facility policy titled Dialysis Pre and Post-Care stated that dialysis access should be assessed upon return to the facility for patency, unusual redness, swelling, or bleeding, and that problems with the access should be addressed immediately.
Infection Control Lapses With Resident Equipment
Penalty
Summary
Provide and implement an infection prevention and control program was not fully implemented when two residents were observed with equipment that was not handled in accordance with infection control practices. Resident 74, who had diagnoses including anemia and anxiety disorder and was assessed as cognitively intact, was observed in bed with a urinal hanging by the side of the bed. The Infection Prevention Nurse stated the plastic urinal had no name label or identifier and that urinals must be labeled to identify the resident and prevent another resident from accidentally using the same urinal bottle. Resident 56, who had diagnoses including COPD and acute respiratory failure with hypoxia and was receiving oxygen therapy, was observed in bed wearing a nasal cannula connected to an oxygen concentrator with the tubing touching the floor. A concurrent observation confirmed the tubing was touching the floor, and RN 2 stated it should not be touching the floor and could place residents at risk for infection. The DON also stated the oxygen tubing should not touch the floor for infection control reasons. The facility policy stated it would provide areas, equipment, and supplies to implement its infection control program with the goal of safe use of disposable and single-use supplies and equipment.
Failure to Provide Physician Choice Form
Penalty
Summary
The facility failed to ensure that one of three sampled residents had the opportunity to choose his or her attending physician. Resident 1 was admitted with diagnoses including cerebral infarction, dementia, dysphagia, type 2 DM, and bipolar disorder. The H&P dated 3/2/2026 indicated Resident 1 did not have the capacity to understand and make decisions, and the MDS dated 5/28/2026 indicated Resident 1’s cognition was severely impaired and that the resident required extensive assistance with eating, oral hygiene, toileting hygiene, dressing, showering, and personal hygiene. During interview, the ADON confirmed that RP 1 emailed the facility administrator requesting that Resident 1’s primary care physician continue as the resident’s physician while residing at the facility. The ADON stated RP 1 was not provided the facility’s Resident’s Right to Choose a Physician form. The ADON also confirmed that residents have the right to choose their physician and stated that RP 1 should have been provided the form, with social work and nursing staff assisting in contacting the requested physician to determine whether the physician would continue providing care to Resident 1 while admitted to the facility. The facility policy titled Resident Rights stated that residents have the right to choose a personal attending physician and be informed how to contact him or her.
Failure to Report Ongoing Low Fluid Intake
Penalty
Summary
The facility failed to notify the physician when Resident 1’s fluid intake remained below the Registered Dietitian’s estimated fluid needs during ongoing intake and output monitoring. Resident 1 was admitted with diagnoses including MI, dysphagia, acute kidney failure, and stage 4 chronic kidney failure, and the MDS indicated moderately impaired cognition with assistance needed for dressing, oral care, personal hygiene, bed mobility, transfers, and supervision or touching assistance with eating. The RD nutrition assessment estimated daily fluid needs at 1,425 ml based on 57 kg and 1,710 ml based on body weight, while weekly I&O reviews showed average 24-hour intake amounts of 975 ml, 1,100 ml, 1,021 ml, 992 ml, and 980 ml over the monitoring period. During interview and record review, the ADON reviewed the I&O records and the RD assessment and stated the facility staff did not notify the physician that Resident 1’s fluid intake had remained below the estimated fluid requirements for approximately one month while I&O monitoring was being conducted. The facility’s policy on change in condition stated that changes in weight and/or intake and signs and symptoms of dehydration or decreased fluid intake should be brought to the licensed nurse or nurse supervisor’s attention, and the I&O policy stated that deficiencies in fluid intake or fluid balance would be reported to the physician by the licensed nurse and recorded in the medical record.
Failure to Include Food Dislikes in Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans to address the food preference and dislike of fish for two residents. The record review showed that both residents had intact cognition and required varying levels of assistance with activities of daily living, including eating and oral hygiene. Their diet slips dated 5/5/2026 listed fish as a food dislike for both lunch and dinner meals. Resident 2’s chart showed diagnoses including DM, anemia, ESRD, and dependence on renal dialysis. During interview, Resident 2 stated that fish was not liked, but kitchen staff continued to periodically serve fish as the main entree, and Resident 2 reported having told kitchen staff multiple times not to serve fish as a main meal item. Resident 3’s chart showed diagnoses including DM, unspecified protein-calorie malnutrition, and major depressive disorder. Resident 3 stated that fish had been identified as a dislike at admission, that family completed dietary preference forms requesting fish not be served, and that fish had continued to be served recently, including the previous week. During concurrent interview and record review, the Dietary Supervisor stated there were no care plans addressing either resident’s dislike of fish and identified the RD as responsible for developing and implementing nutritional care plans related to food preferences and dislikes. The ADON also reviewed the nutritional care plans and stated there were no individualized, person-centered care plans addressing either resident’s dislike of fish, adding that the RD should include food preferences and dislikes in the care plan so nursing staff would have that information. The facility policy required the interdisciplinary team to develop a comprehensive person-centered care plan for each resident with measurable objectives and timeframes to meet identified medical, nursing, mental, and psychosocial needs.
Failure to Honor Documented Food Dislikes
Penalty
Summary
The facility failed to honor documented food preferences for two residents by continuing to serve fish despite both residents having fish listed as a food dislike on their diet slips. Resident 2 was admitted with diagnoses including DM, anemia, ESRD, and dependence on renal dialysis, and had intact cognition on the MDS. Resident 3 was admitted with diagnoses including DM, unspecified protein-calorie malnutrition, and major depressive disorder, and also had intact cognition on the MDS. Resident 2 stated that fish was periodically served as the main entree even though the resident did not like fish and had told kitchen staff on multiple occasions not to serve it. Resident 3 stated that kitchen staff continued to serve fish despite being informed at admission that the resident did not like fish, and the resident's family had completed dietary preference forms requesting that fish not be served. Resident 3 also stated fish had continued to be served recently, including the previous week. During interview and record review, Dietary Aide 1 reviewed the diet slips for both residents and confirmed that fish was listed as a food dislike for lunch and dinner. Dietary Aide 1 stated fish was the lunch entree on a day when the aide was working and said fish should not have been served to either resident. The Dietary Supervisor reviewed the care plans for both residents and stated there were no care plans addressing either resident's dislike of fish, and that the RD was responsible for developing and implementing care plans related to nutritional concerns, including residents' food preferences and dislikes.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Maintain Proper Nail Care and Personal Hygiene for Dependent Residents
Penalty
Summary
The facility failed to provide adequate grooming and personal hygiene care by not ensuring that two dependent residents had their fingernails properly trimmed. One resident, readmitted with diagnoses including metabolic encephalopathy, Alzheimer's disease, blindness in the right eye, history of TIA, and cerebral infarction without residual deficits, was documented on the MDS as having severely impaired cognition and being dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. During an observation in this resident's room, the resident's fingernails were noted to be long and untrimmed. In a concurrent observation and interview, an LVN confirmed that the resident's fingernails were long, extended past the fingertips, and that the undersides of the nails were brown and dirty, and stated she would ask the resident's CNA to trim the nails. Another resident, readmitted with diagnoses including Parkinson's disease without dyskinesia, functional quadriplegia, and lack of coordination, was also documented on the MDS as having severely impaired cognition and being dependent on staff for eating, oral hygiene, toileting hygiene, and personal hygiene. During an observation in this resident's room, the resident's fingernails were observed to be long and untrimmed. In a concurrent observation and interview, the ADON described the resident's fingernails as dry, long, and uneven with sharp edges, and stated that nail care should be provided once a week and that fingernails should be kept short to prevent injury such as residents scratching themselves. Review of the facility's Nail Care policy, last reviewed on 1/15/2026, indicated it is the facility's policy to promote cleanliness, safety, and a neat appearance of residents, which was not followed in these instances.
Failure to Measure and Document Skin Redness per Wound Monitoring Policy
Penalty
Summary
The deficiency involves the facility’s failure to follow its Skin and Wound Monitoring and Management policy by not measuring a documented skin change for a resident. The resident was readmitted with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, right eye blindness, history of TIA, and cerebral infarction without residual deficits, and had an MDS indicating severely impaired cognition and dependence on staff for oral, toileting, personal hygiene, and movement. On the morning of 2/5/2026, a CNA reported redness on the resident’s right lateral abdomen to the treatment nurse, and a Change in Condition (COC) form was completed documenting this skin issue. Later that same day, a physician’s order was obtained to apply triple antibiotic ointment daily to the right lateral abdomen for irritation/scratch. During interview and record review, the treatment nurse acknowledged being notified of the skin-related COC on 2/5/2026 and stated that treatment nurses are responsible for assessing the area, measuring it, notifying the physician, and informing the resident or responsible party. However, the treatment nurse admitted not measuring the redness at that time, explaining they did not think it was necessary and did not believe the condition was serious. A subsequent COC dated 2/8/2026 documented that the irritation had increased in size, but the treatment nurse could not explain how this was determined without measurements. The Assistant DON confirmed there were no measurements documented for the 2/5/2026 skin COC and stated the treatment nurse should have measured the affected area, noting that the facility’s policy requires licensed nurses to assess and evaluate each pressure and non-pressure injury, including measuring the skin injury and describing its nature, location, and characteristics.
Failure to Enforce Fingernail Length Standards for Direct Care Staff
Penalty
Summary
The facility failed to implement its infection prevention and control program and employee handbook requirements regarding fingernail length for direct care staff. During an observation with the Assistant Director of Nursing (ADON), a certified nursing assistant (CNA) was noted to have long, uneven fingernails that extended past the fingertips. The ADON stated that staff who provide direct resident care should keep their fingernails short and trimmed for infection control and resident safety. In a separate observation and interview, a licensed vocational nurse (LVN) who provided direct resident care acknowledged that her fingernails were long and extended past her fingertips. The LVN stated she was aware that staff fingernails were required to be kept short for infection control purposes but explained that she had just had her nails done. In an interview, the Infection Preventionist (IP) confirmed that nursing staff who provide direct resident care should not have long fingernails and that fingernails should not extend past the fingertips, stating that short, trimmed fingernails help decrease the risk of infection and promote resident safety by protecting skin integrity. Review of the facility’s Infection Control policy indicated the infection prevention and control program is a facility-wide effort addressing detection, prevention, and control of infections among residents and personnel. Review of the Skilled Nursing Facility Employee Handbook showed that, for safety and infection control, dietary employees and those providing direct resident care must keep fingernails clean and trimmed, and that fingernails must not extend beyond the end of each finger.
Failure to Timely Report Alleged Staff-to-Resident Abuse
Penalty
Summary
The facility failed to follow its policy and procedures for reporting a reasonable suspicion of a crime, specifically regarding the immediate reporting of an allegation of staff-to-resident physical and verbal abuse. A resident with mildly impaired cognition and significant care needs reported to a third-party Clinical Evaluator that he was held down by five staff members and subjected to verbal aggression. The Assistant Director of Nursing (ADON) was informed of the allegation and notified the Director of Nursing (DON) and the Administrator (ADM) within minutes. However, the ADM stated that the incident had already been investigated and did not ensure that the allegation was immediately reported to the State Agency and local law enforcement as required by both facility policy and state regulations. Record review and interviews confirmed that the facility's policy required immediate reporting of any alleged or suspected abuse, neglect, or exploitation. Despite this, the ADM relied on a prior investigation and did not report the new allegation in a timely manner. This failure to report could have delayed necessary protective actions for residents, as the required notifications to authorities were not made within the mandated timeframe.
Failure to Develop and Implement Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered care plans that addressed the specific needs of three residents. For one resident with a urinary tract infection and a history of falls, the care plan did not include interventions or monitoring related to the prescribed antibiotic therapy, despite physician orders for cephalexin. The Assistant Director of Nursing confirmed that a care plan for antibiotic therapy should have been initiated to monitor for complications such as nausea, vomiting, diarrhea, and dehydration, but this was not done. Another resident, admitted with acute respiratory failure, congestive heart failure, and pneumonia, had a care plan for oxygen therapy that did not match the physician's orders. The care plan incorrectly indicated the use of humidified oxygen, while the physician's order specified continuous oxygen at two liters per minute without humidification. The Director of Nursing acknowledged that the care plan was inaccurate and should have reflected the physician's order to ensure proper care. A third resident, who spoke Armenian and had moderate cognitive impairment, did not have a communication care plan created upon admission, despite the need for an interpreter being identified in the assessment. The care plan addressing the language barrier was only created after a delay, and both the MDS Nurse Consultant and the Director of Nursing confirmed that the communication care plan should have been established earlier to facilitate effective communication and care.
Failure to Reconcile Controlled Medications in Emergency Kits
Penalty
Summary
The facility failed to reconcile eight medication emergency kits (eKITs) containing controlled medications (CMs) in one medication room for the month of April 2025. During an observation, four eKITs stored in a cabinet and four eKITs stored in a refrigerator, all containing CMs, were found without accountability logs documenting reconciliation of CM inventory at every shift change. Both a registered nurse and the Director of Nursing confirmed that these eKITs were not reconciled at each shift change as required, and acknowledged the importance of this process for accountability and prevention of CM diversion or accidental exposure. A review of the facility's policies and procedures indicated that all controlled substances, including those in emergency kits and under refrigeration, must be reconciled by two licensed nurses and documented at each shift change. The lack of reconciliation and documentation for these eight eKITs did not comply with the facility's own policies or with federal and state regulations regarding the handling, storage, and recordkeeping of controlled medications.
Failure to Apply Heel Protectors as Ordered for Pressure Injury Prevention
Penalty
Summary
A deficiency was identified when staff failed to follow a physician's order for a resident who was at risk for developing pressure injuries. The resident, who had diagnoses including palliative care, polyneuropathy, and heart failure, required maximal assistance with hygiene and was dependent on staff for toileting and bathing. The resident's care plan included a physician's order for bilateral heel protectors to be applied while in bed as a preventative measure for skin maintenance. During an observation, it was noted that the resident's heels were in direct contact with the mattress and heel protectors were not in place, contrary to the physician's order. A CNA confirmed that the resident should have been wearing heel protectors to prevent skin breakdown. The DON also acknowledged that staff did not follow the physician's order and emphasized the necessity of such interventions for residents with limited mobility. The facility's policy required the use of pressure-relieving devices to prevent pressure injuries, which was not adhered to in this instance.
Failure to Lock Bed Brakes After ADL Care
Penalty
Summary
A deficiency was identified when staff failed to ensure that a resident's bed brake lock was engaged, resulting in the bed being left unlocked. The resident in question had been admitted and readmitted with diagnoses including failure to thrive, and was assessed as severely cognitively impaired, requiring staff assistance for activities of daily living such as showering, toileting, dressing, and personal hygiene. The resident's care plan indicated a need for assistance with ADLs due to poor balance and gait instability, and the resident was determined to be at medium risk for falls. During an observation, it was noted that the brake at the foot of the resident's bed was not locked, and this was confirmed and corrected by the maintenance resource at the time. Interviews and policy reviews revealed that facility policy requires all staff to ensure that resident beds are locked and in a safe position after providing ADL care, and that beds should be returned to the lowest position with wheels locked unless otherwise indicated in the care plan. The Director of Nursing confirmed that bed brakes should be locked to prevent movement. The failure to follow these procedures resulted in the resident being placed at risk for injury due to the unsecured bed.
Failure to Maintain Proper Catheter Tubing Position
Penalty
Summary
A resident with a history of palliative care, dementia, and previous urinary tract infection (UTI)/sepsis was observed to have an indwelling catheter with a large loop and two coils in the tubing, one of which was nearly kinked. The resident was dependent on staff for hygiene, dressing, toileting, and bathing, and had a physician order for an indwelling catheter. During observation, the catheter bag was hanging on the bedframe, and the tubing was not maintained in a straight position as required. Staff interviews confirmed that the catheter tubing should not be looped or coiled, as this could cause backflow of urine. The Treatment Nurse acknowledged that the observed condition of the tubing was inappropriate and could lead to complications. The Director of Nursing also stated that the tubing must remain straight to ensure proper drainage and prevent infection, especially given the resident's history of UTIs. Facility policy required that catheter and drainage tubing be free of loops and kinks to achieve a free flow of urine.
Failure to Administer IV Antibiotic at Prescribed Rate
Penalty
Summary
A deficiency occurred when a registered nurse failed to administer an intravenous (IV) antibiotic, Vancomycin, at the rate ordered by the physician for a resident. The physician's order specified that 270 ml of Vancomycin should be infused over 2 hours at a rate of 135 ml/hr. However, during observation, the nurse set the manual flow regulator to 200 ml/hr, resulting in the medication being administered more rapidly than prescribed. The nurse acknowledged not following the physician's order and stated that IV medication rates must always be double-checked to ensure accuracy. The resident involved had multiple diagnoses, including dysphagia, heart failure, unspecified dementia, and dependence on supplemental oxygen, and was dependent on staff for all activities of daily living. The facility's policy required that IV medications and fluids be administered as prescribed and that the label be verified against the prescriber's order. The Director of Nursing confirmed that administering the medication at a faster rate than ordered constituted a medication error.
Failure to Ensure Post-Dialysis Assessment and Communication
Penalty
Summary
The facility failed to ensure appropriate post-dialysis care and communication for a resident with end stage renal disease who required hemodialysis. Specifically, there was no follow-up with the dialysis center when post-dialysis weights were missing or when the resident's weight remained the same or increased after dialysis sessions, as documented on several occasions. The facility's care plan required obtaining vital signs and weights per protocol, and the facility's policy indicated ongoing communication and documentation with the dialysis center. However, there was no evidence that the facility contacted the dialysis center to clarify missing or abnormal weight documentation. Interviews with facility staff, including a registered nurse and the DON, confirmed that licensed nurses should have communicated with the dialysis center regarding missing or abnormal post-dialysis weights, but no such documentation or communication was provided. The DON acknowledged that the facility is responsible for monitoring and verifying dialysis information, even if it is documented by the dialysis center, and that failure to do so could result in unidentified complications for the resident.
IV Antibiotic Administered at Incorrect Rate
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including heart failure, dementia, and dependence on supplemental oxygen, was administered an intravenous antibiotic (Vancomycin) at a rate faster than prescribed by the physician. The physician's order and the IV medication label specified that the Vancomycin should be infused at 135 ml/hr over two hours. However, during an observation, it was found that the registered nurse manually set the flow regulator to 200 ml/hr, contrary to the prescribed rate. The nurse acknowledged the error during an interview, stating that the medication should have been administered at the ordered rate to prevent potential side effects. The Director of Nursing confirmed that licensed nurses are required to follow physician orders regarding medication administration, including the rate. Facility policy also requires that medications be administered as prescribed and that the label be verified against the order. The error was identified during a random observation and confirmed through interviews and record review.
Failure to Label and Store Multi-Dose Aplisol Vial per Policy
Penalty
Summary
Surveyors observed that an open vial of Aplisol, a medication used for tuberculosis testing, was stored in the medication room refrigerator without a label indicating the date it was opened. Both the registered nurse and the director of nursing confirmed during interviews that the vial was not labeled with the date of first use, which is required to track the 30-day usage period as per the manufacturer's instructions and facility policy. The staff acknowledged that without this labeling, it is not possible to determine if the medication is still within its effective and safe usage period. A review of the facility's policy and procedures confirmed that multi-dose vials must be labeled with the date opened and the corresponding expiration date, in accordance with manufacturer recommendations and pharmacy guidance. The policy also specifies that such vials should be discarded after 28 or 30 days, depending on the guidelines referenced. The failure to label the Aplisol vial as required led to the medication being considered expired and necessitated its removal from use.
Oxygen Tubing Found on Floor During Resident Care
Penalty
Summary
A deficiency was identified when a resident's nasal cannula oxygen tubing was observed lying on the floor while the resident was in bed. The Assistant Director of Nursing (ADON), present during the observation, confirmed that the tubing was contaminated and needed immediate replacement. The facility's policy on oxygen therapy requires safe administration, and the infection prevention and control program includes surveillance of staff practices related to resident care and infection control. The resident involved had a history of dysphagia and anemia, was cognitively intact, and required varying levels of assistance with daily activities. Physician orders indicated the resident was to receive oxygen via nasal cannula as needed to maintain oxygen saturation above 90%. Facility policy and CDC guidelines reviewed indicated that floors can become rapidly contaminated, increasing the risk of infection when medical equipment comes into contact with them.
Failure to Timely Complete Infection Surveillance for Antibiotic Use
Penalty
Summary
The facility failed to implement its antibiotic stewardship program by not conducting timely infection surveillance and not completing the required infection control reporting form after a resident was prescribed an antibiotic. Specifically, a resident with a history of osteomyelitis in the sacral and sacrococcygeal region, who was severely cognitively impaired and dependent on staff for daily activities, was admitted and later readmitted to the facility. Upon readmission, the resident was prescribed intravenous Vancomycin for an infection, and the care plan included administration of the antibiotic as ordered by the physician. According to the facility's policy, an infection surveillance form should be created within 48 to 72 hours of starting an antibiotic, using McGeer's criteria to determine if the resident meets the definition of a true infection. However, the infection surveillance form for this resident was not completed until 12 days after the antibiotic was started. The Infection Control Nurse confirmed that the resident met the criteria for infection, but the delay in completing the surveillance form meant that the physician was not promptly informed if the criteria were not met, as required by the facility's antibiotic stewardship policy.
Failure to Meet Minimum Room Size Requirements for Multiple-Resident Rooms
Penalty
Summary
The facility failed to meet the required room size of 80 square feet per resident for six out of sixty multiple-resident rooms, specifically rooms 108, 109, 208, 209, 215, and 216. Measurements showed that these rooms ranged from 73.2 to 79.2 square feet per resident, which is below the federal requirement for two-bed rooms. The deficiency was identified through observation, interviews, and record review, including a review of a waiver request letter submitted by the Administrator acknowledging the shortfall in room size. During the survey, it was observed that residents in these rooms had sufficient space to move freely, and there were no concerns raised by residents regarding room size during the Resident Council meeting. The rooms were equipped with beds, side tables, and care equipment, and the space was deemed adequate for resident care and services by staff.
Delayed Physician Documentation of H&P
Penalty
Summary
The facility failed to ensure that the attending physician documented the History and Physical (H&P) for residents in a timely manner according to the facility's policy. This deficiency was identified for three residents, each of whom had their H&P completed beyond the 72-hour window required by the facility's policy. Resident 2 was admitted with conditions including a fracture of the right femur and pneumonitis, but their H&P was documented five days after admission. Similarly, Resident 4, admitted with acute respiratory failure and COPD, also had their H&P completed five days post-admission. Resident 5, who was admitted with chronic kidney disease and syncope, had their H&P documented six days after admission. The Assistant Director of Nursing (ADON) confirmed during interviews and record reviews that the H&Ps for these residents were not completed within the required timeframe. The facility's policy mandates that the attending physician provide a current H&P within 72 hours of admission to ensure proper care coordination and timely creation of the residents' care plans. The delay in documentation had the potential to lead to inconsistent care coordination due to incomplete records for the affected residents.
Failure to Document Resident's Lost Jewelry
Penalty
Summary
The facility failed to implement its theft and loss policy by not documenting a resident's lost jewelry on the facility's theft and loss report form. This deficiency involved a resident who was admitted with diagnoses of major depressive disorder and essential hypertension. The resident, who had intact cognition according to the Minimum Data Set, reported missing seven pieces of jewelry in May 2024 to the Social Services Assistant (SSA). However, the SSA did not document this report on the Theft and Loss Log or the Theft and Loss Report form, as required by the facility's policy. The SSA acknowledged during interviews that she did not inform the Administrator of the missing items and failed to document the incident because a psychologist had mentioned that the resident was forgetful. The facility's policy mandates that any loss or theft of property worth more than $25 should be documented and reported to the Administrator for investigation. The Administrator confirmed that the SSA should have documented the missing jewelry to allow for proper follow-up. The facility's policy also requires that thefts of property valued over $100 be reported to local law enforcement within 24 hours.
Incomplete and Inaccurate Discharge Summary
Penalty
Summary
The facility failed to ensure the Discharge Summary for a resident was accurate and complete, which could lead to confusion about the resident's discharge status and delay in post-discharge services. The resident was admitted with diagnoses including a fracture of the right femur, presence of a right artificial hip joint, and pneumonitis. The resident had intact cognition and expressed a strong desire to be discharged home. Despite the resident's insistence on leaving, the Discharge Summary inaccurately stated that the discharge was due to health improvement, omitting the resident's request as the reason. Additionally, the Discharge Summary and Post-Discharge Plan of Care lacked essential contact information for the Home Health agency responsible for the resident's post-discharge care. This omission was identified during a review with the Assistant Director of Nursing, who acknowledged the inaccuracies and the missing information. The facility's policy requires maintaining complete and accurately documented clinical records, which was not adhered to in this case.
Failure to Administer Pain Medication as Ordered
Penalty
Summary
The facility failed to administer pain medication as per the physician's orders for a resident, leading to a potential risk of overmedication. Resident 2, who was admitted with a fracture of the right femur, presence of a right artificial hip joint, and pneumonitis, had intact cognition according to the Minimum Data Set. The physician's orders specified that for mild pain (1-3/10), the resident should receive one tablet of acetaminophen 500 mg, and for moderate pain (4-6/10), two tablets of acetaminophen 325 mg should be administered. However, on a specific date, Resident 2 reported a pain level of three, which falls under the mild pain category. Despite this, the resident was given two tablets of acetaminophen 325 mg, which is intended for moderate pain levels. This discrepancy was confirmed during an interview with the Assistant Director of Nursing, who acknowledged that the resident received more medication than prescribed. The facility's policies on pain management and medication administration emphasize adherence to physician orders, which was not followed in this instance.
Failure to Administer Prescribed Antibiotic Timely
Penalty
Summary
The facility failed to ensure timely administration of a prescribed antibiotic, amoxicillin-pot clavulanate, for a resident admitted with conditions including a fracture of the right femur, presence of a right artificial hip joint, and pneumonitis. The physician's order required the antibiotic to be administered every 12 hours for aspiration pneumonia, starting on the day of admission. However, the resident did not receive the scheduled dose on the evening of admission because the facility was waiting for the medication delivery, despite the antibiotic being available in the facility's emergency medication kit. The Assistant Director of Nursing (ADON) confirmed that the medication was delivered within the administration time frame, but the Licensed Vocational Nurse (LVN) on duty did not administer it. The LVN admitted to not checking the emergency kit for the medication and was unaware of its delivery. The facility's policy requires medications to be administered as per physician's orders, but this was not adhered to, resulting in a delay in the resident receiving the necessary antibiotic treatment.
Failure to Administer Probiotic as Prescribed
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with the physician's order by not continuing the resident's daily probiotic as prescribed. The resident, who was admitted with diagnoses including Parkinson's disease, bipolar disorder, and post-surgical aftercare, had a physician's order for a daily probiotic. However, the order was incorrectly transcribed by a Licensed Vocational Nurse (LVN), who placed the order for 30 days instead of daily, leading to the resident not receiving the probiotic as intended. The resident's Medication Administration Record (MAR) indicated that the probiotic was administered for 30 days, with the last dose given on December 15, 2024. This discrepancy was discovered during an interview with the LVN, who acknowledged the error in transcription. The LVN had received the order from an outside physician and confirmed it with the resident's primary care physician, but failed to ensure the order was correctly entered for daily administration. The Director of Nursing (DON) confirmed the error upon review of the resident's physician orders and acknowledged that the correct process was not followed. The facility's policy requires that all orders be specific and complete, and that licensed nurses are responsible for accurate transcription. The failure to adhere to these procedures resulted in the resident not receiving the prescribed probiotic, which had the potential to affect the resident's health.
Failure to Provide Timely Access to Resident's Clinical Records
Penalty
Summary
The facility failed to provide a resident's representative with copies of the resident's clinical records upon written request, violating the resident's rights. The resident, who was admitted with Parkinson's disease and bipolar disorder, had moderately impaired cognitive skills and required assistance with daily activities. The resident's representative submitted an Authorization for Release of Information (AFROI) form, requesting clinical records, including medication administration records and blood pressure readings. Despite the request, the facility did not provide the requested documents until nearly a month later. The Medical Records Director (MRD) was on vacation when the request was submitted and misunderstood the representative's needs, believing that clarification provided over the phone was sufficient. The facility's policy required that such requests be fulfilled within 48 hours, excluding weekends and holidays, but this was not adhered to. The Administrator confirmed that the facility's policy was not followed, resulting in the delay of providing the requested clinical records to the resident's representative.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, which is a device used by residents to signal their need for assistance from staff. This deficiency was identified for one of the three sampled residents, who was admitted with diagnoses including dementia and cerebral infarction. The resident's Minimum Data Set (MDS) indicated severe cognitive impairment and dependency on staff for various activities of daily living. The care plan for the resident included an intervention to encourage the use of the call light for assistance. During an observation, the resident was found in bed with the call light placed on the floor, out of reach, which the resident confirmed was needed for emergencies. The Director of Staff Development acknowledged that the resident could not use the call light in an emergency due to its placement. The Director of Nursing stated that call lights should always be within reach to ensure residents can use them when needed. The facility's policy requires that call lights be placed within reach before staff leave the room.
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What surveyors actually found near you
We read the 3,563 citations issued within 25 miles in the last 12 months — including the 16 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Chatsworth
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Stoney Point Healthcare Center | 0.5 mi | ★★★★★ | 33 | 0 |
| Topanga Terrace | 3.1 mi | ★★★★★ | 17 | 0 |
| Holiday Manor Care Center | 3.2 mi | ★★★★★ | 21 | 0 |
| West Hills Health And Rehabilitation Center | 3.4 mi | ★★★★★ | 13 | 0 |
| Canyon Oaks Nursing And Rehabilitation Center | 3.8 mi | ★★★★★ | 22 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.