Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Claremont Manor Care Center during CMS and state inspections, most recent first.
Incomplete informed consent for psychotropic medications: The facility did not obtain or complete required IC documentation for two residents receiving psychotropic meds. One resident received Mirtazapine without IC for the initial dose and had a delayed IC when the dose increased, and the IC form omitted the frequency. Another resident’s divalproex sodium IC left blank the reason for use, benefits, probable SEs, significant risks, and alternative treatment options. RN and DON interviews confirmed the forms were incomplete and that psychotropic meds require informed consent before administration.
Controlled Medication Reconciliation Failure: The facility failed to reconcile controlled meds for three residents with dementia and other significant diagnoses. For one resident, lorazepam was removed from controlled storage but not signed as given on the MAR; for another, acetaminophen with codeine was removed but not documented as administered; and for a third, alprazolam was removed but not documented on the MAR. The DON stated the facility did not have a system to reconcile MARs with narcotic records and had not investigated the missing documentation.
Missing Advance Directive Acknowledgement Form: The facility failed to complete and file an ADAF for a resident with intact cognition who was admitted and readmitted with osteoarthritis and macular degeneration. An LVN and the SSD could not locate the form in either the electronic or paper chart, despite the facility policy requiring the form to be completed, signed, and placed in the medical record after admission.
A resident with CKD, acute kidney failure, and UTI had a 12-lb weight loss in one week while receiving Lasix for edema. RN and DON interviews confirmed the loss was significant and that the MD and responsible party should have been notified, but the chart had no documented evidence of notification. The facility policy required timely communication of changes in condition and documentation of all attempts to contact the MD and responsible party.
Failure to Provide Transfer-Discharge and Bed-Hold Notices: A resident with intact cognitive skills and recent surgical aftercare needs was discharged to a hospital, but the record did not contain a completed transfer-discharge notice or documentation that the resident received bed-hold notification. Staff and the DON confirmed the notices were not completed or documented, and the ombudsman was not shown to have been notified.
Failure to follow PI prevention measures was identified for a resident at high risk for skin breakdown. Staff did not consistently turn and reposition the resident, did not float the heels while the resident was lying in bed, and left the LAL mattress in static mode instead of the ordered alternating pressure setting. The resident’s care plan called for frequent repositioning and heel floating, and staff observations showed the resident remained on the back with heels resting on a pillow while an LPN and CNA did not carry out the planned interventions.
A resident with impaired cognition, osteoporosis, osteoarthritis, restless leg syndrome, and a high fall risk had a care plan that included floor mats on the sides of the bed. During observation, the mats were found propped against the wall while the resident was lying in bed. An LVN, CNA, PT, and DON all stated the mats were intended to be alongside the bed when the resident was in bed because the resident had a history of unassisted attempts to get up and was at increased risk for injury if the mats were not used.
Medication Given Outside BP Hold Parameters: An LVN administered Labetalol HCL to a resident even though the resident’s BP was 117/58 and the MAR required the medication to be held if DBP was below 60 or SBP was below 110. The resident had a history of hypertensive heart disease with heart failure and cerebral infarction, and the LVN acknowledged the dose was given outside the ordered parameters. The DON confirmed this was a medication error.
Pill crushers in two medication rooms were observed with visible residue, and staff stated they are to be cleaned daily at the end of each shift. Food items were also found stored in the medication rooms, including chips, an empty beverage cup, and an opened lunch bag. An RN stated food should not be kept in medication rooms, and the DON stated nurses are responsible for cleaning pill crushers and that food items are prohibited in those areas.
Failure to identify food preferences and offer food substitutes for a resident with DM, CKD, and legal blindness. The resident needed partial/moderate assistance with eating and had a care plan addressing nutritional risk, but staff did not ask about daily preferences or offer alternatives when the resident refused part of a meal. The CDM stated preferences were only gathered at admission and not reassessed daily, despite facility policy requiring regular assessment of food and dining preferences and provision of substitutions.
Expired milk was found in the kitchen refrigerator during a concurrent observation and interview with the Kitchen Cook. Five half-gallon containers had a best used by date that had already passed, and the Cook stated expired milk should not be kept in the refrigerator because it could be mistakenly served to residents and potentially cause illness. The DDS later stated expired food items, including milk, must be discarded because keeping them in the refrigerator poses a potential health hazard. Facility policy required food to be stored to prevent contamination and maintain safety for human consumption.
Failure to Disinfect BP Cuff and Use PPE During Wound Care: An LVN used the same BP cuff on two residents without disinfecting it between uses, then provided wound care to a resident with a chronic wound without PPE and without a door sign indicating PPE was required. The resident had dementia, CHF, arthritis, and documented wound care needs, while the facility policy called for disinfecting BP equipment between residents and using enhanced precautions for residents with wounds.
Surveyors found that the facility failed to perform and/or document the required 20-year testing of quick-response sprinkler heads throughout all smoke compartments, as required by NFPA 25. During review of Life Safety records with the Director of Environmental Services, no documentation of a 20-year sprinkler test was available, despite the sprinklers being original to the building. Spare sprinkler heads in stock showed manufacturing dates from the late 1990s, and the outside testing company could not provide historical records to confirm that the mandated 20-year testing had ever been completed.
Surveyors found that the facility did not activate or transmit the fire alarm signal during multiple fire drills conducted during daytime and evening hours, as required by NFPA 101. Documentation showed that three drills held during non-nocturnal hours were recorded as having no alarm activation. In an interview, the DES stated that staff may have avoided pulling the alarm during a drill held around dinner time and also suggested there might have been documentation errors, but could not clearly explain the discrepancies. This practice was cited as having the potential to negatively affect the health and safety of residents, staff, and visitors.
Surveyors observed that an electrical outlet in Nursing Station 1's med room was installed 18 inches from a sink and was not equipped with a required ground-fault circuit interrupter (GFCI), as mandated by NFPA 70, National Electrical Code. The DES confirmed during the survey that this outlet lacked GFCI protection, resulting in a cited deficiency related to utilities and electrical safety in one of the facility’s smoke compartments.
A resident with intact cognition and independence in daily activities was verbally abused by another resident with cognitive impairment and a history of verbal aggression. The incident, which involved yelling, cursing, and threats, was witnessed by staff including an LVN, the Activities Director, and the DON. The affected resident was left scared and unusually quiet, indicating emotional distress. The facility's policy prohibits all forms of abuse, including resident-to-resident verbal abuse, but the event was not prevented.
A resident with severe cognitive impairment and multiple medical conditions made an allegation of sexual abuse to a CNA, who promptly informed an LVN and the DON. Although the police and Ombudsman were notified within the required two-hour window, the facility failed to report the allegation to the Department of Public Health within the mandated timeframe, as required by facility policy.
A resident with severe cognitive impairment was subjected to repeated loud instructions by an LVN, which staff perceived as verbal abuse. Multiple CNAs witnessed or were informed of the incident, but the allegation was not reported to the administrator or authorities within the required two-hour window. The delay in reporting was confirmed through staff interviews and documentation, in violation of facility policy and state regulations.
The facility failed to maintain an effective pest control program, resulting in cockroaches in the kitchen. Grease and dirt buildup were observed, and the kitchen had not been deep cleaned recently. The Infection Preventionist confirmed a 48-hour kitchen closure due to the issue. The facility lacked a pest control policy, and recommendations to address pest entry points had been pending. The facility's policies did not adequately address pest control, leading to the deficiency.
A resident with dementia and a history of falls was left unsupervised in their room, leading to a fall and injuries. Despite increased agitation and confusion, the resident's physician was not notified, and the resident was not adequately monitored. This failure to follow facility policies on dementia care and fall prevention resulted in the resident sustaining a laceration, bruising, and abrasions.
The facility failed to develop and implement individualized care plans for four residents, leading to potential unmet needs and incorrect care. A resident with a change in skin condition did not have a care plan for monitoring and intervention. Another resident on Eliquis lacked a care plan for anticoagulant use, and a resident on Quetiapine had no care plan for antipsychotic use. Additionally, a resident with dementia did not have a care plan addressing cognitive impairment and specific behaviors.
Two residents at a facility experienced inadequate pressure ulcer care and prevention. One resident's low air loss mattress was improperly set, reducing its effectiveness. Another resident did not receive documented repositioning, weekly skin assessments, or timely treatment for a pressure injury. The facility failed to follow its policy for skin and wound assessment, leading to potential worsening of pressure injuries.
The facility failed to document drug allergies accurately for two residents, leading to the administration of contraindicated medications. One resident received Ambien despite it being an allergy, and another had incorrect allergy documentation in their EMR. The discrepancies were not communicated to the pharmacy, posing a risk of adverse reactions.
The facility failed to follow infection prevention guidelines, including improper PPE use during peri-care for a resident under enhanced precautions, lack of a HEPA filtration system for a COVID-19 positive resident, and incorrect PPE use by a visitor. Additionally, a laundry aide prefilled disinfection logs, contrary to policy.
A facility failed to update a resident's code status in the EMR, leading to a discrepancy between a full code MD order and a signed DNR form. Staff interviews revealed that the inconsistency was noted but not corrected, risking incorrect emergency services for the resident.
A resident with Alzheimer's and psychosis showed increased agitation and confusion, attempting to stand unassisted from a wheelchair. The RN failed to notify the physician of this change, contrary to facility policy. Interviews confirmed this was a change in condition requiring immediate notification, which was not done.
A facility failed to ensure the SNFABN form was signed for a resident with severe cognitive impairment, potentially leading to uninformed decisions about denied medical coverage. The resident, diagnosed with dementia, hearing loss, and visual loss, lacked the capacity to make decisions. The Social Services Designee confirmed the absence of signatures could result in billing disputes.
The facility failed to update care plans for two residents, one with Alzheimer's and increased confusion, and another with depression and a change in Trazadone dosage. Staff observations and interviews confirmed the need for care plan revisions to ensure appropriate interventions and medication management, as per facility policies.
A resident with chronic respiratory failure and asthma was found with their nasal cannula disconnected from the oxygen concentrator, and the humidifier bottle was not labeled or dated as per facility policy. The resident expressed uncertainty about receiving oxygen, and staff interviews confirmed the oversight, highlighting the risk of infection and inadequate oxygen delivery.
A resident with a fracture requiring scheduled pain medication did not receive a Lidocaine patch as it was not delivered by the pharmacy on time. The facility's policy required medications to be administered within 60 minutes of the scheduled time, but this was not met, leading to a deficiency in pharmaceutical services.
A resident was prescribed Quetiapine without a documented diagnosis to support its use, despite having severe cognitive impairment and dependency on daily activities. Interviews with the PMHNP and DON confirmed the lack of a clear medical indication for the medication, which was contrary to the facility's policy requiring a thorough evaluation and documented diagnosis before administering psychotropic drugs.
The facility's kitchen failed to maintain sanitary conditions, risking foodborne illness for residents. Observations revealed a cook preparing food without a hairnet, expired food items stored improperly, and dented cans in the dry food area. Interviews with staff confirmed these practices violated facility policies on food safety and sanitation.
A resident with limited mobility and medical decision-making capacity was found with an inaccessible call light, contrary to facility policy. Staff interviews confirmed the call light should have been within reach, as per the facility's procedures.
A facility failed to report an alleged abuse incident involving a CNA and a resident within the required two-hour timeframe. The resident, with conditions like encephalopathy and heart failure, was allegedly subjected to inappropriate touching. The incident was reported to authorities three days late, violating the facility's abuse prevention policy.
A facility failed to remove a CNA from duties during an investigation into alleged inappropriate conduct with a resident. Despite a report of the CNA squeezing a resident's brief inappropriately, the CNA continued working their regular schedule. The resident involved had a history of encephalopathy and other conditions, and the facility's investigation could not substantiate the complaint.
A verbal altercation between two residents during a Cinco de Mayo celebration was not reported to the necessary authorities within the required timeframe. Despite being witnessed by the Activities Director, the incident involving threats and profane language was not communicated to the State Survey Agency, Long-Term Ombudsman, or local law enforcement until over 24 hours later, contrary to facility policy.
Incomplete informed consent for psychotropic medications
Penalty
Summary
The facility failed to obtain informed consent for psychotropic medication use for two residents and failed to complete required consent documentation accurately. For one resident with diagnoses including dementia, major depressive disorder, and chronic kidney disease, the record showed an order for Mirtazapine 15 mg beginning on 6/27/2025 for depression manifested by poor PO intake, followed by discontinuation of that dose and a new order for Mirtazapine 30 mg beginning on 10/2/2025 for depression manifested by inability to sleep at night. Review of the resident’s MARs showed Mirtazapine 15 mg was administered from 6/27/2025 through 10/1/2025 and Mirtazapine 30 mg was administered from 10/2/2025 through 3/12/2026. The resident’s informed consent verification form dated 12/16/2026 listed Mirtazapine 30 mg PO, but did not include the frequency for administration. During interview and record review, RN 1 stated no informed consent was found for the initial administration of Mirtazapine 15 mg, and that consent was not obtained in a timely manner when the dose increased to 30 mg on 10/2/2025. RN 1 also stated the consent should have included the medication name, dosage, frequency, diagnosis, and associated behaviors or manifestations. The DON stated antidepressants are psychotropic medications and require informed consent before administration, and that consent forms should be completed accurately and thoroughly with at least the medication name, dosage, frequency, and indication. For the second resident, the record showed diagnoses including urinary tract infection and dementia with other behavioral disturbance, and the H&P stated the resident did not have the capacity to understand or make decisions. The resident had an order for divalproex sodium 250 mg twice daily for poor impulse control manifested by verbal aggression such as cursing. The psychotherapeutic drug informed consent form dated 3/10/2026 did not include the reason for use and benefits, probable side effects and significant risks, or reasonable alternative modes of treatment including possible nonpharmacological approaches; these sections were left blank. The DON stated the form was not filled out completely and that it was important for the form to be completed so the resident was informed of the specific medication and side effects involved in care.
Plan Of Correction
F552 CFR(s): 483.10(c)(1)(4)(5) Right to be Informed/Make Treatment Decisions Root Cause: The root cause of the deficient practice was failure of licensed nursing staff to consistently follow the established process for obtaining and documenting informed consent prior to medication administration, coupled with lack of consistent oversight to ensure compliance. How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: On 3/12/2026, for residents #35 and #46, the facility contacted the Physician and Responsible Party and obtained complete informed consent for medication administration, including medication name, dose, frequency, risks, benefits, and alternatives particularly for psychotropic medication. Documentation was updated in both the electronic and physical medical records prior to continuation of medication administration. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 3/15/2026, the Medical Records Director (MRD) conducted a 100% audit of all resident charts (electronic and physical) to verify that informed consent was obtained prior to medication administration. The audit confirmed that no other residents were affected. If any resident had been identified without proper informed consent, the facility would have immediately contacted the Physician and Responsible Party to obtain complete informed consent prior to further medication administration. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: On 3/30/2026, the Director of Nursing (DON) conducted mandatory in-service training for all licensed nurses on informed consent requirements. Education included that informed consent must be obtained prior to medication administration and must include, at minimum: medication name, dose, frequency, risks, benefits, and alternatives, with additional emphasis on psychotropic medications.Effective immediately:Licensed nurses are responsible for obtaining and documenting informed consent prior to initiation of any medication and upon any change in physician orders.The MRD will review informed consent documentation during quarterly care plan conferences and during routine chart reviews.Admission and new order workflows have been reinforced to include verification of informed consent prior to implementation.Completion Date: 4/1/2026 How the facility plans to monitor its performance to ensure that solutions are sustained:The facility will maintain a 100% compliance threshold for informed consent completion prior to medication administration.Monitoring Plan:The MRD or designee will conduct weekly audits of 5 randomly selected residents for 4 weeks, followed by monthly audits for 2 months.Audits will verify that informed consent is complete, accurate, and includes all required elements. Any identified noncompliance will result in immediate correction, notification to the DON, and re-education of the responsible licensed nurse prior to the next shift worked. Repeated noncompliance will be addressed through progressive discipline per facility policy. Reporting & Oversight: The MRD will report audit findings to the DON weekly during the monitoring period. The DON is responsible for oversight and ensuring corrective actions are implemented. Results will be presented at the Monthly QA Committee Meeting, and ongoing monitoring will continue until sustained 100% compliance is achieved. Responsible Parties: Licensed Nurses: Obtain and document informed consent prior to medication administration and with any change in orders Medical Records Director (MRD): Conduct audits and report findings Director of Nursing (DON): Provide education, ensure compliance, and oversee monitoring process
Controlled Medication Reconciliation Failure
Penalty
Summary
The facility failed to have an effective medication reconciliation system in place for controlled medications for 3 residents. Resident 8 had diagnoses including dementia and adhesive capsulitis of the right shoulder, and the MDS indicated moderately impaired cognition and impaired ROM in both upper and lower extremities. Resident 48 had diagnoses including dementia and a wedge compression fracture of the fourth lumbar vertebra, and the MDS indicated a short-term memory problem, moderately impaired cognitive skills for daily decision making, and dependence with all ADLs. Resident 49 had diagnoses including dementia and breast cancer, and the MDS indicated moderately impaired cognition. For Resident 8, the narcotic record showed lorazepam 1 mg was removed from controlled storage for administration, but the MAR for that same dose was not signed-marked as administered. For Resident 48, the narcotic record showed acetaminophen with codeine 300-30 mg was removed for administration, but the MAR for that dose was not signed-marked as administered. For Resident 49, the narcotic record showed alprazolam 0.25 mg was removed for administration, but the MAR for that dose was not signed-marked as administered. During interview, the DON stated the facility did not have a system in place where the MARs were reconciled with the narcotic records and had not investigated the controlled medications that were not accounted for. The DON also stated that signing the MAR indicated the resident received the medication and described the process for controlled medications as requiring licensed nurses to remove the medication, sign the narcotic record, and then sign the MAR once the medication was administered. The facility policy required an accurate reconciliation of controlled drugs and documentation of administration on the accountability record and MAR.
Plan Of Correction
F0755 CFR(s): 483.45(a)(b)(1)-(3) Pharmacy Services/Procedures/Pharmacist/Records Root Cause: The root cause of the deficient practice was inconsistent adherence to controlled substance documentation and reconciliation processes, including failure to consistently verify Narcotic Records (NR), Medication Administration Records (MAR), and physical counts, along with lack of a standardized discrepancy resolution process and oversight. The corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: On 3/13/2026, for Residents #8, #48, and #49, the Director of Nursing (DON) and designee completed a full reconciliation of Narcotic Records (NR), Medication Administration Records (MAR), and physical controlled substance counts. Documentation was reviewed, staff were interviewed, and all narcotic counts were verified to ensure accuracy. Any discrepancies identified were immediately investigated and resolved. No adverse resident outcomes were identified. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 3/31/2026, the DON and designee conducted a 100% audit of all residents receiving controlled medications over the past 30 days, verifying: NR documentation accuracyMAR documentation accuracyPhysical count reconciliationCompletion of required signaturesNo additional unresolved discrepancies were identified. Any discrepancies, if identified, would be immediately investigated, reconciled, and documented, with staff re-education provided. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: To prevent recurrence, the facility implemented the following systemic controls:Standardized Reconciliation Process: Controlled substance counts will be completed at every shift change by two licensed nurses, verifying: Narcotic Record (NR) Medication Administration Record (MAR) Physical count of controlled medications Both nurses must sign and verify accuracy at each shift change. Real-Time Documentation Requirements: All controlled medications must be documented immediately at the time of removal, administration, waste, or return. Documentation must include date, time, dose, balance remaining, and two licensed nurse signatures for waste. Discrepancy Process: Any discrepancy will be identified immediately and investigated at the time of discovery. The licensed nurse will notify the DON/designee immediately. A discrepancy report will be completed, including documentation of findings and resolution. If diversion is suspected, the facility will initiate escalation procedures, including Administrator notification, Consultant Pharmacist involvement, and reporting per facility policy and regulatory requirements. Education & Oversight: On 3/30/2026, the DON conducted mandatory in-service training for licensed nurses on controlled substance procedures, reconciliation, and documentation requirements. The Consultant Pharmacist will provide ongoing monthly review and oversight of controlled substance practices. How the facility plans to monitor its performance to ensure that solutions are sustained: The facility will maintain a 100% compliance threshold for controlled substance reconciliation and documentation. Monitoring Plan: The DON or designee will conduct weekly audits of a minimum of 5 residents receiving controlled medications for 4 weeks, followed by monthly audits for 2 months. Audits will include: NR vs MAR vs physical count reconciliation Completion of shift-to-shift narcotic count documentation Presence of required signatures Review of discrepancy identification, documentation, and resolution Corrective Action Loop: Any identified noncompliance will be corrected immediately, including reconciliation of counts and documentation updates. The responsible staff member will receive re-education prior to the end of the shift. A follow-up audit within 24 hours will be conducted to ensure compliance. Repeated noncompliance will be addressed through progressive discipline per facility policy. Reporting & Oversight: Audit findings will be reported weekly to the Administrator and DON during the monitoring period. The Consultant Pharmacist will review findings during monthly pharmacy reviews. Results will be presented at the monthly Quality Assurance (QA) Committee Meeting. The QA Committee will monitor compliance monthly until sustained 100% compliance is achieved. Responsible Parties: Licensed Nurses: Shift-to-shift narcotic counts, real-time documentation, discrepancy identification Director of Nursing (DON)/Designee: Oversight, audits, investigation of discrepancies Consultant Pharmacist: Monthly review and compliance oversight Administrator: Oversight and escalation if needed Completion Date: 4/13/2026
Missing Advance Directive Acknowledgement Form
Penalty
Summary
The facility failed to complete an advance directive acknowledgement form (ADAF) for one resident, as required by its policy and procedure titled, Advance Directives. The resident was admitted and later readmitted to the facility with diagnoses including osteoarthritis and macular degeneration. The resident's MDS dated 2/9/2026 indicated intact cognition, dependence on staff for toileting, and substantial to maximum assistance for bathing. During a concurrent interview and record review on 3/12/2026, an LVN stated the resident's ADAF could not be found in either the electronic medical record or the physical chart. In a separate interview, the SSD also stated the ADAF could not be located and explained that the form was important to identify who should receive information if the resident became unable to make decisions and to follow the resident's wishes for treatment, including code status. The facility's policy stated that upon admission, social services staff or designee would inform and provide written information to the resident about the right to formulate an advance directive, and that an Acknowledgement for Advance Directive form would be completed, signed, and placed in the medical record.
Plan Of Correction
F578 CFR(s): 483.10(c)(6)(8)(g)(12)(i)-(v) Request/Refuse/Discontinue Treatment; Advance Directives Root Cause: The root cause of the deficient practice was failure to ensure consistent completion and verification of the Advance Directive Acknowledgement Form (ADAF) during the admission process, along with lack of a defined accountability structure and oversight to confirm compliance. How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: On 3/12/2026, for Resident #1, the Director of Nursing (DON) met with the resident and completed the Advance Directive Acknowledgement Form (ADAF). The resident was provided written and verbal education regarding their rights to accept or refuse treatment and to formulate an advance directive. The completed ADAF, including acknowledgment of rights, was placed in both the electronic medical record and physical chart. The Physician and Responsible Party were notified of the resident's advance directive status. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 3/19/2026, the Medical Records Director (MRD) conducted a 100% audit of all current residents to verify the presence of a completed ADAF in both the electronic and physical medical record. No additional residents were identified without a completed ADAF. If any resident had been identified without a completed ADAF, the facility would have immediately completed the ADAF, provided resident/responsible party education, and ensured proper placement in the medical record prior to continuation of services. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: To prevent recurrence, the facility has implemented the following systemic changes: On 3/14/2026, the Administrator conducted in-service training for the Admissions Director and Social Services on Advance Directive requirements, including timely completion of the ADAF upon admission and readmission. The Admissions Director (primary responsible party) or designee is accountable for ensuring that all residents or their responsible party receive written and verbal education regarding advance directives and that the ADAF is completed, signed, and placed in the medical record. A process hard stop has been implemented; an admission is not considered complete until the ADAF is completed, signed, and filed in both the electronic and physical medical record. The MRD will verify ADAF completion during admission record review prior to finalizing the admission chart. Completion Date: 4/1/2026 How the facility plans to monitor its performance to ensure that solutions are sustained: The facility will maintain a 100% compliance threshold for ADAF completion and documentation in the medical record. Monitoring Plan: The MRD will conduct weekly audits of 5 randomly selected residents for 4 weeks, followed by monthly audits for 2 months. The MRD will also perform ongoing admission audits to verify ADAF completion prior to chart finalization. Corrective Action Loop: Any identified noncompliance will result in immediate completion of the ADAF, notification to the Administrator and DON, and re-education of the responsible staff member prior to the next admission processed. A follow-up audit within 7 days will be conducted to ensure continued compliance. Repeated noncompliance will be addressed through progressive discipline per facility policy. Reporting & Oversight: The MRD will report audit findings weekly to the Administrator and DON during the monitoring period. The Administrator and DON are responsible for oversight and ensuring corrective actions are implemented. Results will be presented at the Monthly QA Committee Meeting, and monitoring will continue until sustained 100% compliance is achieved. Responsible Parties: Admissions Director: Primary responsibility for ADAF completion at admission Social Services: Support education and documentation as needed Medical Records Director (MRD): Audits and compliance verification Director of Nursing (DON) & Administrator: Oversight and enforcement
Failure to Notify Physician and Responsible Party of Significant Weight Loss
Penalty
Summary
Facility staff failed to notify Physician 1 and the resident’s responsible party of a significant change in condition for Resident 17 after the resident experienced a 12-pound weight loss within one week. Resident 17 was admitted and later re-admitted with diagnoses including chronic kidney disease, acute kidney failure, and UTI. The resident’s MDS indicated severely impaired cognition, partial/moderate assistance with ADLs, and substantial/maximal assistance with mobility. The record showed an order to obtain weekly weights for four weeks for weight management. The weights and vitals summary documented that Resident 17 weighed 169 lbs. on 3/1/2026 and 157 lbs. on 3/9/2026. The MAR showed the resident received Lasix 20 mg at bedtime and Lasix 40 mg in the morning for edema during the same period. During interview and record review, RN 1 stated the 12-pound loss was significant and that Physician 1 and the responsible party should have been notified, but there was no documented evidence that either was informed. RN 1 stated that physician notification was needed to evaluate the ongoing treatment plan, including whether to continue, adjust, or hold diuretic therapy and whether additional monitoring or laboratory testing was necessary. The DON stated that significant weight changes should be communicated to the physician and responsible party and that the medical record must clearly show the communication occurred. The facility policy stated that changes in resident condition are to be communicated timely to the physician and responsible party and that attempts to reach them must be documented in the nursing progress notes.
Plan Of Correction
F0580 CFR(s): 483.10(g)(14)(i)-(iv)(15) Notify of Changes (Injury/Decline/Room, etc.) Root Cause: The root cause of the deficient practice was failure of licensed nursing staff to consistently recognize and act upon the requirement to notify the Physician and Responsible Party for all significant changes in condition, along with lack of consistent oversight to ensure timely notification and documentation. How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: On 3/15/2026, for Resident #17, the attending Physician and Responsible Party were notified of the significant weight change. A Change of Condition (COC) assessment was completed, and documentation was entered into the medical record to reflect the resident's weight loss, clinical status, and physician recommendations. The resident's care plan was reviewed and updated to reflect current interventions and monitoring related to weight changes and diuretic therapy. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 3/17/2026, the Medical Records Director (MRD) conducted a 100% audit of all current residents who experienced a significant change in condition within the past 30 days to verify that Physician and Responsible Party notifications were completed and documented.Any identified discrepancies were immediately corrected through notification, documentation, and care plan updates. No additional residents were identified to be without proper notification. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: To prevent recurrence, the facility implemented the following measures:On 3/18/2026, the Director of Nursing (DON) conducted mandatory in-service training for all licensed nursing staff on Change of Condition requirements.Education emphasized that all significant changes in condition must be reported to the Physician and Responsible Party, regardless of anticipated clinical outcomes, and must be documented in the medical record.Licensed nurses are responsible for initiating and documenting all notifications, including date, time, method of contact, and response received.The DON or designee will review Change of Condition documentation during clinical oversight rounds to ensure compliance. Completion Date: 4/1/2026 How the facility plans to monitor its performance to ensure that solutions are sustained:The facility will maintain a 100% compliance threshold for timely Physician and Responsible Party notification and documentation for all significant changes in condition.Monitoring Plan:A minimum of 5 resident records with documented changes in condition will be reviewed weekly for 4 weeks, followed by monthly audits of 5 records for 2 months.Daily Audits will verify that notification occurred timely and that documentation includes all required elements (date, time, method, and response). Corrective Action Loop: Any identified noncompliance will result in immediate notification (if not already completed), documentation correction, and re-education of the responsible licensed nurse prior to the next shift worked. A follow-up audit within 7 days will be conducted to ensure compliance. Repeated noncompliance will be addressed through progressive discipline per facility policy. Reporting & Oversight: The MRD or designee will report audit findings weekly to the DON during the monitoring period. The DON is responsible for oversight and ensuring corrective actions are implemented. Results will be presented at the Quarterly QAPI Committee Meeting, and monitoring will continue until sustained 100% compliance is achieved. Responsible Parties: Licensed Nurses: Notify Physician and Responsible Party and document all changes in condition Medical Records Director (MRD): Conduct audits and report findings Director of Nursing (DON): Provide education, oversight, and ensure compliance
Failure to Provide Transfer-Discharge and Bed-Hold Notifications
Penalty
Summary
The facility failed to provide transfer-discharge notification documentation and bed-hold notification documentation for Resident 42. Resident 42 was admitted on 1/30/2026 with diagnoses including encounter for surgical aftercare following surgery on the digestive system and unspecified intestinal obstruction. The 2/6/2026 MDS indicated Resident 42's cognitive skills for daily decision making were intact, and the resident required varying levels of assistance with eating, oral hygiene, personal hygiene, toileting, showering, and dressing. Resident 42 was discharged to a general acute care hospital on 2/15/2026, but the medical record did not contain a completed written notice of proposed transfer-discharge. The record also showed a bed-hold notification dated 2/4/2026 that was left blank in the section to be completed upon transfer/discharge, and staff stated the notice of proposed transfer-discharge was not completed and the resident did not receive bed-hold notification upon discharge. The DON confirmed the record did not show that Resident 42 or the ombudsman received the transfer-discharge notice, and did not show that Resident 42 received or was offered bed-hold notification.
Plan Of Correction
F0628 CFR(s): 483.15(c)(2)(iii)(3)-(6)(8)(d)(1)(2); 483.21(c)(2) Transfer and Discharge Process Root Cause: The root cause of the deficient practice was failure to ensure consistent completion and documentation of required transfer/discharge notices and bed-hold notifications prior to or at the time of transfer, along with lack of a standardized process and defined accountability for each step. How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: On 2/15/2026, Resident #42 was discharged. Upon review, the facility ensured that the required transfer/discharge notice and bed-hold notification were completed, including documentation that the resident and/or responsible party were informed of appeal rights, bed-hold policy, and return rights. The record was updated to reflect compliance with regulatory requirements, and the responsible party was re-educated on these rights. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 3/17/2026, the Medical Records Director (MRD) conducted a 100% audit of all residents discharged or transferred within the past 30 days to ensure: Presence of transfer/discharge notice Timeliness of notice Bed-hold notification Documentation of resident/responsible party notification, including appeal and return rights Any identified discrepancies were immediately corrected through completion of required documentation, notification to resident/responsible party as applicable, and staff re-education. No additional F0628residents were identified to be out of compliance. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur:To prevent recurrence, the facility has implemented the following systemic changes:On 3/24/2026, the Director of Nursing (DON) conducted mandatory in-service training for licensed nurses, Social Services, and Admissions on transfer/discharge requirements.Education emphasized that all required notifications and documentation must be completed prior to or at the time of transfer/discharge, including:Written transfer/discharge noticeBed-hold notificationNotification to resident, responsible party, and OmbudsmanDocumentation of appeal rights and return policiesProcess Controls Implemented:A Transfer/Discharge Checklist (hard stop) has been implemented and must be completed prior to any transfer or discharge.The checklist requires verification of all regulatory elements before the resident leaves the facility.The licensed nurse is responsible for initiating the transfer and ensuring clinical documentation is complete.Social Services/Admissions are responsible for completing and documenting all required notices and resident/responsible party education.The DON or designee provides oversight and final verification of compliance.Completion Date: 4/13/2026 How the facility plans to monitor its performance to ensure that solutions are sustained: The facility will maintain a 100% compliance threshold for all transfer/discharge requirements. Monitoring Plan: The MRD or designee will conduct daily audits of a minimum of 5 discharged/transfer residents for 4 weeks, followed by monthly audits of 5 records for 2 months. Audits will verify: Presence and timeliness of transfer/discharge notice Completion of bed-hold notification Documentation of resident/responsible party notification Inclusion of appeal rights and return policy Completion of Transfer/Discharge Checklist Corrective Action Loop: Any identified noncompliance will result in immediate correction, including completion of missing documentation and notification as applicable. The responsible staff member will receive re-education prior to the next shift worked. A follow-up audit within daily will be conducted to ensure compliance. Repeated noncompliance will be addressed through progressive discipline per facility policy. Reporting & Oversight: The MRD will report audit findings daily to the Administrator and DON during the monitoring period. The DON and Administrator are responsible for oversight and ensuring corrective actions are implemented. Results will be presented at the Monthly QAPI Committee Meeting, and monitoring will continue until sustained 100% compliance is achieved. Responsible Parties: Licensed Nurse: Initiates transfer and completes clinical documentation Social Services/Admissions: Completes required notices and resident/responsible party education Medical Records Director (MRD): Conducts Daily audits and verifies compliance Director of Nursing (DON) & Administrator: Oversight, enforcement, and QAPI integration Include dates when corrective actions will be completed. The corrective action completion dates must be acceptable to the State Agency. 4/13/2026
Failure to Follow Pressure Injury Prevention Measures
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not followed for one sampled resident who was admitted to the facility with diagnoses including heart disease with heart failure and arthritis. The resident’s care plan identified a risk for pressure injury development related to decreased mobility and history of ulcers, and later revisions noted fragile skin and a right lateral leg trauma wound. The resident’s assessments showed the resident was bedfast, had very limited mobility, required moderate to maximum assistance with movement, and was at high risk for pressure injury development. During observation, the resident’s low air loss mattress was found set in static mode even though the physician’s order indicated an alternating pressure mattress for skin integrity. The licensed vocational nurse stated static mode needed to be on, while later stating the mattress should have been changed to alternating pressure. During another observation, after a lidocaine patch was applied and the resident was left lying on the back, a pillow was placed lengthwise under the right leg but the heel was not floating. The resident remained on the back during continued observation, with the heels resting on a pillow or directly on top of a pillow. Staff did not consistently turn or reposition the resident as planned. A certified nursing assistant observed during the resident’s care did not offer to turn or reposition the resident, and later stated the resident was not turned every 2 hours because the CNA was busy with another restless resident. The resident stated agreement to be turned and repositioned by staff. The facility policy stated residents at risk for skin impairment should have preventive measures in place, including repositioning in bed, turning and repositioning every 2 hours or less depending on needs, use of pillows and cushions to distribute pressure, and floating the heels.
Plan Of Correction
F686 CFR(s): 483.25(b)(1)(i)(ii) Treatment/Services to Prevent/Heal Pressure Ulcers How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. On 3/11/2026 for Resident 15, the low air loss (LAL) mattress was immediately adjusted to the appropriate alternating pressure setting per physician order. Nursing staff repositioned the resident and ensured heels were floated using appropriate positioning devices. The resident was assessed for skin integrity, and no new pressure injuries were identified. The care plan was reviewed and reinforced with staff to ensure interventions including turning and repositioning every 2 hours, heel floating, and appropriate mattress settings were implemented consistently. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. On 3/16/2026, an audit was conducted by the Director of Nursing (DON) and designee of residents identified as at high risk for pressure injuries. The audit verified appropriate implementation of care plan interventions including repositioning, heel offloading, and correct mattress settings. Any identified discrepancies were immediately corrected, including adjustment of equipment and reinforcement of interventions with staff. No additional residents were identified to be out of compliance. What measures will be put into place or what systemic changes will the facility will make to ensure that the deficient practice does not recur. To prevent recurrence of the deficient practice, the facility has implemented the following measures. On 4/1/2026, the DON conducted an in-service training for licensed nursing staff and CNAs regarding pressure injury prevention protocols, including proper turning and repositioning, heel floating techniques, and verification of specialty mattress settings per physician orders. Staff were educated that all interventions must be implemented regardless of competing priorities and must align with the resident's care plan. This in-service training and process reinforcement will help prevent recurrence of this deficient practice. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system. The MRD or designee will complete weekly audits of 5 randomly selected residents at risk for pressure injuries for 4 weeks, then monthly for 2 months, to ensure compliance with repositioning, heel offloading, and appropriate mattress settings. Any discrepancies will be addressed immediately and reported to the Administrator, DON or designee. Audit results will be reported at the quarterly Quality Assurance and Performance Improvement (QAPI) committee meeting. The QAPI committee will monitor ongoing compliance until substantial compliance is achieved and sustained. Include dates when corrective actions will be completed. The corrective action completion dates must be acceptable to the State Agency. 4/1/2026
Fall Mats Not Positioned Beside Bed for High Fall-Risk Resident
Penalty
Summary
The facility failed to follow fall prevention interventions for Resident 23 when bilateral fall mats were not placed on the ground alongside the resident’s bed while the resident was in bed. Resident 23 was admitted and readmitted with diagnoses including bilateral primary osteoarthritis of the knee, restless leg syndrome, and age-related osteoporosis. The resident’s MDS dated 10/6/2025 indicated moderately impaired cognition and substantial to maximal assistance needed for toileting and personal hygiene. The resident’s fall risk evaluation dated 1/6/2026 identified a high fall risk, and a progress note from the same date documented intermittent confusion and a fall risk score of 11. Resident 23’s care plan, initiated 1/7/2026, identified fall risk related to a history of falls, impaired mobility, urinary incontinence, and cognitive impairment with poor safety awareness, and it included floor mats on the sides of the bed as an intervention. During observation on 3/12/2026, the resident’s floor mats were seen propped against the wall while the resident was lying in bed. LVN 4 stated the mats needed to be on the ground while the resident was in bed because the resident got up unassisted. CNA 2 stated no one informed her that the mats were not alongside the bed and that the resident was more confused in the evening and had tried to get out of bed unassisted before. The PT and DON both stated that when the resident was in bed, fall prevention included keeping the bed low and placing mats alongside the bed, and the DON stated that if the mats were not used, the resident was at increased risk of injury if a fall occurred.
Plan Of Correction
F0689 CFR(s): 483.25(d) Free of Accident Hazards/Supervision/Devices Root Cause: The root cause of the deficient practice was failure to consistently implement and maintain fall prevention interventions (specifically floor mats) in accordance with the resident's care plan, along with lack of clear accountability and oversight to ensure interventions were in place during required timeframes. How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: On 3/12/2026, for Resident #23, the floor mat intervention was immediately implemented at bedside per the care plan. The resident's care plan was reviewed and updated to ensure clarity of fall prevention interventions, including when floor mats must be in place. Staff were re-educated on proper placement and use of floor mats to reduce fall risk. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 3/13/2026, the Director of Nursing (DON) or designee conducted a 100% audit of all residents with floor mat interventions to verify:Floor mats are present at bedsideFloor mats are placed appropriately when the resident is in bedFloor mats are not stored, folded, or propped against the wallInterventions are consistent with the individualized care planAny identified noncompliance was immediately corrected at the time of observation, and responsible staff were re-educated. No additional residents were identified to be out of compliance. If any discrepancies had been identified, immediate correction and care plan review would have been completed. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: To prevent recurrence, the facility has implemented the following measures: On 3/31/2026 the DON conducted mandatory in-service training for all nursing staff (licensed nurses and CNAs) on fall prevention interventions, including proper use and placement of floor mats. Education emphasized that floor mats must be in place at bedside whenever the resident is in bed, in accordance with the individualized care plan.Define (sic) Accountability:CNAs are responsible for placing floor mats at bedside when the resident is in bed and ensuring proper positioning during routine care.Licensed Nurses are responsible for verifying implementation of fall interventions each shift and ensuring care plan accuracy.The DON or designee is responsible for oversight, compliance monitoring, and staff accountability.Trigger Conditions Clarified:Floor mats must be in place whenever the resident is in bed, unless contraindicated or otherwise specified in the care plan.Floor mats must be removed only when the resident is out of bed to prevent tripping hazards, as appropriate. How the facility plans to monitor its performance to ensure that solutions are sustained: The facility will maintain a 100% compliance threshold for implementation of floor mat interventions per care plan.Monitoring Plan:The DSD, or designee will conduct weekly audits of a minimum of 5 residents with fall interventions for 4 weeks, followed by monthly audits of 5 residents for 2 months.Audits will verify:Floor mats are in place at bedside while the resident is in bedFloor mats are not stored, folded, or propped against the wallInterventions are consistent with the care plan Interventions are consistent with the care plan Corrective Action Process: Any identified noncompliance will be corrected immediately at the time of observation. The responsible staff member will receive re-education prior to the end of the shift. The licensed nurse will verify correction within the same shift. A follow-up audit within 24 hours will be completed to ensure sustained compliance. Repeated noncompliance will be addressed through progressive discipline per facility policy. Reporting & Oversight: Audit findings will be reported weekly to the DON and Administrator during the monitoring period. Results will be presented at the monthly Quality Assurance (QA) Committee Meeting. The QA Committee will monitor compliance monthly until sustained 100% compliance is achieved. Responsible Parties: CNAs: Implementation and placement of floor mats Licensed Nurses: Verification and documentation each shift DON/Designee: Oversight, audits, and enforcement Completion Date: 4/13/2026
Medication Given Outside BP Hold Parameters
Penalty
Summary
The facility failed to ensure Labetalol Hydrochloride was held according to the ordered parameters for one resident. The resident was admitted with diagnoses including hypertensive heart disease with heart failure and cerebral infarction, and the MDS indicated intact cognition and dependence on staff for showers/bathing self and toileting hygiene. The MAR for March 2026 directed staff to hold Labetalol HCL if systolic BP was below 110 or diastolic BP was below 60, with those parameters in place since 11/11/2024. During a medication administration observation, an LVN checked the resident’s BP on the right wrist and then the left wrist, with the BP reading 117/58 mm Hg. Despite the diastolic pressure being below the hold parameter, the LVN administered 300 mg of Labetalol HCL with other scheduled medications. In a concurrent interview, the LVN stated the medication was given outside the holding parameters and acknowledged it could lower the resident’s DBP and potentially cause weakness and dizziness. The DON stated the facility did not have a policy and procedure on significant medication errors and confirmed that administering Labetalol outside the parameters was a medication error.
Plan Of Correction
Significant Medication Errors Root Cause:The root cause of the deficient practice was failure of licensed nursing staff to consistently follow physician-ordered holding parameters prior to medication administration, including inadequate review of vital signs and lack of clear documentation of clinical decision-making. How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: On 3/11/2026, for Resident #5, the Physician was immediately notified of the medication administration outside of holding parameters. The resident's blood pressure was monitored closely for 24 hours, and no adverse effects were observed. The resident's care plan and medication administration instructions were reviewed with licensed staff to ensure clarity of holding parameters. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 3/31/2026, the Director of Nursing (DON) and designee conducted a random audit of residents receiving medications with holding parameters over the past 30 days, verifying that medications were administered in accordance with physician orders and documented appropriately.No additional residents were identified to be out of compliance. Any discrepancies, if identified, would have been immediately corrected, including physician notification, documentation update, and staff re-education. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: To prevent recurrence, the facility implemented the following systemic changes:On 3/30/2026, the DON conducted mandatory in-service training for all licensed nursing staff on medication administration protocols, including: Strict adherence to physician-ordered holding parameters Requirement to obtain and review vital signs prior to medication administration Clinical decision-making regarding whether to administer or hold medications Medication Administration Verification Process:Licensed nurses must verify current vital signs (e.g., blood pressure, pulse) and compare them directly to physician-ordered parameters prior to administering medications.If parameters are not met, the medication must be held, and the Physician notified as appropriate.Documentation Expectations:Licensed nurses must document:Vital signs obtained prior to administration Comparison to ordered parameters Clinical decision to administer or hold the medication Accurate MAR documentation, including reason for holding when applicable Accountability:Licensed Nurses: Responsible for medication administration, parameter verification, and documentation DON/Designee: Responsible for oversight, compliance monitoring, and enforcement Completion Date: 4/13/2026 How the facility plans to monitor its performance to ensure that solutions are sustained: The facility will maintain a 100% compliance threshold for medications administered with holding parameters. Monitoring Plan: The DON or designee will conduct weekly audits of a minimum of 5 residents receiving medications with holding parameters for 4 weeks, followed by monthly audits for 2 months. Audits will verify: Presence of documented vital signs prior to medication administration Comparison of vital signs to physician-ordered parameters Confirmation that medications were held when parameters were not met Accurate and complete MAR documentation, including rationale for administration or holding Corrective Action Loop: Any identified noncompliance will be corrected immediately, including physician notification if indicated and documentation correction. The responsible licensed nurse will receive re-education prior to the end of the shift. A follow-up audit within 24 hours will be conducted to ensure compliance. Repeated noncompliance will be addressed through progressive discipline per facility policy. Reporting & Oversight: Audit findings will be reported weekly to the DON and Administrator during the monitoring period. Results will be presented at the monthly Quality Assurance (QA) Committee Meeting. The QA Committee will monitor compliance monthly until sustained 100% compliance is achieved. Responsible Parties: Licensed Nurses: Medication administration, parameter verification, and documentation DON/Designee: Oversight, audits, and enforcement Completion Date: 4/13/2026
Medication Room Sanitation and Pill Crusher Cleaning Deficiency
Penalty
Summary
The facility failed to ensure two pill crushers were cleaned and that the medication rooms were kept free of food items. During a concurrent observation and interview in nurses' station 1, a pill crusher had a reddish-brown color on the hinges and unidentified orange, white, and yellow powder residue. LVN 3 stated the pill crushers are required to be cleaned daily at the end of each shift to prevent cross contamination of medications and avoid potential unintended chemical interactions. During a concurrent observation and interview in nurses' station 2, a pill crusher had a whitish powder residue, and LVN 2 stated the pill crushers are to be cleaned daily at the end of each shift to maintain infection control standards. During a concurrent observation and interview in the medication rooms, a bag of chips and an empty beverage cup were found inside a drawer in nurses' station 1, and an opened lunch bag was inside the medication storage cabinet in nurses' station 2. RN 1 stated food items should not be kept in medication rooms because they can attract bugs into those areas. The Infection Preventionist stated the facility's infection control program includes compliance audits and monitoring of adherence to infection prevention standards, with a focus on safety and sanitation practices. The DON stated nurses are responsible for cleaning pill crushers to prevent medication cross contamination and that food items are prohibited in medication rooms.
Plan Of Correction
F761 CFR(s): 483.45(g)(h)(1)(2) Label/Store Drugs and Biologicals How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. On 3/12/2026, both pill crushers located in nurses' stations 1 and 2 were immediately cleaned and sanitized. All food items were removed from both medication rooms. Licensed nursing staff were re-educated on proper infection control practices related to medication preparation, including cleaning of pill crushers and prohibition of food and beverages in the med rooms. 2 new pill crushers were ordered and put into service on 3/31/2026 with instructions to the licensed nurses to wipe them down with sanitizing wipes at the end of each shift. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. On 3/13/2026, an audit was conducted by the Director of Nursing (DON) and Infection Preventionist (IP) of all medication rooms and medication preparation equipment to ensure compliance with infection control and medication storage standards. No additional areas were identified to be out of compliance. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. To prevent recurrence of the deficient practice, the facility has implemented the following measures. On 3/18/2026, the IP conducted an in-service training for licensed nursing staff regarding infection control practices in medication preparation areas, including proper cleaning of pill crushers after use, use of protective pouches when crushing medications, and prohibition of food and beverages in medication rooms. This in-service training and process reinforcement will help prevent recurrence of this deficient practice. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluate for its effectiveness. The POC is integrated into the quality assurance system. The DON or designee will complete weekly audits of medication rooms and medication preparation equipment for 4 weeks, then monthly for 2 months, to ensure compliance with infection control and medication storage standards. Audit results will be reported at the quarterly Quality Assurance and Performance Improvement (QAPI) committee meeting. The QAPI committee will monitor ongoing compliance until substantial compliance is achieved and sustained. Include dates when corrective actions will be completed. The corrective action completion dates must be acceptable to the State Agency. 4/1/2026
Failure to Identify Food Preferences and Offer Substitutes
Penalty
Summary
The facility failed to identify food preferences and offer food substitutes for one of three sampled residents, Resident 4. Resident 4 had an initial admission with diagnoses including a wedge compression fracture of the first lumbar vertebra, type 2 diabetes mellitus with diabetic polyneuropathy, hypertensive heart disease, chronic kidney disease, and legal blindness. The MDS dated 2/25/2026 indicated Resident 4 needed partial/moderate assistance with eating, and the resident also had active diagnoses of cataract, glaucoma, and macular degeneration. The care plan dated 2/19/2026 identified Resident 4 as at risk for nutritional deficit and included interventions to offer substitutes for food not eaten and assess food preferences. The order summary dated 2/24/2026 showed a consistent carbohydrate diet, regular texture, regular consistency, and a dietary supplemental health shake twice daily. During interview, Resident 4 stated no one asked about daily preferences or offered satisfying food substitutes such as finger foods, especially given the resident's blindness. During a concurrent observation and interview, Resident 4's breakfast tray contained scrambled eggs, a bread roll, and slices of oranges, and when Resident 4 refused the scrambled egg, CNA 3 did not ask for preferences or offer substitutes. CNA 3 stated Resident 4 should consume whatever was on the meal served. The CDM stated residents' meals are based on the RD's nutrition recommendations, including diet, texture, allergies, and preferences, and that Resident 4's preferences were only gathered at admission and were not reassessed daily. The RD stated it is important to understand each resident's choices and preferences to provide appropriate meal alternatives, and that dietary aides along with the CDM identify residents' preferences during admission and as needed. The facility policy stated individual food and dining preferences are obtained on a regular basis and food substitutions are provided when the resident chooses not to consume meal items served.
Plan Of Correction
F806 CFR(s): 483.60(d)(4)(5) Resident Allergies, Preferences, Substitutes How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. On 3/16/2026 for Resident 4, the Certified Dietary Manager (CDM) and Dietary staff met with the resident to reassess food preferences and identify appropriate substitutes, including finger foods to support the resident's visual impairment. The resident's dietary profile and care plan were updated to reflect current preferences and needs. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. On 3/26/2026, an audit was conducted by the CDM and Registered Dietician (RD) of current residents to ensure food preferences were identified, documented, and that substitutes were offered when meals were refused. No additional residents were identified to be out of compliance. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. To prevent recurrence of the deficient practice, the facility has implemented the following measures. On 4/1/2026/2026, the CDM conducted an in-service training for dietary staff and CNAs regarding resident-centered dining practices, including obtaining and updating food preferences, offering substitutes of similar nutritive value when meals were refused, and accommodating residents with sensory impairments. Staff were educated that residents have the right to refuse meals and must be offered alternatives consistent with their dietary needs. This in-service training and process reinforcement will help prevent recurrence of this deficient practice. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system. The CDM, RD or designee will complete weekly audits of 5 randomly selected residents for 4 weeks, then monthly for 2 months, to ensure food preferences are documented and appropriate substitutes are offered when meals are refused. Audit results will be reported at the quarterly Quality Assurance and Performance Improvement (QAPI) committee meeting. The QAPI committee will monitor ongoing compliance until substantial compliance is achieved and sustained.Include dates when corrective actions will be completed. The corrective action completion dates must be acceptable to the State Agency.4/1/2026
Expired Milk Stored in Kitchen Refrigerator
Penalty
Summary
Expired milk was found in the kitchen refrigerator during a concurrent observation and interview on 3/10/2026 at 9:20 AM with the Kitchen Cook. Five half-gallon containers of milk with a best used by date of 2/26/2026 were present in the refrigerator. The Kitchen Cook stated that expired milk should not be kept in the refrigerator because it could be mistakenly served to residents and potentially cause illness. During an interview on 3/11/2026 at 9:15 AM, the Director of Dining Services stated that expired food items, including milk, must be discarded because keeping them in the refrigerators poses a potential health hazard to residents. Review of the facility policy titled Production, purchasing, storage indicated that all food and supplies used in food preparation shall be stored to prevent contamination and maintain safety of food for human consumption. The policy also stated refrigerated storage life of food uses the manufacturer’s expiration date and/or milk should be plus three days after opening or by expiration date, if sooner.
Plan Of Correction
F812 CFR(s): 483.60(i)(1)(2) Food Procurement, Store/Prepare/Serve – Sanitary How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. On 3/10/2026, all expired milk was immediately removed and discarded from the kitchen refrigerator. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. On 3/10/2026, an audit was conducted by the RD of refrigerated and dry storage areas to ensure no expired food items were present. No additional expired food items were identified. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. To prevent recurrence of the deficient practice, the facility has implemented the following measures. On 4/1/2026, the CDM conducted an in-service training for dietary staff regarding food safety standards, including monitoring expiration dates, proper labeling, and timely disposal of expired food items. This in-service training and process reinforcement will help prevent recurrence of this deficient practice. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system. The CDM or designee will complete weekly audits of food storage areas for 4 weeks, then monthly for 2 months, to ensure compliance with food safety standards and proper handling of expiration dates. Any discrepancies will be addressed immediately and reported to the quarterly Quality Assurance and Performance Improvement (QAPI) committee meeting. The QAPI committee will monitor ongoing compliance until substantial compliance is achieved and sustained. Include dates when corrective actions will be completed. The corrective action completion dates must be acceptable to the State Agency. 4/1/2026
Failure to Disinfect BP Cuff and Use PPE During Wound Care
Penalty
Summary
The facility failed to follow infection control practices when an LVN used the same BP cuff on two residents without cleaning or disinfecting it between uses. During observation, the LVN checked one resident’s BP, placed the cuff on top of the medication cart without cleaning it, and then later used the cuff on another resident without disinfecting it first. The LVN stated that the cuff had been forgotten after use on the first resident and before use on the second resident. The facility policy for cleaning vital sign equipment stated that BP equipment used on multiple residents is to be disinfected between residents. The facility also failed to ensure appropriate PPE use during wound care for a resident with a chronic wound. During observation, the LVN provided wound care without wearing PPE, and there was no sign at the resident’s door indicating PPE was to be worn. The resident had diagnoses including dementia, CHF, and arthritis, and records showed a reopened vascular wound requiring daily wound care as well as a later right posterior shin skin tear with wound care documented. The infection preventionist stated the resident was not placed on Enhanced Barrier Precautions because the wound was considered only a skin tear, while the wound care physician stated the resident had a chronic wound. The facility’s infection prevention and control policy stated that Enhanced Standard Precautions include gown and glove use during high-contact care for residents with wounds and other high-risk conditions.
Plan Of Correction
F880 CFR(s): 483.80(a)(1)(2)(4)(e)(f) Infection Prevention and Control Root Cause: The root cause of the deficient practice was inconsistent adherence to infection control protocols related to disinfection of shared equipment, inappropriate PPE use, and timely identification and implementation of Enhanced Barrier Precautions (EBP), along with lack of consistent oversight and accountability. How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: On 3/11/2026, licensed nursing staff immediately disinfected all shared equipment, including blood pressure cuffs. For Resident #15, Enhanced Barrier Precautions (EBP) were initiated based on the presence of a chronic wound, and appropriate signage was placed to indicate required PPE use. Residents #5 and #15 were assessed, and no adverse outcomes were identified. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 3/13/2026, the Infection Preventionist (IP) and Director of Nursing (DON) conducted a 100% audit of all residents requiring wound care and/or transmission-based or enhanced precautions to ensure appropriate PPE use and required signage were in place. On 3/18/2026, a facility-wide audit of shared equipment (including BP cuffs and vital sign machines) was conducted to verify proper cleaning and disinfection between each resident use. Any identified discrepancies were immediately corrected at the time of observation, and staff were re-educated. No additional residents were identified to be out of compliance. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: To prevent recurrence, the facility implemented the following systemic changes: On 4/1/2026, the Infection Preventionist (IP) conducted mandatory in-service training for licensed nurses and CNAs on: Proper cleaning and disinfection of shared equipment between each resident use Appropriate PPE use during wound care and resident contact Criteria for initiating and maintaining Enhanced Barrier Precautions (EBP) On 4/1/2026, the IP conducted training with the Wound Physician and nursing staff on timely identification and reporting of wound changes, including progression to chronic wounds requiring EBP. Systemic Process for EBP: Residents will be evaluated for EBP based on presence of wounds, MDRO status, or other infection risk criteria. The licensed nurse is responsible for initiating EBP and ensuring appropriate orders and documentation. The IP and DON/designee will verify EBP implementation, including signage and PPE compliance, during routine rounds. Defined Accountability: CNAs and Licensed Nurses: Perform proper disinfection of shared equipment between each resident use and adhere to PPE requirements Licensed Nurses: Initiate and maintain EBP and ensure proper documentation Infection Preventionist (IP): Conduct audits and infection control surveillance DON/Designee: Provide oversight, enforce compliance, and ensure corrective actions How the facility plans to monitor its performance to ensure that solutions are sustained: The facility will maintain a 100% compliance threshold for all infection control practices. Monitoring Plan: The Infection Preventionist (IP) or designee will conduct weekly audits for 4 weeks, followed by monthly audits for 2 months, of a minimum of 5 residents and associated care practices. Audits will include: Verification that shared equipment (e.g., BP cuffs, vital sign machines) is disinfected between each resident use Observation of appropriate PPE use during wound care and resident contact Verification of presence of required isolation/EBP signage and implementation when indicated Corrective Action Loop: Any identified noncompliance will be corrected immediately at the time of observation. Staff will receive re-education and return demonstration prior to the end of the shift. The IP or designee will complete a follow-up audit within 24 hours to ensure compliance. Repeated noncompliance will be addressed through progressive discipline per facility policy. Reporting & Oversight: Audit findings will be reported weekly to the DON and Administrator during the monitoring period. Results will be presented at the monthly Quality Assurance (QA) Committee Meeting. The QA Committee will monitor compliance monthly until sustained 100% compliance is achieved. Responsible Parties: CNAs & Licensed Nurses: Infection control practices (PPE and equipment disinfection) Licensed Nurses: Initiation and maintenance of EBP Infection Preventionist (IP): Audits and surveillance DON/Designee: Oversight and enforcement Completion Date: 4/13/2026
Failure to Perform and Document Required 20-Year Sprinkler Head Testing
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to conduct the required 20-year testing of quick-response sprinkler heads in accordance with NFPA 25. During an interview and record review with the Director of Environmental Services (DES), the facility’s Life Safety materials binder was found to lack any record of a 20-year sprinkler test for the quick-response sprinkler heads installed throughout all four smoke compartments. The DES reported that the sprinklers were original to the building, which was constructed in 1999, and stated that the required testing may have been done in 2009, but there was no documentation on site to verify that the test had occurred. Further observation and interview showed that spare quick-response sprinkler heads in the facility’s stock had manufacturing dates such as 1996 and 1999 printed on them, confirming the age of the system components. The DES indicated that the outside testing company was unable to locate records from that time period to confirm whether the 20-year sprinkler testing had been performed. As a result, there was no evidence available to demonstrate that the required 20-year sprinkler head testing had been completed for the sprinkler system serving all four smoke compartments, as required by NFPA 25 and related Life Safety Code provisions.
Plan Of Correction
K353 – Sprinkler System Maintenance and Testing (NFPA 25) How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. There were no residents identified as directly affected by this deficient practice. Upon identification on 3/12/2026, the facility immediately contacted a licensed fire protection vendor to schedule the required 20-year sprinkler head testing. The sprinkler system remains fully operational and monitored, ensuring continued fire protection coverage while corrective actions are implemented. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. On 3/13/2026, the Director of Environmental Services (DES) conducted a review of all available Life Safety documentation to confirm the absence of records for the 20-year sprinkler testing across all smoke compartments. The contracted licensed vendor has been engaged and performed testing on representative sprinkler heads throughout the facility in accordance with NFPA 25 standards on 3/19/2026. Response time, response time index and water seal release all passed. The report is dated 3/20/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. To prevent recurrence, the facility has implemented a Life Safety compliance tracking system that includes all required inspection, testing, and maintenance schedules in accordance with NFPA 25. On 3/13/2026, the DES re-educated staff on regulatory requirements for sprinkler system testing, including 20-year testing requirements for quick-response sprinkler heads. The facility will maintain all Life Safety documentation in a centralized, secure, and readily accessible binder and electronic file. Additionally, the facility will contract with a licensed fire protection vendor to ensure ongoing compliance with all inspection and testing requirements. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system. The DES or designee will track all required Life Safety inspections and testing through a compliance calendar and conduct monthly audits to ensure all required documentation is current and on file. Results of these audits will be reported to the Administrator and reviewed quarterly in the Quality Assurance and Performance Improvement (QAPI) committee meeting. Any identified gaps will be addressed immediately. The QAPI committee will monitor compliance until sustained. Include dates when corrective actions will be completed. The corrective action completion dates must be acceptable to the State Agency.
Failure to Activate Fire Alarm System During Day and Evening Fire Drills
Penalty
Summary
Surveyors identified a deficiency in the facility’s conduct of fire drills, specifically the failure to activate and transmit the fire alarm signal during drills that occurred between 6:00 a.m. and 9:00 p.m., as required by NFPA 101, 2012 Edition, Section 19.7.1. Review of the Life Safety materials binder on 3/12/2026 showed that three of twelve documented fire drills—held at 9:30 a.m. on 4/8/2025, 5:30 p.m. on 5/2/2025, and 8:30 p.m. on 8/19/2025—were conducted outside the nocturnal hours of 9:00 p.m. to 6:00 a.m., yet the records indicated that the fire alarms were not activated during these drills. During an interview, the DES reported that for the 5:30 p.m. drill, staff may have chosen not to pull the alarm because it occurred around dinner time, and also suggested that the technician might have mistakenly documented that alarms were not activated, but the DES could not explain why the records were marked that way. This deficient practice was cited as having the potential to negatively affect staff response during an actual fire emergency, potentially affecting the health and safety of residents, staff, and visitors.
Plan Of Correction
K712 – Fire Drills (NFPA 101) How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. There were no residents identified as directly affected by this deficient practice. Upon identification on 3/12/2026, the Director of Environmental Services (DES) immediately re-educated staff responsible for conducting fire drills on requirements to activate and transmit the fire alarm signal during all drills conducted between 6:00 a.m. and 9:00 p.m. Fire drill procedures were reinforced to ensure compliance with NFPA 101 standards. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. On 3/13/2026, the DES conducted a review of all fire drill documentation for the past 12 months to ensure compliance with required alarm activation and documentation standards. Any identified discrepancies were reviewed, and staff involved were re-educated on proper fire drill procedures. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. To prevent recurrence, the facility has revised its fire drill policy to clearly require activation of the fire alarm system during all drills conducted between 6:00 a.m. and 9:00 p.m. On 3/12/2026, the DES contacted the company responsible for fire drills to ensure understanding of regulatory requirements, proper documentation, and expectations. On 3/31/2026 the DES in-serviced staff on compliance with required alarm activation and documentation standards. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system. The DES or designee will review all fire drill documentation monthly for 3 months to ensure compliance with alarm activation requirements and proper documentation. Findings will be reported to the Administrator and included in the quarterly QAPI meeting. Any identified issues will be corrected immediately. The QAPI committee will monitor compliance until sustained. Include dates when corrective actions will be completed. The corrective action completion dates must be acceptable to the State Agency. 4/1/2026
Non-GFCI Electrical Outlet Near Sink in Medication Room
Penalty
Summary
Surveyors found that the facility failed to ensure electrical safety in accordance with NFPA 70, National Electrical Code, 2011 Edition, Section 210.8. During an observation in Nursing Station 1's medication room, an electrical outlet was identified 18 inches from a sink that was not equipped with the required ground-fault circuit interrupter (GFCI). The Director of Environmental Services (DES) was present during the observation and confirmed that the outlet, located near the sink, did not have a GFCI. This deficiency affected one of four smoke compartments and was cited as noncompliance with NFPA 101 requirements for utilities, gas, and electric systems. No specific residents or their medical conditions were mentioned in relation to this deficiency, and the report focused solely on the physical environment and the noncompliant electrical installation near the sink in the medication room.
Plan Of Correction
K511 - Utilities - Gas and Electric (NFPA 70) How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. There were no residents identified as directly affected by this deficient practice. Upon identification on 3/12/2026, the facility immediately removed the outlet from use and implemented interim safety measures. A licensed electrician was contacted to install a GFCI-protected outlet at Nursing Station 1 medication room sink area. The GFCI outlet was installed on 3/12/2026 to ensure compliance with NFPA 70 requirements and reduce risk of electrical shock. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. On 3/12/2026, the Director of Environmental Services (DES) conducted a facility-wide audit of all electrical outlets located within proximity to water sources, including medication rooms, kitchen areas, and resident care areas. Any outlets identified as not GFCI-protected were immediately removed from service and scheduled for correction by a licensed electrician. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. To prevent recurrence, the facility has implemented a preventive maintenance program that includes routine inspection of all electrical outlets near water sources for GFCI compliance. On 3/13/2026, the DES re-educated staff on NFPA 70 requirements, specifically related to GFCI installation near sinks and wet locations. The facility will ensure that all future electrical work is reviewed for compliance with applicable codes and completed by licensed professionals. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system. The DES or designee will conduct weekly environmental rounds for 3 months to ensure all outlets near water sources are GFCI-protected and functioning properly. Findings will be reported to the Administrator and included in the quarterly QAPI meeting. Any deficiencies will be corrected immediately. The QAPI committee will monitor compliance until sustained. Include dates when corrective actions will be completed. The corrective action completion dates must be acceptable to the State Agency. 4/1/2026
Failure to Prevent Resident-to-Resident Verbal Abuse
Penalty
Summary
The facility failed to prevent verbal abuse when one resident verbally threatened, cursed, and yelled at another resident in the activities room. The resident who was verbally abused had intact cognitive skills and was generally independent in daily activities, while the resident who initiated the verbal aggression had moderately impaired cognitive skills and a history of verbal aggression. Multiple staff members, including an LVN, the Activities Director, and the Director of Nursing, directly observed or were made aware of the incident, which involved one resident yelling, cursing, and threatening to physically harm another resident. Following the incident, the affected resident was observed to be scared, upset, and unusually quiet for the remainder of the shift. The facility's policy explicitly states a zero-tolerance approach to any form of abuse, including resident-to-resident abuse, and defines verbal abuse as yelling, cursing, and threatening another resident. Despite this policy, the incident occurred and was witnessed by staff, with the affected resident experiencing emotional distress as a result. The report documents that the facility did not prevent the occurrence of verbal abuse between residents, as required by their own policy and regulatory standards.
Failure to Timely Report Alleged Abuse to State Authorities
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident to the California Department of Public Health within the required two-hour timeframe, as specified in the facility's policy and procedure. The resident, who was admitted with diagnoses including urinary tract infection, metabolic encephalopathy, and hypertension, was assessed as severely impaired in cognitive skills and required significant assistance with daily activities. On the morning of the incident, the resident reported an allegation of sexual abuse to a CNA, who then informed an LVN. The LVN subsequently notified the Director of Nursing (DON) and stated that all allegations of abuse must be reported within two hours to the police, Ombudsman, and the Department. Despite the internal notifications, the facility did not report the allegation to the Department within the required two-hour window. The administrator confirmed that the report to the Department was faxed more than three hours after the initial allegation was made, although notifications to the police and Ombudsman were made within the required timeframe. The facility's policy, revised in April 2018, clearly states that any observed, suspected, or known abuse must be reported to the Department, Ombudsman, law enforcement, and the administrator immediately, but not later than two hours.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to ensure that an alleged incident of abuse involving a resident with severe cognitive impairment was reported immediately, but no later than two hours after the allegation was made, as required by facility policy and state regulations. The resident, who had diagnoses including Alzheimer's disease and unspecified psychosis, was observed by staff attempting to get up from a wheelchair. During this event, a Licensed Vocational Nurse (LVN) was reported by multiple Certified Nursing Assistants (CNAs) to have repeatedly and loudly instructed the resident to sit down, which was perceived as yelling and considered by staff to be a form of verbal abuse. Despite the incident occurring on the same day as a documented fall, the allegation of abuse was not reported to the facility administrator or other required authorities within the mandated two-hour timeframe. Interviews with staff, including the Director of Staff Development (DSD), revealed that the administrator was not notified until the day after the incident, and the official report to the State Agency was not completed until over a month later. Facility policy and in-service training materials clearly stated that all suspected abuse must be reported immediately to the administrator and appropriate authorities. Documentation reviewed included progress notes, staff statements, and the facility's Report of Suspected Dependent Adult/Elder Abuse (SOC 341), all of which confirmed the delay in reporting. The failure to promptly notify the administrator and external agencies as required resulted in a delay in initiating protective measures and investigation for the resident involved.
Facility Lacks Effective Pest Control Program, Leading to Cockroach Infestation in Kitchen
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of cockroaches in the kitchen of a 59-bed facility. During an inspection, grease and dirt buildup were observed on the pipes and kitchen exhaust hood, and cockroaches were found near the dishwashing area. The kitchen had not undergone a deep cleaning recently, and the head chef, who was new to the facility, was unaware of the last deep cleaning date. The kitchen staff performed daily cleaning, but it was insufficient to prevent pest infestation. The Infection Preventionist (IP) confirmed that the kitchen had been closed for 48 hours due to the cockroach issue, and no food from the kitchen would be served to residents after lunch on the day of the inspection. The Director of Environmental Services (DES) and Housekeeping Supervisor (HKS) stated that a professional deep cleaning was conducted twice a year, with the last one completed several months prior. However, the housekeeping department did not clean the kitchen area, leaving it to the kitchen staff. The facility lacked a pest control policy, and the Administrator, who was also new, relied on vendor recommendations for pest control services. A review of vendor receipts revealed that recommendations to remove debris and seal entry points for pests had been pending since the previous year. The facility's policies did not include specific cleaning protocols for the kitchen, and the Infection Prevention & Control Program did not adequately address pest control measures. The U.S. Food & Drug Administration Food Code requires effective measures to eliminate pests in food establishments, which the facility failed to implement, leading to the observed deficiency.
Failure to Prevent Fall in Dementia Resident
Penalty
Summary
The facility failed to provide appropriate care and services to a resident diagnosed with dementia, leading to a fall and subsequent injuries. The resident, who had a history of Alzheimer's Disease and psychosis, was admitted to the facility with an unsteady gait and poor balance, making them at risk for falls. Despite these known risks, the facility did not ensure that the resident received adequate supervision or that their physician was notified of changes in their condition, such as increased agitation and confusion. On the day of the incident, the resident attempted to stand up unassisted from their wheelchair multiple times, indicating a change in condition that required immediate attention. However, the registered nurse failed to notify the resident's physician about these changes, as required by the facility's policy. Additionally, a certified nurse assistant took the resident to their room and left them unsupervised in bed, despite the resident's increased confusion and agitation. This lack of supervision resulted in the resident falling out of bed, sustaining a laceration, bruising, and abrasions. Interviews with staff revealed that the resident was known to be at risk for falls and required constant monitoring. However, there was a breakdown in communication and supervision, as the resident was left unsupervised in their room, leading to the fall. The facility's policies on dementia care, change in resident condition, and fall prevention were not followed, contributing to the incident and the resident's injuries.
Failure to Develop Individualized Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement individualized person-centered care plans for four residents, leading to potential unmet needs and incorrect care. Resident 37 experienced a change in skin condition on 1/11/2025, but a care plan was not developed to address this change. The resident's records indicated a new order for Optifoam dressing for protection, but no care plan was created to monitor and implement specific interventions for the unstageable pressure injury or deep tissue injury identified. Resident 27 was receiving Eliquis for atrial fibrillation, but there was no care plan for anticoagulant use. This omission meant there was no identification of the resident as high risk for bleeding or bruising, which could guide staff in implementing necessary interventions. Similarly, Resident 6 was on Quetiapine for poor impulse control, but no care plan was developed for antipsychotic use, leaving staff without guidance on monitoring the drug, its goals, and specific interventions for the resident's behavior. Resident 5, diagnosed with dementia, did not have a care plan addressing cognitive impairment and specific behaviors related to dementia. The absence of a care plan for this resident meant that their needs and continuity of care, especially concerning behavioral issues, were not adequately addressed. The facility's policy and procedure required comprehensive care plans to be developed within 14 days and updated quarterly or upon a change of condition, but these requirements were not met for the residents in question.
Deficient Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for two residents, Resident 32 and Resident 37, who were at risk for skin breakdown and pressure injuries. For Resident 32, the low air loss (LAL) mattress was improperly set at 550 pounds, despite the resident weighing only 138 pounds. This incorrect setting reduced the mattress's effectiveness in redistributing pressure and managing moisture, which are critical for preventing skin damage and pressure injuries. The Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) acknowledged that the mattress setting was too high and emphasized the importance of adjusting it according to the resident's weight to ensure effective pressure relief and prevent skin damage. Resident 37 experienced multiple deficiencies in care related to pressure ulcer prevention and treatment. The facility failed to document evidence of repositioning every two hours during the night shift over a month-long period, as required by the resident's care plan. Additionally, weekly skin assessments were not performed as indicated, and treatment for an unstageable pressure injury on the coccyx was missed on one occasion. The facility also delayed the initiation of pressure-relieving devices when the pressure injury was discovered. The Infection Prevention Nurse (IPN) and Registered Nurse (RN) acknowledged these lapses, noting that the lack of documentation and missed treatments could lead to worsening of the pressure injury. The facility's policy and procedure for skin and wound assessment and treatment were not followed, as evidenced by the lack of a change of condition documentation and the failure to implement a low air loss mattress promptly for Resident 37. The Director of Nursing and other staff members recognized the importance of creating a change of condition to inform the care team and ensure proper monitoring and treatment of pressure injuries. The deficiencies in care for both residents had the potential to result in the development of new pressure injuries and the worsening of existing ones.
Failure to Document Drug Allergies Accurately
Penalty
Summary
The facility failed to implement its policy on ordering and receiving non-controlled medications for two residents, leading to incorrect documentation of drug allergies in their electronic medical records (EMR). Resident 28, who had 12 documented drug allergies, received Ambien nine times in December 2024, despite it being listed as an allergy. Additionally, Resident 27's EMR did not reflect allergies to clindamycin and Norco, and incorrectly listed allergies to prednisone and prednisolone. Resident 28 was admitted with diagnoses including major depressive disorder, muscle weakness, and atrial fibrillation. Despite having intact cognitive abilities, Resident 28's EMR failed to accurately reflect their drug allergies, leading to the administration of Ambien, which was known to cause anxiety in this resident. Similarly, Resident 27, who had chronic systolic heart failure and hyperlipidemia, reported allergies to penicillin, sulfa, Norco, and some antibiotics, which were not accurately documented in their EMR. Interviews with staff and record reviews revealed that the discrepancies in allergy documentation were not communicated to the pharmacy, which could lead to the administration of contraindicated medications. The Director of Nursing acknowledged that the EMR's failure to trigger alerts for drug allergies posed a risk of adverse reactions, including anaphylaxis, due to incorrect allergy documentation.
Infection Control Lapses in PPE Use and Environmental Measures
Penalty
Summary
The facility failed to adhere to its infection prevention guidelines in several instances, leading to potential risks of infection transmission. In one case, a Certified Nursing Assistant (CNA) entered a resident's room without donning the required gown, despite the room being under enhanced barrier precautions due to the resident's medical condition. The CNA proceeded to perform peri-care without the appropriate personal protective equipment (PPE), which was acknowledged as a necessary measure to prevent the spread of multidrug-resistant organisms (MDROs). The Infection Prevention Nurse confirmed that proper PPE, including gowns and gloves, should have been used during such high-contact activities. In another instance, the facility did not follow its policy regarding the use of a portable HEPA filtration system for a resident who tested positive for COVID-19. The resident's door was left open to monitor for fall risks, but no air purifier was placed in the room, contrary to the facility's infection control policy. This oversight was acknowledged by both the Licensed Vocational Nurse and the Infection Prevention Nurse, who noted that the absence of an air purifier increased the risk of COVID-19 transmission to other residents, staff, and visitors. Additionally, a family member visiting the COVID-19 positive resident was observed not wearing the correct PPE, including gloves, a face shield, and a properly fitted N95 mask. The Infection Prevention Nurse noted that visitors are required to don all necessary PPE to prevent the spread of infection. Furthermore, a laundry aide prefilled disinfection logs, indicating tasks were completed before they were actually done, which was against the facility's policy. This practice was confirmed by the Environmental Services Director, who emphasized that logs should only be signed after tasks are completed to ensure proper infection control measures are followed.
Failure to Update Resident's Code Status
Penalty
Summary
The facility failed to implement its policy on Advance Directives by not ensuring the correct code status for a resident, referred to as Resident 27. Resident 27 had a Medical Doctor (MD) order for full code status, which indicates that all lifesaving procedures should be performed if the resident's heart stops or they stop breathing. However, there was also an Emergency Medical Services Prehospital Do Not Resuscitate (EMSPDNR) form signed, indicating a DNR status, which means no cardiopulmonary resuscitation should be performed. This inconsistency in documentation could lead to Resident 27 receiving incorrect emergency services. Interviews with staff, including a Licensed Vocational Nurse (LVN 1), the Social Services Designee (SSD), and the Director of Nursing (DON), revealed that the discrepancy was noted but not corrected in the electronic medical record (EMR). The SSD confirmed that the responsible party for Resident 27 had signed the DNR form, but the EMR still reflected a full code status. The DON acknowledged that the nursing staff should have updated the code status in the EMR upon seeing the signed EMSPDNR form. The facility's policy on Advance Directives requires staff to verify and update code statuses, which was not followed in this case.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to ensure that a registered nurse (RN 1) notified the physician (MD 1) regarding a change in condition for a resident (Resident 92). On 1/20/2025, Resident 92, who was diagnosed with Alzheimer's Disease and psychosis, exhibited increased agitation and confusion, attempting to stand unassisted from a wheelchair multiple times. Despite these changes, RN 1 did not inform MD 1 about the resident's altered condition, which was against the facility's policy and procedure for notifying physicians of changes in resident conditions. Interviews with the Director of Nursing (DON) and the RN Consultant (RNC) confirmed that the increased confusion and attempts to stand unassisted were considered a change in condition, requiring immediate notification to the physician. The hospice registered nurse (HRN 1) also indicated that the hospice agency was not informed of the resident's increased confusion, which would have prompted further assessment and potential intervention. The facility's policy, revised in 2016, mandates timely communication of any sudden or serious change in a resident's condition to the physician, which was not adhered to in this case.
Failure to Obtain Signed SNFABN Form for Resident
Penalty
Summary
The facility failed to ensure that the Advance Beneficiary Notice of Non-coverage (SNFABN) form was signed for a resident, identified as Resident 26. This form is crucial as it informs residents or their responsible parties about potential non-coverage of certain services by Medicare. The deficiency was identified during a review of Resident 26's records, which showed that the SNFABN form was not signed by either the resident or their responsible party. The Social Services Designee (SSD) confirmed that the absence of signatures on the SNFABN form could lead to disputes over billing and costs, as it indicates that the resident or their responsible party was not informed about the services and associated costs after the last covered date. Resident 26 was originally admitted to the facility with diagnoses including dementia, hearing loss, and visual loss, and was readmitted later. The resident's cognitive abilities were severely impaired, as indicated by the Minimum Data Set (MDS) and the History and Physical (H&P) documents, which noted that Resident 26 lacked the capacity to understand and make decisions. The facility's failure to have the SNFABN form signed meant that the resident or their responsible party might not have been able to make informed decisions regarding potential denied medical coverage.
Failure to Update Care Plans for Residents with Cognitive and Depressive Disorders
Penalty
Summary
The facility failed to revise the care plans for two residents, leading to deficiencies in their care. Resident 92, diagnosed with Alzheimer's Disease and psychosis, experienced increased confusion and agitation, as observed by staff on multiple occasions. Despite these changes, the resident's care plan was not updated to reflect the need for increased monitoring and interventions. Interviews with staff confirmed that the care plan should have been revised to address the resident's altered cognitive function and ensure appropriate care. Similarly, Resident 5, who has dementia and a depressive disorder, was prescribed Trazadone 100 mg for depression, but the care plan was not updated to reflect this change in medication dosage. The care plan still indicated a previous dosage of 50 mg, which did not align with the current physician's order. Staff interviews highlighted the importance of updating care plans to ensure that all staff are aware of the current treatment regimen and can provide proper care. The facility's policies on care planning and changes in resident condition emphasize the need for timely updates to care plans, which were not adhered to in these cases.
Failure to Implement Oxygen Therapy Policy
Penalty
Summary
The facility failed to adhere to its policy on Oxygen Therapy, resulting in a deficiency related to the care of a resident requiring supplemental oxygen. During an observation, it was noted that the resident's nasal cannula tubing was disconnected from the oxygen concentrator machine and was found on the floor, while the machine was still running at 3 liters. Additionally, the humidifier bottle attached to the oxygen concentrator was not labeled or dated as required by the facility's policy. The resident, who was admitted with chronic respiratory failure, asthma, and a dependence on supplemental oxygen, expressed uncertainty about receiving oxygen through the nasal cannula. Interviews with the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) revealed that the staff is responsible for dating the humidifier bottle, which should be changed weekly, and ensuring the nasal cannula is properly connected. The LVN acknowledged that the disconnection might have occurred accidentally during repositioning and emphasized the risk of infection from the nasal cannula touching the floor. The DON confirmed that the humidifier bottle should be dated to track its usage duration and reiterated the importance of connecting the nasal cannula to ensure the resident receives the necessary oxygen therapy.
Failure to Provide Scheduled Pain Medication
Penalty
Summary
The facility failed to ensure that a routine pain medication was available for a resident, leading to a deficiency in pharmaceutical services. The resident, who was admitted with a diagnosis of an unspecified fracture of the lower end of the left humerus, was on a scheduled pain medication regimen that included a Lidocaine external patch for pain relief. The Minimum Data Set indicated that the resident had frequent pain and required both scheduled and as-needed pain medication. However, during a medication administration observation, it was noted that the Lidocaine patch was not applied as scheduled because it was not available at the facility. Interviews with the Licensed Vocational Nurses (LVNs) revealed that the patch was not delivered by the pharmacy in time for the scheduled administration. The facility's Medication Administration Policy and Procedure required medications to be administered within 60 minutes of the scheduled time, but this was not adhered to due to the unavailability of the medication. The resident expressed the need for the Lidocaine patch to manage pain in the right shoulder, which was used more frequently than the left. The delay in medication delivery and administration was documented in the resident's Medication Administration Record and Progress Notes.
Inappropriate Use of Psychotropic Medication Without Documented Diagnosis
Penalty
Summary
The facility failed to ensure that psychotropic drugs were not used unnecessarily for one of the sampled residents, identified as Resident 32. The resident was prescribed Quetiapine, a medication used to treat bipolar disorder and schizophrenia, without a clear, documented diagnosis in the medical record to support its use. The resident's Admission Record indicated diagnoses of hemiplegia/hemiparesis, muscle weakness, and a need for assistance with personal care. The Minimum Data Set showed severe cognitive impairment and dependency on activities of daily living and mobility. Despite these conditions, there was no documented diagnosis justifying the use of Quetiapine for the resident's impulse control disorder, which was manifested by constantly calling for help. Interviews with the Psychiatric-Mental Health Nurse Practitioner and the Director of Nursing revealed that the prescription of Quetiapine was inappropriate due to the lack of a documented diagnosis. The facility's policy on psychotherapeutic medication use emphasized the need for a thorough clinical evaluation and a clear diagnosis before administering such medications. The policy also required gradual dose reductions and behavioral interventions unless clinically contraindicated. The failure to adhere to these guidelines resulted in the potential for unnecessary use of psychotropic drugs, which could lead to side effects and adverse consequences for Resident 32.
Sanitation and Food Handling Deficiencies in Kitchen
Penalty
Summary
The facility failed to ensure that the dietary staff stored and prepared food under sanitary conditions in the kitchen, which placed residents at risk for foodborne illness. During an observation, a cook was seen preparing rice while wearing a ball cap without a hairnet underneath, which is against the facility's policy for proper hair containment during food preparation. Additionally, expired food items, including cottage cheese containers and a cake mix, were found stored in the refrigerator and dry food area, respectively. Dented cans of marinara sauce were also stored in the dry food area, which could compromise the safety and integrity of the food. Interviews with the Sous-Chef and the Director of Dining Services confirmed that these practices were not in line with the facility's policies and procedures. Both staff members acknowledged that expired food should not be stored and that dented cans should be discarded due to the risk of contamination and potential for foodborne illness. They also emphasized the importance of wearing hairnets to prevent food contamination. The facility's policy on Food-Nutrition Services requires adherence to professional standards for food service safety, including proper sanitation and food handling practices to prevent foodborne illness.
Call Light Inaccessibility for Resident
Penalty
Summary
The facility failed to ensure that the call light was within reach for Resident 4, who was observed lying in bed with the mechanical pad call button tucked and hanging on the backside of the bed between the wall and the headboard, making it inaccessible. Resident 4 had been admitted with diagnoses including contracture of muscle, hemiplegia/hemiparesis, and age-related osteoporosis, and was dependent on assistance for activities of daily living and mobility. The resident could make needs known but could not make medical decisions, highlighting the importance of having the call light within reach. Interviews with staff, including a CNA and the DON, confirmed that the call light should have been clipped to the resident's gown or side rail for easy accessibility. The facility's policy and procedure on the call system, revised in 2009, stated that call cords should be placed within the resident's reach at all times. The failure to adhere to this policy had the potential to delay or prevent Resident 4 from obtaining necessary care and services.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of physical abuse involving a resident to the California Department of Public Health (CDPH) and law enforcement within the required two-hour timeframe. The incident involved a Certified Nursing Assistant (CNA) who allegedly squeezed the resident's brief around the genitalia area to check if it was wet. The facility's investigation commenced on September 13, 2024, after receiving a complaint through the corporate compliance department. However, the incident was not reported to the CDPH, local police, and Ombudsman until September 16, 2024, which was beyond the mandated reporting period. The resident involved had been admitted to the facility with diagnoses including encephalopathy, muscle weakness, hypertensive heart disease, and acute diastolic heart failure. The resident was capable of making needs known but unable to make medical decisions. The facility's abuse prevention policy and procedure required immediate reporting of suspected abuse resulting in serious bodily injury within two hours. The delay in reporting this incident resulted in a deficiency, as it had the potential to subject residents to further abuse.
Failure to Remove CNA During Abuse Investigation
Penalty
Summary
The facility failed to immediately remove a potential threat to a resident after receiving a report of alleged inappropriate conduct by a Certified Nursing Assistant (CNA). The incident involved CNA 1, who was reported to have squeezed a resident's brief around the genitalia area to check if it was wet. Despite the report, the facility did not suspend CNA 1 from resident care duties during the investigation, which is contrary to the facility's abuse prevention policy that mandates making every attempt to prevent further potential abuse while an investigation is in progress. Resident 2, who was involved in the incident, had a medical history including encephalopathy, muscle weakness, hypertensive heart disease, and acute diastolic heart failure. The resident was capable of making needs known but could not make medical decisions. The facility's investigation report, which commenced on the same day the complaint was received, was unable to substantiate the complaint of inappropriate touching. However, CNA 1 continued to work their regular schedule throughout the investigation period, indicating a failure to adhere to the facility's policy of non-tolerance towards any form of behavior that might be construed as abuse.
Delayed Reporting of Verbal Abuse Incident
Penalty
Summary
The facility failed to report an alleged verbal abuse incident involving two residents within the required timeframe to the State Survey Agency, Long-Term Ombudsman, and local law enforcement. The incident occurred in the dining room during a Cinco de Mayo celebration, where one resident verbally threatened another. Despite the altercation being witnessed by the Activities Director, it was not reported immediately to the appropriate authorities or facility staff, leading to a delay in addressing the situation. Resident 2, who was admitted with multiple diagnoses including hypertensive heart disease and moderate cognitive impairment, was involved in a verbal altercation with Resident 3. Resident 3, also with multiple diagnoses and moderate cognitive impairment, was reported to have used profane language and threatened Resident 2. The altercation was documented by a Licensed Vocational Nurse and later communicated to the Director of Nursing, who notified the Primary Care Provider. However, the incident was not reported to the necessary external agencies until more than 24 hours later. The facility's policy requires immediate reporting of any suspected abuse to the relevant authorities within two hours. Interviews with staff revealed a lack of immediate action and communication regarding the incident, contributing to the delay in reporting. The Administrator confirmed the late reporting, which was contrary to the facility's established procedures for handling abuse allegations.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Claremont
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pilgrim Place Health Services Center | 0.2 mi | ★★★★★ | 20 | 0 |
| Mount San Antonio Gardens | 0.6 mi | ★★★★★ | 1 | 0 |
| Claremont Heights Post Acute | 1 mi | ★★★★★ | 24 | 0 |
| Claremont Care Center | 1.4 mi | ★★★★★ | 14 | 0 |
| Landmark Medical Center | 1.4 mi | ★★★★★ | 26 | 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 July 2026) and official state health department websites.