Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at College Vista Post-acute during CMS and state inspections, most recent first.
The facility failed to address significant weight loss for one resident and failed to manage fluid intake for another resident. One resident with DM and depression lost over 16% of body weight in six months, while staff did not reassess food preferences, document IDT follow-up, or monitor supplement intake. Another resident with ESRD on hemodialysis had a fluid restriction order, but staff left a full water pitcher at bedside and the restriction was not reflected in the care plan as assessed by the RD.
Ice machine cleaning and hand hygiene lapses were observed. A dietary staff member and the Maintenance Supervisor identified that the ice machine reservoir pan had not been cleaned as required, and black particles were seen when the pan was wiped. During meal service, a CNA set up one resident’s tray, left without hand hygiene, and then delivered another resident’s tray; the CNA said she was in a hurry and forgot. The residents involved had severe cognitive impairment, and one required setup assistance with eating while the other had dementia and Parkinson’s disease.
A DOR who was a COTA transcribed PT findings into JMAs for two residents instead of the JMAs being independently assessed by a qualified PT. One resident had Parkinson's Disease, hemiplegia/hemiparesis, and contractures, yet the JMA understated severe ROM limits documented in the PT eval and observed during PROM. Another resident with dementia and lower-extremity limitations had a JMA showing WFL despite PT and bedside observations showing impaired positioning and mobility. The DOR stated she transposed the PT assessment into the JMA and did not know what the impairment levels meant in degrees.
A resident with parkinsonism, dementia, impaired vision, and dependence with ADLs was observed in bed with the flat call light placed above the pillow at the head of the bed rather than within reach. A CNA stated the resident could not use the call light because her hands were tucked under the blanket and he had forgotten to place it back on her chest after lunch. The DON also observed the call light out of reach and stated the resident needed the flat call light because she could not use a button call light.
Failure to Ensure Ombudsman Notification for Transfer/Discharge: A resident admitted with acute respiratory failure, Type 2 DM, and lung cancer was discharged to a hospital, but the facility did not ensure the Notice of Proposed Transfer/Discharge was successfully sent to the State LTC Ombudsman. The fax transmission report showed a busy signal, and an LVN stated he faxed the notice but did not notice the failed transmission.
A facility failed to ensure the MDS accurately reflected ROM limitations for two residents. One resident with Parkinson’s disease, prior stroke, and contractures had PT findings showing severe lower-extremity limitations, but the JMA/MDS documented lesser impairment. Another resident with spinal stenosis and dementia had inconsistent MDS entries regarding lower-extremity ROM, while staff stated the MDS information came from the JMA completed by rehab staff. The DON acknowledged that inaccurate JMA information made the MDS inaccurate and that accurate MDS data was important for the care plan and needed services.
A comprehensive person-centered care plan was not developed for one resident's fluid limitation and another resident's ankle contracture. One resident with ESRD, chronic pulmonary edema, and DM had edema and fluid-shift-related weight changes, but the care plan addressed diet and weight monitoring rather than fluid restriction. Another resident with spinal conditions and dementia had limited ankle mobility, yet the care plan did not specifically address the ankle contracture despite staff acknowledging the joint limitation.
Inaccurate ROM Assessments and MDS Documentation: The facility failed to accurately document joint mobility for two residents with limited ROM. One resident with Parkinson’s disease, stroke-related weakness, and knee contracture had PT findings showing fixed or severely limited knee and ankle movement, but the JMA and MDS entries did not match those findings and reflected less impairment. Another resident with spinal stenosis and dementia had lower-extremity mobility documented inconsistently across OT/PT records, JMA, and MDS, and the annual lower-extremity PT assessment was not completed for the prior year.
Failure to monitor psychotropic medication side effects: A resident with Alzheimer’s disease, dementia, and psychosis had an order for Risperidone 0.5 mg BID for sudden angry outbursts, but staff did not have specific side effects listed in the MD order to guide monitoring. An LVN said altered mental status would be monitored, another LVN cited nausea and vomiting, and the DON stated the side effects needed to be included in the physician order; the care plan directed staff to notify the MD if behaviors, side effects, or adverse effects were present.
Inaccurate documentation was found for two residents. A resident with dementia and anxiety had Lorazepam given for anxiety, but the MAR recorded no behavior observed before the dose. Another resident with ESRD, DM, and chronic pulmonary edema had Dilaudid documented at the wrong dose in the progress note, and the resident’s current weight was also entered incorrectly in the IDT record. The DON confirmed the medication and weight entries were inaccurate, and the facility policy required factual, accurate, and complete documentation.
Failure to Explain Arbitration Agreement to Residents: The facility did not ensure that three residents with intact cognition and documented capacity understood the binding arbitration agreement or their right to refuse it. Each resident stated they did not recall the agreement being explained or did not remember signing it, while the AC said she was responsible for explaining the agreement within 48-72 hours of admission and relied on asking residents if they understood it.
The facility did not develop or implement individualized care plans with measurable objectives and interventions for four residents with complex medical needs, including one on anticoagulant therapy, one with impaired immunity, one with severe vision impairment, and one requiring a therapeutic diet. The absence of these care plans was confirmed by the DON and dietary supervisor, and relevant monitoring and documentation were not performed as required.
Surveyors found that expired medication was not discarded and controlled drugs were not stored in a separately locked compartment. An LVN and the DON confirmed that expired glucose gel remained in the medication room past its expiration date, and Lorazepam for two residents with severe cognitive impairment was stored with non-controlled medications in a single-locked refrigerator, contrary to facility policy.
Two residents dependent on care were observed asleep in bed with their bodies and briefs exposed, as their blankets were left to the side. Both the DON and a CNA acknowledged the exposure as a dignity and privacy issue, which was not in line with the facility's policy to maintain resident dignity and privacy.
A resident with cellulitis and depression was discharged home with home health services, but the MDS was incorrectly coded as a transfer to an acute hospital. Record review and staff interviews confirmed the error, with the MDS Coordinator acknowledging the mistake and the DON confirming the inaccuracy in documentation.
A resident receiving Lovenox for DVT prophylaxis was not adequately monitored for side effects, specifically signs and symptoms of bleeding, as required by facility policy. Despite administration of the medication, there was no documentation in the electronic medical record to show that staff monitored for adverse effects, and this was confirmed by the DON during record review and interview.
A resident with multiple medical conditions was prescribed Lovenox for DVT prophylaxis, to be administered subcutaneously. An LVN was observed preparing to administer the medication intramuscularly, initially stating the incorrect route and not checking the MAR before preparation. The error was identified before administration, but the incident revealed a failure to follow proper medication administration procedures for high-risk medications.
Surveyors found unsanitary conditions in the kitchen, including white residue under the sink, paint remnants on the floor from a fallen tile, and exposed drywall. Both the Dietary Supervisor and Maintenance Supervisor confirmed these findings and acknowledged the potential for food contamination, which was inconsistent with the facility's food safety policy.
Two residents with cognitive impairment were asked to sign Arbitration Agreements without proper explanation or notification of their right to refuse or rescind. Staff failed to provide information in an understandable manner, and agreements were backdated due to missing records. This resulted in a violation of residents' rights to make informed decisions about their care.
A resident with severe cognitive impairment and multiple fall risk factors experienced a fall resulting in a fracture, but the facility did not complete a new fall risk assessment or revise the care plan as required. Staff did not implement the facility's fall prevention protocols, such as the Falling Star Program or visual alerts, and the DON confirmed that assessments and care plan updates were not performed according to policy.
A resident with hepatic encephalopathy and cirrhosis of the liver filed a grievance after a disturbance with their roommate. Although a room change was made, the facility failed to provide a written grievance decision as required by policy. The Social Service Director did not document the grievance in progress notes or provide a report to the family, deferring communication to the DON and Administrator. The facility's policy required a written summary, but only a nursing progress note was given to the family.
A resident at high risk for pressure injuries developed a Stage 2 pressure injury due to the facility's failure to provide necessary care and interventions. The resident, with conditions such as hepatic encephalopathy and morbid obesity, was not repositioned every two hours or kept clean and dry, leading to the injury. Despite a care plan indicating the need for frequent repositioning and skin care, the injury was confirmed upon discharge to home health services.
A resident did not receive necessary wound care as ordered by the physician, leading to discharge with staples still in place. The TXN failed to assess and document the resident's skin condition, and the LVN copied previous notes instead of conducting her own assessment. This resulted in a lack of proper wound care and communication among staff.
A resident was discharged without proper coordination of Home Healthcare services and Lovenox injection instructions, leading to a lapse in necessary medical care. The facility lacked documentation and a policy for ensuring referrals and communication for discharged residents, as acknowledged by the DON.
A resident at an LTC facility suffered second-degree burns after smoking a cigarette while on oxygen, due to inadequate supervision and failure to adhere to the facility's smoking policy. The resident, known for non-compliance, accessed smoking materials and lit a cigarette, resulting in a flash fire. The facility did not implement the resident's care plan interventions or maintain control of smoking materials, and lacked designated staff for smoking supervision.
A resident with COPD was involuntarily secluded by an LVN who blocked access to the patio with a table, preventing the resident from smoking outside scheduled times. The resident's care plan required supervision for smoking due to oxygen use, but the LVN's actions led to the resident feeling upset. The facility's policy on resident protection was not followed.
A resident receiving continuous oxygen therapy was left unsupervised and lit a cigarette, resulting in second-degree burns due to a fire. The facility's smoking policy lacked specific actions for noncompliant residents, particularly those using oxygen. The resident, with a history of COPD and moderate cognitive impairment, was usually supervised, but staff failed to remove his oxygen on this occasion.
A resident with dementia experienced agitation, leading to a transfer to a hospital. The facility failed to notify the resident's responsible party in a timely manner, informing them nearly seven hours after the change in condition. The Director of Nursing intended to notify the family but became busy, resulting in a delay that violated the facility's policy and the resident's rights.
A resident was found unresponsive and not breathing, but the LVN delayed CPR to check the code status, contrary to facility policy. The resident, with a full code status, was later pronounced dead at a hospital. The facility's emergency cart was also inadequately stocked, lacking essential CPR items.
A resident with respiratory failure, pneumonia, and COPD did not receive adequate respiratory care in a facility. Despite expressing feeling unwell and requesting an oxygen tank replacement, the LVN did not conduct a respiratory assessment or notify the physician. The facility also failed to develop a care plan or notify the physician of changes in the resident's condition. When the resident was found unresponsive, CPR was delayed while the LVN verified the code status, contributing to the resident's transfer to a hospital where she later passed away.
The facility failed to ensure call lights were within reach for four residents, as required by policy and care plans. A resident with dementia had her call light behind the bed headboard, while another's was hanging off the bed. Two other residents had their call lights either touching the floor or wrapped around equipment. Staff confirmed the importance of accessible call lights to prevent accidents and ensure timely assistance.
A resident with a full code status was found unresponsive, but CPR was delayed as staff verified the code status. Despite the facility's policy for immediate CPR, the LVN and CNAs did not start CPR until the code status was confirmed from the paper chart, leading to a delay in life-saving measures.
A facility failed to follow enhanced standard precautions when an LVN provided care to a resident with a G-tube without wearing a gown, despite the resident being on enhanced precautions due to long-term G-tube use. The LVN acknowledged the oversight, and the DON confirmed the necessity of PPE to prevent infection spread. The facility's policy requires gowns and gloves during high-contact care activities.
A resident was transported to the shower room without proper body coverage, exposing their upper legs, which compromised their dignity. The incident was observed by the DON, who instructed the CNA to cover the resident. The resident had conditions including diabetes and hyperlipidemia and was capable of making decisions. Interviews with staff emphasized the importance of maintaining resident dignity.
A resident at risk for pressure ulcers was found on a low air loss mattress incorrectly set for a weight over 350 lbs, while the resident weighed 197.4 lbs. This setting error, confirmed by an LVN, contradicted the facility's policy requiring mattress settings based on weight, potentially compromising pressure ulcer prevention.
A facility failed to ensure a physician documented a response to a pharmacist's recommendation regarding the use of Seroquel for a resident. The pharmacist suggested reevaluating the medication and considering a gradual dose reduction, but the physician's response was not recorded. The facility did not follow its policy to act on medication review recommendations.
A facility failed to ensure the correct route of medication administration for a resident, as the bubble pack labels did not match the physician's orders and MAR. The resident, with severe cognitive impairment and multiple diagnoses, was prescribed medications to be administered via a gastrostomy tube, but the labels indicated oral administration. An LVN identified the discrepancy during a medication verification process, highlighting the importance of matching physician orders with medication labels to prevent errors.
Failure to Manage Weight Loss and Fluid Restriction
Penalty
Summary
The facility failed to maintain acceptable nutritional status for two residents. Resident 28, admitted with diagnoses including type II diabetes mellitus and depression, lost 17.3 pounds, or 16.29% of body weight, over six months. The record showed the resident had intact cognition and required varying levels of assistance with eating, hygiene, toileting, bathing, and transfers. The IDT care conference documented that the resident was receiving fortified foods, Health Shake three times daily, snacks three times daily, and Boost three times daily, with average meal intake of 61% and no snack intake. The conference also noted significant weight loss and recommended medical evaluation for an appetite stimulant. Resident 28’s weight continued to decline, and the facility did not reassess the resident’s food preferences after the weight loss was identified. The resident stated she preferred Asian foods such as Pilipino and Chinese food, but the facility did not offer those choices and staff did not ask her what she liked or disliked eating. The Dietary Supervisor stated she did not reassess and document the resident’s likes and dislikes after the severe weight loss began. The DON stated she failed to document key clinical actions related to the resident’s significant and continued weight loss, including the Change of Condition documentation and required IDT meetings. The DON also stated the facility did not inform the family, did not ask them to provide preferred foods, did not document the rationale for the physician declining an appetite stimulant, and did not monitor or record supplement intake to determine whether the supplements were effective. The facility also failed to manage Resident 8’s fluid intake as ordered. Resident 8 had ESRD, chronic pulmonary edema, diabetes mellitus, and received hemodialysis. The RD assessed the resident and recommended a fluid intake of 1800 ml based on caloric needs, but this recommendation was not included in the care plan. The care plan later included a fluid restriction of 1200 ml every 24 hours, and the physician order also reflected a 1200 ml restriction. Despite this, the resident was repeatedly observed with a full water pitcher at the bedside, and the resident stated he was not aware of the fluid restriction. The CNA stated the resident was not on a fluid water restriction, while the LVN stated the resident should not have had a full water pitcher at bedside due to the physician order. The RD stated he did not include the recommended fluid intake in the care plan, and the DON stated the resident should have been on a fluid restriction.
Ice Machine Cleaning and Hand Hygiene Lapses
Penalty
Summary
The facility failed to ensure the ice machine was cleaned according to manufacturer specifications and its own monthly cleaning policy. During observation, the bottom of the reservoir pan inside the ice machine was wiped with a paper towel and small black particles were seen on the towel. The Dietary Supervisor stated the particles should not be inside the reservoir pan, and a staff member stated the reservoir pan had not been cleaned even though the inside of the ice machine had recently been cleaned. The Maintenance Supervisor reviewed the monthly cleaning log and stated the ice machine was not cleaned for 57 days between documented cleanings. The Infection Preventionist stated the ice machine should be thoroughly cleaned inside and outside every 30 days to ensure ice is free of contamination and prevent infection among residents. The facility also failed to ensure hand hygiene was performed between resident contacts during meal service. Resident 23 had diagnoses including CHF and dementia, with severely impaired cognition and memory and required setup or clean-up assistance with eating. Resident 7 had dementia and Parkinson's disease, with severely impaired cognition and memory and required substantial assistance with several activities of daily living. During dining observation, a CNA set up Resident 23's meal tray, assisted the resident to sit up, and then left the room without performing hand hygiene before obtaining and delivering Resident 7's meal tray. The CNA stated she was in a hurry and forgot to perform hand hygiene before and after passing meal trays between residents. The DON stated hand hygiene is important when passing meal trays between residents to prevent the spread of infection, and the facility policy required hand hygiene between resident contacts.
Inaccurate JMA Documentation by Unqualified Staff
Penalty
Summary
The facility failed to ensure that specialized rehabilitative services were provided by qualified personnel when the Director of Rehabilitation, who was a Certified Occupational Therapist Assistant, transcribed Physical Therapist evaluation findings into the Joint Mobility Assessment for two residents. The Joint Mobility Assessment was supposed to be completed by rehabilitative staff, and the report states that the DOR completed and documented the JMA based on the PT's assessment rather than independently assessing the residents. The facility's policy stated that rehabilitative staff would complete the JMA upon admission, annual assessment, and change in condition. For one resident, the record showed diagnoses including Parkinson's Disease, hemiplegia/hemiparesis after cerebral infarction, and a left knee contracture. The PT evaluation documented severe limitations, including the right knee fixed in neutral with no flexion or extension, the left knee bent at 40 degrees and unable to straighten fully, and both ankles fixed in 50-degree plantar flexion with no dorsiflexion. However, the JMA completed by the DOR described the left knee flexion as within functional limits, the right knee extension as minimally impaired, and the bilateral knees and ankles as moderately impaired. During observation, the resident's legs and feet were positioned in a way consistent with contractures, and the restorative aide stated the resident's legs and ankles were stiff and could not move normally during PROM exercises. For the second resident, the record showed diagnoses including lumbar spinal stenosis, lumbar spondylolysis, and dementia, with severe cognitive impairment and need for moderate assistance with ADLs and transfers. The PT evaluation documented bilateral lower extremity ROM as within functional limits, while the JMA completed by the DOR also stated the bilateral knees and ankles were within functional limits. Yet the resident was observed sitting and later lying with both ankles and toes pointed downward and away from the body. The PT stated that a resident who does not ambulate would not be considered within functional limits on the JMA, and the DOR stated that she transposed the PT's assessment into the JMA and did not know what the impairment levels meant in degrees.
Call Light Not Within Reach
Penalty
Summary
The facility failed to ensure the call light was within reach for one sampled resident who was re-admitted with diagnoses including parkinsonism, dementia, and type 2 diabetes mellitus. The resident’s MDS indicated clear speech, minimum hearing difficulty, impaired vision, intermittent understanding, a mechanically altered diet, bowel and bladder incontinence, and dependence with ADLs. The care plan identified an ADL self-care performance deficit related to activity intolerance, impaired balance, and functional quadriplegia, with an intervention to encourage use of the call bell for assistance. During observation, the resident was in bed talking to self and stated her back was itchy while trying to wiggle against the mattress; the flat call light was observed at the head of the bed above the pillow. A CNA stated the call light was beyond the resident’s reach and that the resident could not use it because she could not move her hands, which were tucked under the blanket. The DON also observed the call light hanging over the head of the bed and stated it was not within reach. The CNA later stated he usually places the call light on the resident’s chest but had forgotten to put it back after serving lunch. The DON stated the resident has parkinsonism and rigidity, that the flat call light was provided because she could not use a button call light, and that the call light should always be within reach. The facility policy stated staff will ensure the call light is within reach of the resident and secured as needed.
Failure to Ensure Ombudsman Notification for Transfer/Discharge
Penalty
Summary
The facility failed to ensure that the Notice of Proposed Transfer/Discharge was sent to the Office of the State Long-Term Care Ombudsman for one resident who was discharged to a general acute care hospital. The resident was admitted with diagnoses including acute respiratory failure, Type 2 DM, and malignant neoplasm of the lung. A history and physical dated 12/25/2025 indicated the resident had the capacity to understand and make decisions, while a later MDS dated 4/29/2026 indicated the resident's cognitive skills for daily decision making were moderately impaired. During interview and record review, the Medical Records Director reviewed the transmission verification report for the fax sent on 1/2/2026 and stated the result showed the transmission to the Ombudsman was busy, meaning the Ombudsman did not receive the required notice of the resident's transfer/discharge. An LVN stated he signed the Notice of Transfer/Discharge and faxed it to the Ombudsman on 1/2/2026, but did not notice that the fax result was busy. The facility policy titled Transfer and Discharge stated the facility will maintain evidence that the notice was sent to the Ombudsman.
Inaccurate MDS documentation of residents’ ROM limitations
Penalty
Summary
The facility failed to ensure that the MDS accurately reflected residents’ functional ROM limitations for two sampled residents. For one resident with Parkinson’s disease, prior stroke with left-sided hemiplegia/hemiparesis, and a left knee contracture, the record showed limited mobility and ROM needs, including PROM exercises and splint use. The resident’s PT evaluation documented severe limitations in the lower extremities, including a right knee fixed in neutral with no flexion or extension, a left knee bent at 40 degrees and unable to fully straighten, and both ankles fixed in plantar flexion with no dorsiflexion available. However, the JMA entered into the MDS described the left knee flexion as within functional limits, the right knee extension as minimally impaired, and the bilateral knees and ankles as only moderately impaired. For the second resident, who had spinal stenosis, lumbar spondylolysis, and dementia, the care plan included assisted ROM to both lower extremities and monitoring for immobility-related issues. The MDS first indicated no functional ROM limitations in the upper and lower extremities, and another MDS later indicated impairment on one side of the lower extremity. The PT evaluation documented bilateral lower extremity ROM within functional limits, while the JMA also stated the bilateral lower extremities were within functional limits. During interviews, the MDS nurse stated the MDS information came from the JMA completed by rehabilitation staff, and the DOR stated that PT assessed residents for the JMA and that because the resident was not walking, the lower extremities were within functional limits. Survey observations and interviews showed inconsistencies between the residents’ actual joint status and the documentation used for the MDS. One resident was observed with the left leg bent at the knee and both ankles positioned in plantar flexion, and restorative staff described the resident’s legs and ankles as stiff with limited movement. PT staff later stated that the JMA entries understated the severity of the ROM limitations and that the documented findings should have reflected more severe impairment. The DON stated that if the JMA was inaccurate, then the MDS was inaccurate, and that accurate MDS information was important for the interdisciplinary plan of care and necessary services. The facility’s P&P stated that licensed nurses complete the appropriate MDS sections to reflect residents’ functional and movement abilities and that the assessment process includes direct observation and communication with the resident and staff.
Care Plans Not Developed for Fluid Restriction and Ankle Contracture
Penalty
Summary
A comprehensive person-centered care plan was not developed and implemented for Resident 8 to address fluid limitation. The resident was admitted with diagnoses including ESRD, chronic pulmonary edema, and DM. The MDS dated 3/9/2026 indicated intact cognitive skills and that the resident needed assistance with meals. The care plan titled "The Resident Has Nutritional Problem or Potential Nutritional Problem," dated 3/11/2026, focused on diet compliance, food preferences, weight monitoring, and intake monitoring, but did not address fluid restriction. Resident 8's nutritional assessment dated 3/12/2026 documented non-pitting edema to both lower extremities, a history of large weight changes due to fluid shifts, and a recommended fluid intake of 1800 ml. During interview, the DON stated that Resident 8 was not on a fluid restriction diet as recommended by the RD and stated that dialysis residents, unless they refused, should have a fluid restriction care plan. The facility policy on fluid restriction stated that fluid restriction is to be followed as ordered by the physician and is used for underlying medical conditions such as ESRD. A person-centered care plan was also not developed for Resident 34's left ankle contracture. Resident 34 was admitted with diagnoses including spinal stenosis, spondylolysis, and dementia. The MDS dated 2/5/2026 indicated severely impaired cognitive skills, moderate assistance needs for ADLs and functional mobility, and no functional ROM limitations in the upper or lower extremities. The existing care plan, revised 5/9/2024, addressed limited physical mobility related to spinal stenosis and lumbar spondylosis and included monitoring for immobility-related issues, but did not include a specific care plan for the ankle contracture. During record review and interview, the MDSN stated there was no care plan developed for the right ankle contracture and that, because both ankles were limited, there should have been a care plan to address the joint limitation and prevent further decline. PT 1 later assessed Resident 34 and stated the resident had joint mobility limitation in both the right and left ankle.
Inaccurate ROM Assessments and MDS Documentation
Penalty
Summary
The facility failed to ensure that two residents with limited ROM received accurate joint mobility assessment and MDS documentation, and it failed to ensure that one resident received the annual PT assessment in 2025. Resident 5 had diagnoses including Parkinson’s disease, hemiplegia/hemiparesis following cerebral infarction, and left knee contracture. The resident’s PT evaluation documented fixed or severely limited movement in the right knee and both ankles, and the left knee could not fully straighten to neutral. However, the JMA entries did not match the PT findings: the 2025 JMA described the left knee as minimally impaired and the right knee and bilateral ankles as severely impaired, while the 2026 JMA described the left knee as within functional limits, the right knee as minimally impaired, and the bilateral knees and ankles as moderately impaired. The MDS entries also did not accurately reflect the resident’s functional ROM limitations. Resident 34 had diagnoses including lumbar spinal stenosis, lumbar spondylolysis, and dementia, and the care plan called for assisted ROM to the bilateral lower extremities with hip, knee, and ankle flexion and extension exercises. The record showed that the resident’s lower extremities were not accurately assessed or documented across the rehabilitation and MDS process. An OT evaluation documented upper extremity strength but did not document lower extremity assessment, and the JMA recorded the bilateral lower extremities as within functional limits. The MDS initially indicated no functional ROM limitations in the upper or lower extremities, and a later MDS indicated impairment on one side of the lower extremity. The PT evaluation on 4/28/2026 documented bilateral lower extremity ROM as within functional limits, but the PT did not document Resident 34’s right ankle strength because the resident complained of discomfort and was not reassessed that day. Surveyor interviews and observations showed that the documentation did not align with the residents’ actual joint mobility. Resident 5 was observed with the left leg bent at the knee and both ankles positioned in plantar flexion, and RNA staff described fixed or stiff lower extremities during ROM exercises. PT staff stated that the JMA entries were inaccurate compared with the PT evaluations, including a 5-degree loss of ROM in Resident 5’s right knee from the prior year. For Resident 34, PT staff stated that the JMA showing bilateral lower extremities within functional limits was not accurate for a resident who did not ambulate, and the DOR stated that Resident 34 did not receive the annual lower extremity evaluation for 2025. The facility policy required JMA completion on admission, annually, and with change in condition, and the PT job description required accurate documentation of evaluations and treatment records.
Failure to Monitor Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to prevent unnecessary use of psychotropic medication for one resident by not monitoring side effects of Risperidone in accordance with the physician's order and the facility policy titled, Use of Psychotropic Medication(s). The resident was admitted with diagnoses of Alzheimer's Disease, dementia, and psychosis, and had an order for Risperidone oral tablet 0.5 mg twice a day for psychosis manifested by sudden angry outburst. The resident's care plan for psychosis directed staff to notify the MD if any behaviors, side effects, or adverse effects were present. During interviews, an LVN stated the physician order did not specify which side effects to monitor and that altered mental status would be monitored, while another LVN stated nausea and vomiting would be considered even though they were not included in the order. The DON stated staff should know where to locate medication side effects, that nurses need to look them up, and that the side effects need to be included in the physician order. The facility policy stated psychotropic medication effects should be monitored on an ongoing basis in accordance with nurse assessment and medication monitoring consistent with standards of practice.
Inaccurate MAR, weight, and medication documentation
Penalty
Summary
The facility failed to accurately document Resident 4’s use of Lorazepam in the MAR. Resident 4 was admitted with diagnoses including dementia and anxiety disorder, and the MDS dated 5/4/2026 indicated severely impaired cognition and memory. The physician ordered Lorazepam 1 mg by mouth every 8 hours as needed for anxiety manifested by verbalization of anxiety or excessive crying for 14 days, but the MAR for 5/4/2026 showed the medication was administered at 10:11 AM with the behavior observation documented as “NO,” indicating no anxiety behaviors were recorded before the dose was given. During interview, the LVN who administered the medication stated he mistakenly documented “No” under behaviors observed on 5/4/2026 and acknowledged the MAR was inaccurate because Resident 4 did have behavioral symptoms at the time. The DON also reviewed the MAR and stated the nurse had documented Lorazepam as administered without a specific behavior indicated for the intended use of the medication. The facility policy on documentation required entries to be factual, objective, accurate, and complete. The facility also failed to accurately document Resident 8’s weight and Dilaudid administration. Resident 8 had diagnoses including ESRD, chronic pulmonary edema, and DM, and the MDS dated 3/9/2026 indicated intact cognitive skills. The physician ordered Dilaudid 1 mg by mouth every 6 hours as needed for severe pain, but the progress note dated 5/12/2026 at 3:39 AM documented that 2 mg was administered by mouth. In addition, Resident 8 was weighed at 179.7 lbs on 5/12/2026, but the Interdisciplinary Care Conference dated 5/11/2026 documented a current weight of 171.6 lbs; the DON stated this was not the correct weight and that the resident had been documented incorrectly in the clinical record.
Failure to Explain Arbitration Agreement to Residents
Penalty
Summary
The facility failed to inform and ensure that three residents understood the terms of the facility’s binding arbitration agreement and their right to refuse it, as required by the facility’s policy titled Arbitration Agreement. Resident 6 was admitted with diagnoses including MS, GERD, and hydronephrosis; the H&P indicated the resident had capacity to understand and make decisions, and the MDS indicated intact cognitive skills. During interview and record review, Resident 6 stated the signed arbitration agreement looked like her signature, but she did not recall anyone explaining what an arbitration agreement was and said she may have been confused on admission or may have been told to sign it without explanation. Resident 20 was admitted with diagnoses including acute kidney failure, hypothyroidism, and acute respiratory failure with hypoxia; the H&P indicated capacity to understand and make decisions, and the MDS indicated intact cognitive skills. During interview and record review, Resident 20 stated the arbitration agreement looked vaguely familiar but she did not recall what it was about and said the form did not look familiar. Resident 12 was admitted with diagnoses including rhabdomyolysis, cardiomegaly, and Type 2 DM; the H&P indicated capacity to understand and make decisions, and the MDS indicated intact cognitive skills. During interview and record review, Resident 12 stated the arbitration agreement record did not look familiar and he did not remember it being explained to him. The Admission’s Coordinator stated she was responsible for explaining the arbitration agreement within 48-72 hours of admission and assessed understanding by asking residents if they understood it; the facility’s arbitration agreement record stated the resident and/or representative certifies the agreement has been read, understood, and a copy provided.
Failure to Develop and Implement Individualized Care Plans for Residents with Complex Needs
Penalty
Summary
The facility failed to develop and implement individualized, person-centered care plans with measurable objectives, timeframes, and interventions for four residents with diverse and significant medical needs. For one resident receiving Lovenox, an anticoagulant, there was no care plan addressing interventions and goals related to the medication, despite physician orders and administration records confirming its use. The Director of Nursing (DON) acknowledged that a care plan was necessary for anticoagulant therapy to guide staff in monitoring for adverse effects such as bleeding and to provide appropriate interventions in emergencies, but no such plan was present. Another resident with impaired immunity due to a viral infection, specifically HIV, had a care plan that included monitoring for delirium as an intervention. However, there was no evidence that staff were monitoring or documenting signs and symptoms of delirium as required. The DON confirmed that the care plan did not specify the frequency of monitoring or documentation, and that this monitoring was not being performed, despite its importance in preventing complications related to immune deficiency. A third resident with severe vision impairment due to glaucoma and diabetes had no care plan addressing their specific activity needs. The DON stated there was no coordination with the activity director to develop a plan tailored to the resident's visual impairment, which could lead to isolation or behavioral issues. Additionally, a fourth resident with diabetes and chronic kidney disease did not have a care plan addressing their nutritional needs, including interventions for monitoring food brought from outside the facility. The dietary supervisor and DON both confirmed the absence of a care plan for this resident's therapeutic diet, despite the risk of noncompliance with dietary restrictions.
Improper Storage and Handling of Expired and Controlled Medications
Penalty
Summary
Surveyors identified that the facility failed to properly store and discard expired medication and did not store controlled substances in accordance with facility policy and professional standards. During an observation in the medication storage room, a box of expired Microdot glucose gel was found in a cabinet. The LVN present acknowledged that the medication was expired and had not been noticed or discarded as required. The DON confirmed that expired medications were supposed to be checked and removed weekly but admitted missing the removal of the expired glucose gel at the end of the previous month. Additionally, the facility did not store Lorazepam, a controlled medication, in a separately locked compartment as required. Two vials of Lorazepam for one resident and one vial for another were found stored with non-controlled medications in a single-locked medication refrigerator. Both the LVN and DON confirmed that Lorazepam should be double locked and stored separately from non-controlled medications, in line with facility policy. The residents involved had significant cognitive impairments and required substantial assistance with daily activities.
Residents Left Exposed in Bed, Violating Dignity and Privacy
Penalty
Summary
Two residents were not treated with respect and dignity when their bodies were left exposed while they were asleep in bed. For one resident with dementia and alcoholic cirrhosis, observations showed that the resident's brief was visible and their gown was up, exposing the chest, arms, and lower body, with the blanket placed to the side. The resident was dependent on care and unable to make medical decisions, and the DON confirmed that the resident's lower body was exposed and identified this as a dignity issue. For another resident with a history of cerebral vascular accident and hemiplegia, who was also dependent on care and had moderately impaired cognition, observations revealed that the resident's lower body and brief were exposed, with the blanket placed to the side. A CNA present during the observation acknowledged that the resident's body was exposed and stated this was a privacy issue. A review of the facility's policy on promoting and maintaining resident dignity indicated that residents should be treated with respect and dignity, and their privacy should be maintained. The policy emphasized the importance of caring for residents in a manner that maintains or enhances their quality of life and recognizes their individuality. The observed incidents were not in accordance with this policy, as both residents were left exposed and their privacy was not maintained.
Inaccurate MDS Discharge Coding for Resident Discharged Home
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for a resident who was discharged home with home health services. The MDS was incorrectly coded to indicate that the resident had been transferred to an acute hospital, which did not reflect the actual discharge disposition. This error was identified during a review of the resident's records, which included an admission for cellulitis of the right lower limb and depression, physician orders for discharge home with home health, and progress notes confirming the resident left the facility in stable condition to go home. Interviews with the MDS Coordinator and the Director of Nursing confirmed that the discharge status was inaccurately documented in the MDS. The MDS Coordinator acknowledged the mistake and stated that the discrepancy was not noticed until pointed out by the surveyor. The Director of Nursing also confirmed the inaccuracy in the documentation. The CMS Resident Assessment Instrument (RAI) Manual requires that MDS discharge assessments accurately reflect the resident's discharge location and care needs, which was not met in this instance.
Failure to Monitor and Document Anticoagulant Side Effects
Penalty
Summary
The facility failed to ensure adequate monitoring and documentation of potential side effects for a resident who was receiving Lovenox, an anticoagulant medication. The resident, who had a history of a displaced intertrochanteric fracture of the left femur, anemia, and hyperlipidemia, was prescribed Lovenox injections for DVT prophylaxis. Despite receiving the medication as ordered, there was no documentation in the electronic medical record to indicate that the resident was monitored for signs and symptoms of bleeding, a known risk associated with anticoagulant therapy. During interviews and record reviews, the Director of Nursing confirmed that staff are expected to monitor and document any side effects of Lovenox, including bleeding, in the electronic medical record. However, a review of the resident's Medication Administration Record and electronic medical record revealed no evidence that such monitoring occurred during the period the resident received Lovenox. The facility's policy on high-risk medications, including anticoagulants, requires staff to monitor for adverse consequences and document these observations, but this was not followed in this case.
Failure to Ensure Proper Administration Route for Anticoagulant Medication
Penalty
Summary
Facility staff failed to ensure that a resident receiving anticoagulant therapy was free from significant medication errors. The resident, who had a history of a displaced intertrochanteric fracture of the left femur, anemia, and hyperlipidemia, was prescribed Lovenox to be administered subcutaneously for deep vein thrombosis prophylaxis. The physician's orders and the facility's policies clearly indicated that Lovenox should be given via the subcutaneous route. During medication administration, a licensed vocational nurse (LVN) was observed preparing to administer Lovenox to the resident. The LVN initially stated that the medication was to be given intramuscularly and was about to proceed with this incorrect route. Upon further review and verification, the LVN realized the error and acknowledged that the medication should be administered subcutaneously, as per the physician's order. The LVN also admitted to not checking the Medication Administration Record (MAR) prior to preparing the injection, which contributed to the near-miss error. Interviews with the LVN and the Director of Nursing (DON) confirmed that administering Lovenox intramuscularly would have been a significant medication error, as the correct route is subcutaneous. The facility's policies require staff to verify the medication, dose, and route against the MAR before administration, especially for high-risk medications like anticoagulants. The failure to follow these procedures resulted in a deficiency related to medication administration practices.
Unsanitary Kitchen Conditions and Food Contamination Risk
Penalty
Summary
Surveyors observed that the facility failed to maintain a safe and sanitary kitchen environment. During the initial kitchen tour, white residue was found underneath the sink by the drainage pipe, and white paint remnants were present on the kitchen floor due to a fallen tile. Additionally, there was an area of exposed drywall in the kitchen. These conditions were confirmed during interviews with both the Dietary Supervisor and the Maintenance Supervisor, who acknowledged the presence of residue, paint chips, and exposed drywall. Both supervisors stated that these unsanitary conditions had the potential to contaminate food prepared for residents. The facility's policy and procedure on food safety and storage indicated that food should be stored, prepared, distributed, and served in accordance with professional standards to prevent contamination. The policy defined contamination as the unintended presence of potentially harmful substances, including microorganisms, chemicals, or physical objects, and noted that foodborne illness could result from ingestion of contaminated food or beverages.
Failure to Properly Explain Arbitration Agreement and Inform Residents of Rights
Penalty
Summary
The facility failed to properly explain the Arbitration Agreement to two residents, both of whom had moderately impaired memory and cognition as documented in their Minimum Data Set assessments. One resident was asked to sign the agreement during a physical therapy session without any explanation or opportunity to read the document, and was not informed of the right to refuse or rescind the agreement. The resident later expressed concern about potentially giving up the right to present disputes in court and stated a desire to discuss the agreement with family before signing. Another resident was approached by two staff members and asked to sign the Arbitration Agreement without any explanation of its contents, being told only that it was "not something bad." The resident was unaware of the right to refuse to sign or to rescind the agreement, and the date on the form was entered by someone else without the resident's knowledge. Both residents' agreements were backdated by the Director of Admission due to missing electronic records, and the Director admitted to not providing a proper explanation or being aware of the residents' right to rescind. Interviews with staff revealed a lack of understanding regarding the Arbitration Agreement and the residents' rights associated with it. The facility's policy requires that the agreement be explained in a manner understandable to the resident or representative, explicitly inform them of their right not to sign, and grant the right to rescind within 30 days. These requirements were not met, resulting in a violation of the residents' rights to make informed decisions about their care.
Failure to Revise Care Plan and Implement Fall Prevention After Resident Fall
Penalty
Summary
The facility failed to revise the care plan for a resident who was at high risk for falls, following a significant event where the resident sustained a fall resulting in a humerus fracture. The resident had a history of osteoarthritis and glaucoma, with severely impaired memory and cognition, and required varying levels of assistance with daily activities. Upon admission, the resident was assessed as high risk for falls, with a fall risk score of 17, and exhibited multiple risk factors including intermittent confusion, being chair bound, balance problems, use of assistive devices, polypharmacy, and multiple predisposing diseases. Despite these risk factors and the occurrence of a fall, the facility did not complete a new fall risk assessment after the incident, nor did they update the resident's care plan to reflect the change in condition. The care plan remained unchanged after the fall, and the resident was not placed in the facility's Falling Star Program, which is intended for residents with high fall risk scores. The facility's policies required fall risk assessments upon admission, annually, and after significant changes, but these were not followed in this case. Interviews with staff revealed a lack of awareness and implementation of fall prevention protocols, such as the use of a yellow star sticker to alert staff to residents at risk for falls. The DON confirmed that the required assessments and care plan revisions were not completed as per facility policy, and that the resident should have been included in the Falling Star Program based on their risk score and fall history.
Failure to Provide Written Grievance Decision
Penalty
Summary
The facility failed to provide a written grievance decision to a resident who filed a grievance, as required by their policy. The resident, who had been admitted with hepatic encephalopathy and cirrhosis of the liver, experienced a disturbance with their roommate. The grievance form indicated that a room change was made to address the issue, and it was noted that the resident and their family were satisfied. However, the form lacked signatures from the resident or their family, and verbal consent was noted without a date. Interviews with facility staff revealed that the Social Service Director (SSD) was informed of the incident and filled out the grievance form but did not document the grievance in the residents' progress notes. The SSD did not provide a grievance investigation report to the family due to previous issues with them and deferred communication to the Director of Nursing (DON) and Administrator (ADM). The facility's policy required a written summary report, but the DON admitted that no such report was prepared, and only a nursing progress note was provided to the family.
Failure to Prevent Pressure Injury in High-Risk Resident
Penalty
Summary
The facility failed to provide necessary care and interventions to prevent pressure injuries for a resident, resulting in the development of a facility-acquired Stage 2 pressure injury. The resident, who was at high risk for pressure injuries due to conditions such as hepatic encephalopathy, cirrhosis of the liver, morbid obesity, and moderate cognitive impairment, was not turned, repositioned, or offloaded every two hours while in bed. Additionally, the resident was not kept clean and dry after bowel movements or wetness from urine due to incontinence. The resident's Braden Score Assessment indicated a high risk for developing pressure injuries, and the care plan included interventions such as keeping the skin clean and dry and frequent repositioning. Despite these measures, the resident developed a Stage 2 pressure injury on the intergluteal cleft, which was noted on 2/16/25. The Treatment Nurse initially classified the injury as a pressure injury but later reclassified it as moisture-associated skin damage (MASD) due to the appearance of the skin. The facility's policy on pressure injury prevention and management emphasizes the prevention of avoidable pressure injuries and the provision of treatment to heal existing injuries. However, the facility's failure to adhere to these protocols resulted in the resident developing a pressure injury, which was confirmed upon discharge to home health services. The home health assessment noted the presence of a Stage 2 pressure injury with skin irritation, redness, and infection.
Failure to Provide Wound Care as Ordered
Penalty
Summary
The facility failed to provide necessary wound care according to the physician's orders for a resident who had undergone surgery. The Treatment Nurse (TXN) did not assess or provide wound care for the resident's surgical incision at the right hip, which had staples, from a specified date. Additionally, the TXN did not assess or provide wound care for the resident's left shin and perineal area on several occasions, as required by the physician's orders. The resident was admitted with a right hip fracture and required surgical wound care. The facility's records indicated that the resident had a surgical wound on the right hip with staples and another wound on the right lateral thigh. However, the TXN failed to conduct a thorough assessment and document the resident's skin condition weekly, as required. The TXN also discontinued the wound care order prematurely, assuming that the staples had been removed during an orthopedic appointment, which was not the case. The Licensed Vocational Nurse (LVN) involved did not assess the resident's skin condition accurately and copied previous notes instead of conducting her own assessment. This lack of proper documentation and communication among the nursing staff led to the resident being discharged with staples still in place, without appropriate instructions for wound care and follow-up. The Director of Nursing acknowledged these failures, emphasizing the importance of thorough assessments and accurate documentation to prevent such deficiencies.
Failure in Discharge Planning and Coordination
Penalty
Summary
The facility failed to develop and implement an effective discharge planning process for a resident, resulting in the resident not receiving necessary Home Healthcare services and Lovenox injections as prescribed by the physician. The resident was discharged with a bag of medications, including Lovenox syringes, without proper instructions on administration. The resident's representative expressed concerns about the lack of guidance and attempted to contact the facility for clarification but received no response. Interviews with facility staff revealed that the Registered Nurse instructed the resident's representative to contact the insurance company to set up home health services, but there was no documented evidence that the Social Service Designee coordinated these referrals. The Director of Nursing acknowledged the absence of a policy for contacting and documenting referrals for discharged residents, emphasizing the importance of ensuring residents receive required services upon discharge to prevent health decline.
Resident Suffers Burns Due to Inadequate Smoking Supervision
Penalty
Summary
The facility failed to ensure a resident was free from accident smoking hazards, leading to a serious incident. The resident, who was non-compliant with the facility's smoking policy, went to the outdoor patio to smoke a cigarette while on oxygen. This resulted in a flash fire that caused second-degree burns to the resident's face and hands. The resident was subsequently transferred to a burn center for further treatment. The facility did not implement the resident's care plan interventions, which required supervision while smoking. Despite being aware of the resident's non-compliance with the smoking schedule and policy, the facility staff failed to supervise the resident adequately. The resident was able to access smoking materials and light a cigarette while on oxygen, which was against the facility's policy. The facility's nursing staff did not maintain control of the resident's smoking materials as per the policy. Additionally, the care plan was not updated to reflect the resident's non-compliance with smoking protocols. The facility also lacked a designated staff member responsible for supervising residents while smoking, contributing to the incident.
Removal Plan
- Complete body assessment and inventory of Resident 1's personal belongings on readmission.
- Interdisciplinary team will provide education to Resident 1 on readmission regarding Resident Smoking policy, smoking information, and storage of smoking paraphernalia by nursing in a lockbox.
- All delivery/packages will be opened by the Activity Director in front of the resident to check for smoking paraphernalia.
- Daily room sweep by the assigned department manager and Manager of the Day on weekends.
- Resident 1 will be on one-on-one monitoring.
- Interdisciplinary team conducted care conference with Residents 2 and 3 that are smokers to discuss smoking safety, facility's smoking practices, and plan of care.
- Smoking safety assessment and care plans for Residents 2 and 3 were reviewed and revised by the Director of Nursing.
- Staff conducted room sweep for all residents with resident's permission to ensure there is no smoking paraphernalia stored in the rooms.
- Smoking schedule was revised by the interdisciplinary team to reflect assigned department who will oversee smoking schedule.
- Director of Staff and Development will in-service staff with various topics related to smoking safety and policy.
- Inservice to Activity Department regarding resident's package delivery.
- New hire or staff who were not able to attend the in-service will be educated prior to start of their scheduled shift.
- Interdisciplinary team created a preliminary Resident Smoking policy that reflects additional safety measure for non-compliance.
- The interdisciplinary team will obtain a written or verbal consent from the resident prior to the resident opening the package or delivery.
- The Nursing management team will oversee assigned caregivers and residents during designated smoking times.
- Interdisciplinary team will review admission and readmission to verify if resident uses tobacco.
- Activity Department or designee will deliver packages to the resident and will open the package in front of the resident.
- Department Managers or designee will conduct room rounds and Manager for the Day on weekends.
Involuntary Seclusion of Resident by LVN
Penalty
Summary
The facility failed to ensure that a resident was free from involuntary seclusion, which is defined as the separation of a resident from other residents or confinement to their room against their will. This incident involved a licensed vocational nurse (LVN) who blocked a door leading to the outdoor patio with a long table, preventing a resident from accessing the patio. The resident, who was a smoker, was upset by this action as it restricted their movement within the facility. The resident involved had a history of chronic obstructive pulmonary disease (COPD) and was using oxygen therapy. The resident's care plan included interventions for smoking safety, such as removing the oxygen tank before smoking and seeking staff supervision. Despite these interventions, the resident was non-compliant with the smoking schedule and protocols. On the night of the incident, the resident requested to smoke outside of the scheduled times, leading to a confrontation with the LVN. The LVN's actions were documented in a written statement, which indicated that the table was placed in a way that made it difficult for a wheelchair to pass. The Director of Nursing (DON) confirmed that the LVN intentionally blocked the resident's access to the patio, which was considered a form of seclusion causing psychosocial distress. The facility's policy on abuse, neglect, and exploitation emphasizes the protection of residents' rights and the prevention of harm, which was not upheld in this situation.
Failure to Ensure Smoking Safety for Resident on Oxygen Therapy
Penalty
Summary
The facility failed to develop a comprehensive smoking policy that ensured the safety of a resident who was noncompliant with the smoking policy. The resident, who was receiving continuous oxygen therapy, was allowed to keep a cigarette and lighter in his possession, which led to a serious incident. On the specified date, the resident was left unsupervised on the patio and lit a cigarette while still connected to an oxygen supply, resulting in a fire. The incident caused the resident to sustain second-degree burns on his face and hands, necessitating hospital transfer. The resident had a history of COPD exacerbation, respiratory failure, epilepsy, and muscle weakness, and was assessed as having moderate cognitive impairment. Despite these conditions, the facility's smoking safety assessments only recommended smoking cessation discussions and supervised smoking, without addressing the specific risks associated with oxygen therapy. Interviews with the Director of Nursing revealed that the facility's smoking policy lacked specific actions for noncompliant residents, particularly those using oxygen. The policy did not include increased monitoring or safety measures to prevent such incidents. The resident reported that staff usually removed his oxygen before smoking but failed to do so on this occasion, leading to the accident.
Failure to Notify Responsible Party of Resident's Change in Condition
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the notification of a resident's responsible party in the event of a change in condition. Resident 1, who was diagnosed with unspecified dementia, cognitive communication deficit, and dysphagia, experienced a change in condition due to agitation. Despite the facility's policy requiring notification of the resident's responsible party, the family member was informed nearly seven hours after the change in condition and after the resident had been transferred to a general acute care hospital. The incident began when Resident 1 exhibited signs of agitation, including stealing other residents' nasal cannulas and belongings. A Licensed Vocational Nurse (LVN) observed these behaviors and documented them in a Change in Condition Evaluation. The LVN was instructed by the Director of Nursing (DON) not to contact the family member, as the DON intended to do so herself. However, the DON became busy and did not notify the family member until much later, resulting in a significant delay in communication. The facility's policies clearly state the requirement to inform the resident's representative of any significant changes in condition, treatment alterations, or transfers. The DON acknowledged the oversight and admitted that the family member should have been informed prior to the resident's transfer to the hospital. This failure to communicate in a timely manner violated the resident's rights and the facility's own policies, potentially impacting the resident's well-being.
Failure to Initiate Immediate CPR and Inadequate Emergency Cart Stocking
Penalty
Summary
The facility failed to provide immediate CPR to a resident, identified as Resident 41, who was found unresponsive, without a pulse, and not breathing. The Licensed Vocational Nurse (LVN 1) delayed initiating CPR because they first checked the resident's code status and called for assistance instead of starting CPR immediately. This delay occurred despite the facility's policy and procedure, which required immediate CPR initiation in such situations unless a Do Not Resuscitate (DNR) order was present. Resident 41 had a full code status, meaning they wished to be revived if their heart stopped beating or they stopped breathing. The resident was admitted with diagnoses including congestive heart failure, acute respiratory failure with hypoxia, and chronic obstructive pulmonary disease. On the day of the incident, the resident was found unresponsive in bed by LVN 1, who then left the room to verify the resident's code status before starting CPR. This delay in initiating CPR was critical, as the resident was later transferred to a General Acute Care Hospital, where they were pronounced dead. Additionally, the facility's emergency cart was found to be inadequately stocked with essential items needed for CPR, such as an Ambu-bag, glucometer, and pulse oximeter. This lack of preparedness could have further contributed to the delay in providing life-saving measures. The facility's policy required that emergency carts be fully stocked and ready for use, but this was not adhered to, as evidenced by the missing items during the surveyor's inspection.
Removal Plan
- (DON) had a 1:1 in-service with the licensed nurse assigned to Resident 41 regarding Medical Emergency Response. Disciplinary action was taken with licensed nurse who delayed the CPR on the full code resident and was suspended pending investigation.
- The Medical Records Director (MRD) or designee completed a chart audit on every resident and compared the Advance Directive/Physician Orders for Life Sustaining Treatment (POLST) to the physician order for accuracy.
- The facility emergency cart checklist was revised by the DON. The glucometer, glucose strips, lancets, nebulizer, and nebulizer kit were added. The updated form will be utilized by licensed nurses. The emergency cart was checked by the DON for appropriate supplies and equipment. No issues were identified.
- The Resource Nurse Consultant (RNC) and Respiratory Therapy Consultant designee educated licensed nurses and certified nurse assistance (CNAs) on the facility's policy and procedure for Medical Emergency Response and location of code status for each resident. Licensed nurses and CNAs were not permitted to work a shift until education was completed. Nurses on leave will receive education prior to their next scheduled shift.
- The RNC and Respiratory Therapy Consultant initiated Code Blue drill to be completed on all shifts randomly by using the facility landline's paging system located at the nurse's station, hallway outside room, between rooms, activity room, rehabilitation room and office rooms (Administrator, DON, Dietary, SSD office), and announcing Code Blue to room. Licensed nurses and CNAs were in-serviced by the RNC regarding the paging system. The licensed nursing and CNAs staffs who were not scheduled to work will participate in the Code Blue drill during their scheduled shift.
- The RNC, (Director of Nursing) DON and (Director of Staff Development) DSD conducted an audit of licensed nurses and certified nurse assistants (CNAs) CPR certification. No issues were identified.
- Newly hired licensed nurses and CNAs will have their CPR certification card on file and have competency prior to their scheduled shift.
- DON or designee will audit new admissions chart to compare the resident's Advance Directives/ POLST to the physician orders for accuracy. This audit will continue for three months. Findings will be reviewed at the monthly QA (Quality Assurance) Committee meeting for discussion and recommendations.
- Licensed nurse will print the daily code status from PCC orders and will place it in the binder labeled Code Status located at the nurse's station. The SSD will oversee that the code status is available and updated daily. In the absence of SSD, the license nurse working will verify that the code status is updated.
- The POLST will be reviewed and verified by the DON and SSD immediately after admission of the resident to the facility. The RN Sup will oversee the POLST in the A Quality Assurance Performance Improvement (QAPI) Performance Improvement Project (PIP) was implemented.
- DON or designee to complete weekly mock code drills on all shifts and monitor code status compliance by interviewing licensed nurses about facility CPR policy and procedure, as well as requesting return demonstration of CPR process. Any trends will be discussed during monthly Quality Assurance meeting which will be held scheduled monthly. The DON will conduct compliance audits weekly for three months. Findings will be reported at monthly QA Committee meeting for discussion and recommendations.
- The DON will randomly audit the emergency cart on a weekly basis in addition to the daily checks from licensed nurse to ensure that the equipment and supplies are stocked as indicated on the emergency cart checklist. This audit will continue for three months. Findings will be reviewed at the monthly QAA (Quality Assurance) Committee meeting for discussion and recommendations.
Failure to Provide Adequate Respiratory Care and Emergency Response
Penalty
Summary
The facility failed to provide adequate respiratory care for a resident with respiratory failure, pneumonia, and COPD, who was receiving continuous oxygen therapy. The resident expressed feeling unwell and requested a replacement for what she believed was an empty oxygen tank. However, the Licensed Vocational Nurse (LVN) did not conduct a respiratory assessment or notify the primary physician, despite the resident's medical history and symptoms. The facility did not evaluate the need for a physician's order for oxygen therapy upon the resident's admission, nor did they notify the physician to administer oxygen at the prescribed rate. Additionally, the facility failed to develop a resident-centered care plan addressing the resident's respiratory needs and did not notify the physician of changes in the resident's condition, as required by the facility's policies. When the resident was found unresponsive, the LVN delayed initiating CPR while attempting to verify the resident's code status, contrary to the facility's emergency response policy. This delay, along with the lack of proper respiratory assessment and physician notification, contributed to the resident's transfer to a hospital where she was found pulseless and later passed away.
Removal Plan
- Administrator notified the facility Medical Director of Immediate Jeopardy incident.
- Licensed nurses identified was in-serviced by the DON regarding Physician notification when there is a change of condition focusing on respiratory system, respiratory assessment, and management of disease such as COPD, respiratory failure with hypoxia and oxygen therapy. Identified license nurse was suspended pending investigation.
- The DON and Registered Nurse (RN) Supervisor reviewed the 13 residents with oxygen therapy orders, COPD diagnosis and respiratory distress with hypoxia for signs of respiratory distress or change of condition.
- The Minimum Data Set (MDS, a comprehensive standardized assessment and screening tool) nurse reviewed in-house residents with diagnosis of COPD and respiratory failure with hypoxia for the implementation of resident centered care plans.
- Licensed nurses will check that residents are receiving the appropriate oxygen therapy as ordered at the start of their shift. When placing residents from oxygen concentrators to oxygen tanks, licensed nurses will verify the oxygen order to ensure that the liters per minute being administered matches the order.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that the call lights were within reach for four residents, as required by the facility's policy and the residents' care plans. Resident 34, who was admitted with diagnoses including unspecified dementia and Alzheimer's disease, was observed with her call light behind the bed headboard and out of reach. During an interview, Resident 34 stated she did not know where her call light was located, and a certified nursing assistant confirmed that the call light should be within reach to prevent accidents and falls. Resident 17, admitted with metabolic encephalopathy and unspecified dementia, was observed with the call light hanging off the bed and touching the floor, making it inaccessible. A certified nursing assistant confirmed that the call light should be within reach to allow the resident to alert staff for assistance and prevent accidents. The Director of Nursing also emphasized the importance of having the call light within reach to avoid distress and potential accidents. Residents 29 and 31 also experienced similar issues with their call lights. Resident 29's call light was found hanging from the bed and touching the floor, while Resident 31's call light was wrapped around a feeding pump, making it inaccessible. Staff members confirmed that the call lights should be within reach to enable residents to call for help and prevent accidents. The facility's policy on call light accessibility was not adhered to, leading to the potential for delayed care and increased risk of falls for these residents.
Delay in CPR Initiation Due to Code Status Verification
Penalty
Summary
The facility failed to ensure that five out of five employees had the necessary competencies and skills to provide cardiopulmonary resuscitation (CPR) for a resident, identified as Resident 41, who required life-saving measures. This deficiency was identified during a review of the incident where Resident 41 was found unresponsive in bed. Despite having a POLST indicating full code status, there was a delay in initiating CPR due to the staff's inability to immediately verify the resident's code status. Resident 41 had a history of acute on chronic systolic heart failure, acute respiratory failure with hypoxia, and chronic obstructive pulmonary disease. The resident's POLST, signed by both the resident and a physician, indicated that CPR should be attempted in the event of cardiac arrest. However, when the resident was found unresponsive, the Licensed Vocational Nurse (LVN) on duty delayed CPR to verify the code status, which was not immediately available in the electronic medical records. This delay occurred despite the facility's policy that CPR should be initiated immediately unless a Do Not Resuscitate (DNR) order is confirmed. Interviews with staff revealed that the LVN and Certified Nursing Assistants (CNAs) present did not start CPR until the LVN confirmed the code status from the paper chart. The Director of Nursing (DON) confirmed that the facility's policy required immediate CPR initiation, and any delay could result in adverse outcomes. The facility's policies emphasized the importance of high-quality CPR and immediate action in emergencies, which were not adhered to in this case, leading to a delay in life-saving measures for Resident 41.
Failure to Follow Enhanced Standard Precautions
Penalty
Summary
The facility failed to adhere to their enhanced standard precaution protocol, which is designed to prevent the transmission of multi-drug resistant organisms (MDROs) in skilled nursing facilities. This deficiency was observed when a Licensed Vocational Nurse (LVN) provided care to a resident without wearing the appropriate personal protective equipment (PPE), specifically a gown, while handling the resident's gastrostomy tube (G-tube). The resident, who had severe cognitive impairment and was on enhanced standard precautions due to long-term G-tube use, was at risk of exposure to infectious organisms due to this oversight. The incident was confirmed through interviews and record reviews. The LVN acknowledged the failure to wear a gown during the procedure, despite the presence of a blue sticker indicating the need for enhanced standard precautions. The Director of Nursing (DON) confirmed that enhanced standard precautions were necessary for residents who could expose staff to bodily fluids, such as during G-tube care, to prevent the potential spread of infections. The facility's policy on enhanced barrier precautions, revised in April 2024, mandates the use of gowns and gloves during high-contact resident care activities, including device care of feeding tubes.
Failure to Maintain Resident Dignity During Transport
Penalty
Summary
The facility failed to ensure that a resident was treated in a dignified and respectful manner, as evidenced by an incident involving a Certified Nursing Assistant (CNA) transporting a resident to the shower room without appropriate body coverage. During the observation, it was noted that the resident's left and right upper legs were exposed while being transported in a shower chair through the hallway. This incident was observed by the Director of Nursing (DON), who instructed the CNA to cover the resident appropriately to maintain dignity and privacy. The resident involved in the incident had been admitted to the facility with diagnoses including type 2 diabetes mellitus, hypokalemia, and hyperlipidemia. The resident was noted to have the capacity to understand and make decisions. Interviews with the CNA and the DON highlighted the importance of ensuring residents' bodies are fully covered to uphold their dignity and prevent feelings of exposure or discomfort. The facility's policy on promoting and maintaining resident dignity, dated December 19, 2022, emphasizes the responsibility of all staff members to respect resident rights and dignity.
Incorrect Mattress Setting for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to ensure that a resident's low air loss mattress was set correctly according to the resident's weight, which is crucial for the prevention of pressure ulcers. The resident, who was at risk for developing pressure ulcers, was observed lying on a mattress set at a level intended for individuals weighing over 350 pounds, while the resident's actual weight was 197.4 pounds. This incorrect setting was identified during an observation and interview with an LVN, who confirmed that the mattress should have been set at a lower level based on the resident's weight. The resident, who had severe cognitive impairment and required assistance with mobility, was at risk for pressure ulcers as indicated by their Braden Scale assessment. The facility's policy required that support surfaces be used according to physician orders and evidence-based practices, which included setting the mattress according to the resident's weight. The Director of Nursing acknowledged that incorrect settings could lead to ineffective pressure ulcer management, placing the resident at risk for developing pressure ulcers or other complications.
Failure to Document Physician Response to Pharmacist's Medication Review
Penalty
Summary
The facility failed to ensure that the attending physician acted upon and documented the rationale for the consultant pharmacist's recommendation regarding the use of the psychotropic medication Seroquel for a resident. The consultant pharmacist had recommended reevaluating the necessity of the medication, considering a gradual dose reduction (GDR), and documenting the rationale for continuing therapy if deemed necessary. However, the physician's response to this recommendation was not documented in the resident's clinical records. The resident involved had been admitted with diagnoses including metabolic encephalopathy and cellulitis. The resident's medication review report indicated an active order for Seroquel to manage psychosis symptoms. Despite the consultant pharmacist's recommendation, there was no documented evidence that the facility had notified the resident's primary physician or obtained a response regarding the continued use of Seroquel. The facility's policy required action on all medication regimen review recommendations, but this was not followed in this case.
Medication Administration Route Discrepancy
Penalty
Summary
The facility failed to ensure that the route of medication administration matched the label on the bubble pack, the physician's orders, and the Medication Administration Record (MAR) for a resident. This deficiency was observed during a review of the resident's medication administration process. The resident, who had diagnoses including metabolic encephalopathy, parkinsonism, and unspecified dementia, was prescribed Bromocriptine Mesylate and Divalproex Sodium to be administered via a gastrostomy tube. However, the bubble pack labels indicated oral administration, which did not align with the physician's orders. During an observation, a Licensed Vocational Nurse (LVN) verified the medications and noted discrepancies between the bubble pack labels and the MAR. The LVN acknowledged the importance of matching the physician's orders with the medication labels to prevent potential medication errors, such as choking. The facility's policy on medication administration emphasized the need for licensed nurses to administer medications as ordered by the physician and to verify the medication source with the MAR to ensure accuracy in resident name, medication name, form, dose, route, and time.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 8,135 citations issued within 25 miles in the last 12 months — including the 24 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Los Angeles
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Solheim Senior Community | 0.6 mi | ★★★★★ | 17 | 0 |
| Ararat Convalescent Hospital | 0.7 mi | ★★★★★ | 14 | 0 |
| Ararat Post Acute | 1.3 mi | ★★★★★ | 19 | 0 |
| Glendale Adventist Medical Center Dp/snf | 1.5 mi | ★★★★★ | 0 | 0 |
| Leisure Glen Post Acute Care Center | 1.7 mi | ★★★★★ | 14 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.