Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 Courtyard Care Center during CMS and state inspections, most recent first.
Surveyors found that staff failed to document meal assistance three times daily for two cognitively impaired, fully dependent residents who had orders for fortified, texture-modified diets and a feeding program. Review of Minimum Data Set assessments and active diet orders showed both residents required staff support for all ADLs, including eating, yet Documentation Survey Reports for multiple days in two consecutive months lacked evidence that meals were assisted and recorded. An RN supervisor confirmed the missing documentation during interview and record review, despite a facility policy requiring provision of a nourishing, well-balanced diet that meets each resident’s nutritional and special dietary needs.
A resident with dementia, muscle weakness, and dependence on staff for all ADLs, including feeding, had orders for a fortified mechanical soft diet and participation in a restorative nursing assistant feeding program, yet there was no documented evidence of feeding assistance for multiple meals on a specific day. Resident council minutes documented that call lights were not being answered in a timely manner, and a family member reported that there were not enough nurses, especially on weekends, causing delays in care. The RN supervisor confirmed the lack of meal-assistance documentation, and the DON confirmed CNA DHPPD on several days fell below the required 2.4 hours, stating that short staffing affected resident care, contrary to the facility’s staffing policy.
Two residents did not receive medications as ordered, and required MAR documentation was missing. One resident with severe cognitive impairment and multiple chronic conditions had undocumented and unadministered doses of Alendronate, Omeprazole, and Synthroid on several mornings. Another resident with dementia, a lower extremity fracture, and muscle weakness did not receive an ordered dose of Visine eye drops. An RN supervisor confirmed the missed administrations, and the DON stated that unsigned MAR entries indicate medications were not given, contrary to the facility’s medication administration policy.
Two residents with moderately impaired cognition and significant cardiopulmonary conditions developed new respiratory symptoms, including shortness of breath, cough, and congestion, but were not promptly tested for influenza, Covid-19, or a respiratory pathogen panel, and one was not immediately placed on TBP. Documentation showed several days’ delay between onset of symptoms and diagnostic testing, and delayed initiation of TBP for one resident. The IPN confirmed that both residents should have been tested for flu and Covid-19 right away and that TBP should have been implemented immediately, contrary to the facility’s infection control P&P and LA Department of Public Health guidance requiring immediate testing and empiric TBP for symptomatic individuals.
A resident with dementia, muscle weakness, and dependence on staff for all ADLs was found with a switch adaptive call light lying on the floor and out of reach, despite the resident’s stated need to have the device positioned under the forearm to activate it. A CNA confirmed the call light was inaccessible, and the DON acknowledged that all residents must have call lights within reach. Facility policy on answering call lights also required that call lights be kept within residents’ reach, but this was not followed, resulting in a delay in care and services.
QAPI Committee Failed to Implement Call Light Response Improvement Plan: The facility’s QAPI Committee did not implement its performance improvement project for staff call light response for all 56 residents. The QAPI plan identified call light response as a system issue, and the action plan called for the ADM and managers to ask residents about call light response to measure improvement. During record review, the ADM stated the Angel Daily Room Rounds did not document resident interviews about call light response and there was no documented evidence that the project elements were being carried out.
Incomplete Legionella Water Management Program: The facility failed to develop and implement a Water Management Plan for all residents. The MS stated he only measured water temperatures and ensured the ice machine was clean, while the IPN identified missing elements in the plan. The ADM stated there were no control measures applied or monitored, no interventions if limits were not met, and no documentation of program activities. The facility policy required an interdisciplinary team, water system diagram, identification of Legionella risk areas and situations, control measures, monitoring, response steps, and documentation.
Medication administration error rates were 7.41%, above the required 5% limit, because an LVN gave a resident two ordered meds without food even though both Indomethacin and Metformin were prescribed to be taken with food. The resident had DM, osteoarthritis, and gout, and both the resident and LVN stated breakfast had already been finished before the meds were given.
Opened medications were found without required dating for three residents. An LVN observed an opened UTI-Stat bottle without an open date, an RNS found an opened Lantus pen without an open date or expiration date, and another LVN observed an opened multivitamin with minerals bottle without an open date. The residents involved had diagnoses including DM, Parkinson's disease, and dementia, and facility staff stated the medications needed open dates for proper time-frame tracking.
Unsafe Food Storage and Handling Practices: Food items were found in the kitchen and storage areas without required dates or resident identifiers, including undated refrigerated items, dry goods, and frozen foods, while some dry goods were expired. During food prep, a CK wiped hands on clothing, kept spoons in a pocket, and changed tasks without hand hygiene, and the DS was observed wearing a watch that touched the food service counter.
Improperly Covered Trash Dumpsters: Two of two outside trash dumpsters were observed not completely closed and covered, with trash still present after pickup had not occurred. The DS stated the lids should be closed because open lids can allow bugs in and create an unsanitary environment. Facility policy required food waste to be placed in sealed containers, and Food Code required outside refuse units to be kept covered with tight-fitting lids or doors.
The facility failed to maintain documented COVID-19 2025 to 2026 vaccination status and evidence of education on the benefits and potential side effects of the vaccine for all employees, including physicians. The IPN reviewed the COVID staff vaccination roster and stated it was undated, did not show that all staff were educated or offered the current booster, and did not include physicians even though they have direct access to residents. The DON stated all staff need to be educated and offered the current COVID-19 booster, and the facility policy identified HCP as including physicians.
Failure to Notify Physician of Missed Dialysis Treatment: The facility did not notify the physician when a resident with ESRD and dependence on renal dialysis missed a scheduled dialysis session. Record review showed the resident had orders for dialysis three times weekly, but there was no documentation that the treatment was received or that the MD was informed. The DON stated physician notification was important so the MD could intervene and determine the next step.
A resident with a lumbar compression fracture and COPD did not receive the NOMNC at least 48 hours before the end of skilled coverage. The resident had no cognitive impairment and was able to understand and make decisions, but the NOMNC was dated earlier and signed on the last covered day. The MDSC and DON stated the notice should have been given at least 2 days before skilled services ended, consistent with facility policy.
A resident's MDS was coded inaccurately by indicating insulin injections were given when the MAR and physician orders showed no insulin administration or insulin orders. The MDSC confirmed the error during record review, and the DON stated assessments should accurately reflect the resident's plan of care and orders.
An LVN did not have an active BLS certification on file. The DSD reviewed the employee file and confirmed the certification was not active, while the DON stated all nursing staff, including CNAs, LVNs, and RNs, are required to maintain current BLS credentials and that expired certifications could affect CPR performance. The facility policy also required BLS/CPR certification for key clinical staff involved in resuscitative efforts.
Missed Scheduled Dialysis Session: A resident with ESRD and dependence on renal dialysis had orders for dialysis three times weekly, but the record lacked documentation that the resident received a scheduled treatment. The resident stated they missed a dialysis session, and the RNS confirmed there was no documentation of the treatment and that a missed session can lead to fluid overload; the DON stated missing dialysis can cause health deterioration or death.
Annual performance evaluations were not completed for two employees, CNA 2 and RNA 1. During record review, the DSD confirmed neither employee had a performance evaluation in the last 12 months, and the DON stated evaluations should be done every year. The facility policy stated evaluations are completed after the 90-day probationary period and at least annually thereafter.
A resident receiving IV Ceftriaxone for a right foot infection was not fully screened under the facility’s antibiotic stewardship process. The IPN stated the Individual Surveillance Form for Possible Infection was incomplete and did not show whether McGeer’s criteria were met or whether the MD was notified, while the DON stated all residents on antibiotics, including those started in the hospital, should be screened on admission and documented if the MD continues the antibiotic.
Two residents with severe cognitive impairment and significant medical conditions experienced unwitnessed falls, after which neurological checks were not completed at the required intervals according to facility policy. The DON confirmed that the neuro checks for both residents did not follow the specified protocol.
A resident with multiple serious diagnoses, including acute respiratory failure, CHF, and dementia, was transferred to a hospital and later expired. Nursing progress notes for this resident included late entries that were not properly identified as such, nor did they include the actual date and time of the events. The RN acknowledged the omission, and the DON confirmed that documentation must be accurate and complete, as required by facility policy.
Two residents with obstructive sleep apnea refused to wear their BiPAP masks, and the facility failed to notify their primary care doctors as required. Despite documentation of refusals, there was no evidence of physician notification, which is crucial for managing potential respiratory issues or sleep disturbances. Staff interviews confirmed the importance of notifying physicians, aligning with the facility's policy.
A resident with cognitive impairment and multiple diagnoses was left in a wet diaper for over five hours due to a CNA's failure to inform the charge nurse of the resident's initial refusal for a change. The CNA prioritized other tasks and a lunch break, leading to the resident's discomfort and potential risk for skin breakdown.
A resident did not receive timely refills of Norco for severe pain, leading to a gap in medication availability. Additionally, a discontinued medication was not removed from the medication cart, risking potential medication errors. The facility failed to document the refill process and adhere to policies for handling discontinued medications.
A CNA failed to perform hand hygiene between caring for two residents, using alcohol pads instead of the facility's required alcohol-based hand sanitizer. This incident involved a resident with multiple health conditions, including COPD and moderate cognitive impairment. The facility's policy mandates hand hygiene before and after resident contact to prevent infection spread.
A facility failed to ensure a safe discharge plan for a cognitively impaired resident who was taken AMA by a significant other. The resident, who required assistance with ADLs and medication, was found in a homeless encampment without necessary care. The facility did not assess the resident's condition or involve emergency services, allowing the resident to sign an AMA form without ensuring safety.
A resident with severe cognitive impairment and multiple medical conditions was taken from the facility by an unauthorized person, resulting in the resident being found in a homeless encampment two days later. The facility failed to ensure proper supervision and communication, as the significant other had previously refused to provide contact information and had expressed intentions to take the resident out against medical advice. The facility's policy on safety and supervision was not effectively followed, leading to the resident's unsafe removal.
The facility failed to maintain sanitary conditions in the kitchen, with opened food items not labeled with dates and an unclean dry storage area. Additionally, the residents' refrigerator and freezer were operating above recommended temperatures, posing a risk for food contamination.
The facility failed to assess, obtain informed consent, and secure physician orders for the use of beds against the wall as restraints for three residents with severely impaired cognition. Observations revealed that the beds restricted movement, and interviews confirmed the lack of necessary documentation and assessments as per the facility's restraint policy.
The facility failed to accurately code the MDS for two residents, leading to potential deficiencies in care planning. One resident's range of motion limitations were not correctly documented, and another resident's anxiety disorder was omitted from the MDS despite being treated for it. These inaccuracies could impact the care and services provided.
The facility failed to provide essential medications for three residents, leading to deficiencies in medication administration. A resident did not receive magnesium oxide due to stock issues, another missed lactulose for bowel management, and a third was not given gabapentin for pain due to a pharmacy delivery error. Additionally, a resident was given aspirin in a manner inconsistent with the physician's order, potentially affecting its effectiveness.
The facility failed to manage psychotropic medications properly for two residents. One resident received PRN Lorazepam without a specified duration, non-pharmacological interventions, behavior monitoring, or informed consent. Another resident was given Mirtazapine without updated informed consent for the increased dosage and changed behavior monitoring. These actions violated the facility's policies on medication management and informed consent.
A LTC facility failed to maintain a medication error rate below 5%, resulting in a 13.33% error rate. One resident did not receive magnesium oxide due to stock issues, another missed lactulose and improperly received aspirin, and a third did not receive gabapentin for pain. These errors were due to stock shortages and administrative oversights.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a gastrostomy tube, lacking physician orders and documentation. A CNA provided care without an isolation gown, despite EBP requirements. Additionally, a medication cart contained an open incinerator bin, risking contamination of medications. The facility's policies on infection prevention and medication storage were not adhered to, resulting in these deficiencies.
A facility failed to provide simultaneous feeding assistance to two residents with severe cognitive impairments, resulting in an undignified dining experience. One resident had to wait for assistance while the other was being fed due to insufficient staffing. Interviews with the DSD and DON highlighted the importance of maintaining residents' dignity during meals.
A resident with severe impairments and high fall risk was found unable to reach the call light, which was on the floor, due to impaired vision. An LVN confirmed the call light should be within reach, and the DON stated that call lights must be accessible to meet residents' needs. The facility's policy requires call lights to be within easy reach.
A resident with major depressive disorder and PTSD was inaccurately assessed in their PASARR Level I screening, which failed to indicate the presence of a mental disorder. This oversight prevented the necessary Level II PASARR evaluation, which is crucial for ensuring appropriate placement and services. The MDS nurse and DON confirmed the error, highlighting the need for accurate assessments as per the facility's PASARR policy.
The facility failed to develop comprehensive care plans for two residents, one with severe cognitive impairment and another with severe visual impairment. Resident 25, dependent on staff for all ADLs, lacked a care plan for activities. Resident 1, with cataracts and impaired vision, had no care plan addressing visual deficits, leading to difficulties in locating the call light. The facility's policy requires comprehensive care plans, but these were not implemented, resulting in deficiencies.
A resident receiving artificial nutrition through a G-tube had an outdated care plan that did not reflect the current physician's orders. The care plan indicated a discontinued feeding formula, while the resident was observed receiving a different formula as per the new order. The MDS nurse acknowledged the care plan was not updated, and the DON stressed the importance of accurate care plans for continuity of care.
A resident with ROM limitations in both legs experienced a decline in mobility due to the facility's failure to provide necessary ROM exercises. Despite recommendations for a Restorative Nursing Aide Program, staff did not perform ROM exercises, assuming others were responsible. The resident's condition worsened over time, with no additional therapy services initiated, contrary to facility policies requiring evaluations and communication for changes in ROM.
The facility failed to properly remove expired and discontinued medications, store Brimonidine tartrate ophthalmic solution at room temperature, and label an insulin Glargine pen with accurate opened dates. These deficiencies involved three residents and increased the risk of medication errors and ineffective treatments.
Failure to Document Meal Assistance for Dependent Residents on Specialized Diets
Penalty
Summary
The facility failed to ensure that two dependent residents received and had documented assistance with meals three times a day as ordered. Resident 2 was admitted with conditions including a left tibia medial malleolus fracture, GERD, dementia, and muscle weakness, and had an MDS showing moderately impaired cognition and dependence on staff for all ADLs. Orders in effect included a fortified mechanical soft diet with thin liquids and a Restorative Nursing Assistant feeding program. Review of Resident 2’s Documentation Survey Reports for February and March 2026 showed missing documentation that the resident was assisted with meals three times daily on multiple specified dates, despite the resident’s dependence on staff and specialized diet and feeding program orders. Resident 8 was admitted with COPD, kidney transplant status, dementia, anemia, and morbid obesity, with an MDS indicating severely impaired cognition and dependence on staff for all ADLs. Active orders included a fortified pureed diet with mildly thick consistency. Review of Resident 8’s Documentation Survey Reports for February and March 2026 similarly showed no documented evidence that the resident was assisted with meals three times a day on multiple specified dates. During interviews and concurrent record reviews, the RN Supervisor confirmed the lack of documentation for both residents on the identified dates and acknowledged the need to ensure meals were recorded and that residents eat at least three times a day. The facility’s Food and Nutrition Services policy stated that each resident is to be provided with a nourishing, palatable, well-balanced diet that meets daily nutritional and special dietary needs.
Insufficient Nursing Staff Leading to Missed Feeding Assistance and Delayed Call Light Response
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff to meet residents’ needs, including failure to ensure documented feeding assistance for a dependent resident and timely response to call lights. One resident was admitted with multiple diagnoses including a left tibia medial malleolus fracture, GERD, dementia, and muscle weakness, and had an MDS showing moderately impaired cognition and dependence on staff for all ADLs. This resident had orders for a fortified mechanical soft diet with thin liquids and participation in a restorative nursing assistant feeding program. However, review of the resident’s February documentation showed no documented evidence that the resident was assisted with meals three times a day on a specific date, including breakfast and lunch, despite the resident’s dependence on staff for feeding. Additional evidence of insufficient staffing came from resident council meeting minutes on two dates, which documented concerns that call lights were not being answered in a timely manner. A family member reported during a phone interview that there were not enough nurses to help residents, particularly on weekends, which delayed care and services. During interviews and record reviews, the RN supervisor confirmed the lack of documented meal assistance for the dependent resident on the identified date, and the DON confirmed that Certified Nurse Assistant DHPPD on several dates, including the date of missing meal assistance documentation, were below the required 2.4 hours per patient day. The DON stated that short staffing affected resident care. The facility’s own staffing policy indicated it would provide enough nursing staff to deliver nursing and related care services for all residents, which was not met on the identified dates.
Failure to Administer and Document Ordered Medications for Two Residents
Penalty
Summary
The facility failed to ensure medications were administered as ordered for two residents, as evidenced by missing administrations and documentation on their Medication Administration Records (MARs). One resident with severe cognitive impairment and multiple diagnoses including COPD, GERD, bilateral hip osteoarthritis, and a bone density disorder had active orders for Alendronate Sodium 70 mg once weekly on Sundays, Omeprazole 20 mg daily, and Synthroid 75 mcg every morning. Review of this resident’s March MAR showed no documented evidence that Alendronate Sodium and Omeprazole were administered at 6 a.m. on 3/1, no documented evidence that Synthroid was administered at 6:30 a.m. on 3/1 and 3/3, and no documented evidence that Omeprazole was administered at 6 a.m. on 3/3. During interview and concurrent record review, the RN Supervisor confirmed these medications were not administered as ordered, and the DON stated that if the MAR was not signed, it meant the medication was not administered. A second resident, admitted with a left tibia medial malleolus fracture, dementia with moderately impaired cognition, and muscle weakness, was dependent on staff for all ADLs and had an active order for Visine Dry Eye Relief Ophthalmic Solution 1%, one drop in both eyes three times daily. Review of this resident’s March MAR showed no documented evidence that Visine was administered at 6 a.m. on 3/3. The RN Supervisor confirmed that this medication was not administered as ordered. The facility’s 2024 “Administering Medications” policy stated that medications are to be administered as prescribed and that the individual administering the medication must document the date, time, dosage, route, and their signature and title on the MAR, which did not occur in these instances.
Delayed Respiratory Testing and TBP Implementation for Symptomatic Residents
Penalty
Summary
The deficiency involves the facility’s failure to promptly implement its infection prevention and control policies for residents who developed respiratory symptoms. One resident with chronic obstructive pulmonary disease and pulmonary fibrosis, and with moderately impaired cognition and dependence on staff for several ADLs, developed shortness of breath, coughing, and congestion as documented on an SBAR form on 2/14/2026 at 9:30 p.m. Despite these symptoms, the resident was not placed on transmission-based precautions until 2/18/2026 at 8:33 p.m., and testing for a respiratory pathogen panel was not performed until 2/19/2026 at 5 a.m. The Infection Prevention Nurse (IPN) confirmed during interview and record review that this resident should have been tested for a respiratory pathogen panel or at least influenza and Covid-19 immediately when symptoms appeared and should have been placed on transmission-based precautions right away. Another resident, admitted with acute pulmonary edema and anemia, also had moderately impaired cognition and required set-up assistance with eating and oral hygiene and was dependent on staff for showering and toileting hygiene. This resident developed a productive cough documented on an SBAR form on 2/21/2026 at 8:29 p.m., but testing for a respiratory pathogen panel was not completed until 2/23/2026 at 3:30 a.m. The IPN confirmed that this resident likewise should have been tested for a respiratory pathogen panel or at least influenza and Covid-19 immediately when respiratory symptoms manifested. The facility’s own infection prevention and control policy stated it would maintain a safe environment to prevent and manage the spread of infections and follow current best practices, and the LA Department of Public Health toolkit specified that residents with signs or symptoms of respiratory illness should be immediately tested for Covid-19 and influenza and placed on empiric transmission-based precautions while awaiting results. The surveyors determined that these delays constituted a failure to implement infection control policies and public health guidance.
Failure to Keep Dependent Resident’s Adaptive Call Light Within Reach
Penalty
Summary
The facility failed to ensure a resident’s adaptive call light was accessible and within reach, resulting in a delay in care and services. The resident had been admitted with a fracture of the medial malleolus of the left tibia, dementia, and muscle weakness. According to the MDS dated 1/14/2026, the resident’s cognition was moderately impaired and she was dependent on staff for all activities of daily living. During an observation and interview in the resident’s room, the resident’s switch adaptive call light was found on the floor away from her, and CNA 1 confirmed that the call light was out of the resident’s reach. During the same observation, the resident stated she needed the call light positioned under her forearm so she could press it when she needed assistance from staff. In a separate interview, the DON stated that all residents must have an accessible call light within reach to ensure they can call for help. Review of the facility’s 2024 policy and procedure titled “Answering the Call Light” indicated that call lights need to be within residents’ reach. These observations, interviews, and record reviews showed that the resident’s call light was not positioned as required by facility policy or as needed by the resident, leading to the identified deficiency.
QAPI Committee Failed to Implement Call Light Response Improvement Plan
Penalty
Summary
The facility’s QAPI Committee failed to implement the action plan for its performance improvement project regarding staff call light response for 56 out of 56 residents. The QAPI plan, initiated 8/1/2025, identified call light response as a system issue and an area of improvement, and the program action plan stated that the Administrator and managers would ask residents about call light response to measure performance improvement. During a concurrent interview and record review on 12/12/2025 at 9:24 a.m., the Administrator reviewed the facility’s Angel Daily Room Rounds and stated the rounds did not show staff interviews of residents regarding call light response. The Administrator stated there was no documented evidence of interviews conducted to measure performance improvement and that there were missing elements of the project indicating the QAPI program was being implemented. The facility policy on QAPI stated the committee would address specific care and quality issues, track and measure performance, establish goals and thresholds, analyze underlying causes, implement corrective action, monitor effectiveness, and adjust the plan.
Incomplete Legionella Water Management Program
Penalty
Summary
The facility failed to develop and implement a Water Management Plan for 56 out of 56 residents. During an interview with the Maintenance Supervisor, he stated that he only measured water temperatures, ensured the ice machine was clean, and had no other tasks related to the water management plan. During a concurrent interview and record review with the Infection Prevention Nurse, the facility’s water management plan was reviewed and the IPN stated that there were missing elements in the plan. During an interview with the Administrator, the Administrator stated the facility should complete the water management assessment because it was required. The Administrator also stated the water management had no control measures applied and monitored, there were no interventions created if control measures were not met, and there was no documentation of all activities of the program. Review of the facility policy titled, Legionella Water Management Program, revised 7/2017, showed the plan was to include an interdisciplinary team, a detailed description and diagram of the water system, identification of areas and situations that could encourage Legionella growth, specific control measures, control limits, monitoring, a plan when limits were not met, and documentation of the program.
Medication Administration Error Rate Exceeded Limit
Penalty
Summary
Medication administration error rates were found to be 7.41 percent, exceeding the required limit of 5 percent. The facility failed to ensure an LVN administered two medications for one resident with food as ordered by the physician. Resident 15 was admitted with diagnoses including DM, osteoarthritis, and gout, and the MDS indicated intact cognition and the need for set-up assistance with eating. Resident 15’s orders included Indomethacin 25 mg twice daily with food and Metformin 500 mg twice daily with food. During a concurrent observation and interview, the LVN administered both medications while stating the resident had already eaten breakfast earlier and that there was no breakfast tray at the bedside, meaning the medications were not given with food. Resident 15 stated breakfast had been finished earlier that morning. The DON stated that if instructions indicate to give a medication with food, it must be administered with food or it is an error. The facility’s Medication-Administration policy was reviewed and indicated it was intended to ensure safe, timely medication administration as ordered.
Opened Medications Not Labeled With Required Dates
Penalty
Summary
Drugs and biologicals used in the facility were not labeled in accordance with accepted professional principles when an opened UTI-Stat bottle for Resident 15 was found without an open date. Resident 15 had diagnoses including DM, osteoarthritis, and gout, and the MDS indicated intact cognition and a need for assistance with eating. During observation and interview, an LVN was preparing the UTI-Stat and stated there was no open date on the already opened supplement bottle. The label was reviewed and indicated the bottle should be discarded after 3 months of opening, and the LVN stated the bottle needed an open date so it could be discarded after three months of opening. An opened Lantus SoloStar insulin pen for Resident 10 was also found without an open date and expiration date. Resident 10 had DM and severely impaired cognition, and was dependent on staff for all ADLs. During observation, the RNS reviewed the insulin pen on the medication cart and found it was not dated and not labeled with the new expiration date. The RNS stated the medication needed the date it was opened because it is only good for a prescribed time frame. The Lantus prescribing information reviewed by surveyors indicated the insulin pen is good for 28 days after opening and stored at room temperature. An open bottle of multivitamins with minerals for Resident 24 was observed without an open date. Resident 24 had Parkinson's disease and dementia, did not have capacity to understand and make decisions, and had severe cognitive impairment with dependence for multiple ADLs. During medication preparation, the LVN observed the multivitamin bottle had no open date and stated medications should be labeled with an open date. The facility's medication storage and administering policies stated that when a manufacturer's seal is broken, the container or vial is to be dated and the date opened recorded on multidose containers.
Unsafe Food Storage and Handling Practices
Penalty
Summary
Food was not stored in a sanitary manner to prevent growth of microorganisms that could cause foodborne illness. During an initial kitchen tour and interview, a brown bag dated 12/8/2025 with no resident name was found in the refrigerator and was identified by CK 1 as belonging to an unknown resident who goes to dialysis. A plate with a lid was also observed in the kitchen refrigerator with no resident identifier or date; CK 1 stated it was a resident’s fruit plate that had been placed back in the refrigerator because the resident wanted to eat it later. During the same tour, unopened small milk cartons and a container of individual butter pats were observed without a received-on date. In the dry storage area, the Dietary Supervisor observed multiple items without dates, including six tapioca mix bags, Cinnamon Streusel, a box of tea bags, a box of iced tea mix, and a container of relish packets. A container of dry peas and a box of dry lentils were dated 5/11/2023, and two panko bags had an expiration date of 7/9/2025. In the freezer, several items were undated, including one Chef pumpkin pie, two chocolate flavored cream pies, a bag of tater tots, a bag of meatballs, and an opened bag of barbeque pork rib patty with no open date. The DS stated dates are needed to know when items came in and calculate use-by dates, and that expired items should not remain in dry storage or the freezer. During pureeing of food items, CK 2 was observed wiping hands on clothing, storing three black plastic spoons in an upper arm pocket, handing a spoon from that pocket, and moving to the next task without performing hand hygiene. The DS was also observed wearing a watch that touched the counter area where hot foods were stored.
Improperly Covered Trash Dumpsters
Penalty
Summary
The facility failed to dispose of garbage and recyclables properly by not completely covering two of two trash dumpsters outside the kitchen area. During a concurrent observation and interview with the Dietary Supervisor, the dumpsters were found not completely closed and covered, and the Dietary Supervisor stated the trash had not been picked up from Monday and was still present. The Dietary Supervisor also stated the trash lids should be closed and that if the lids are not closed, bugs can come in and bags can break, creating an unsanitary environment. A review of the facility's Garbage and Trash policy indicated that all food waste must be placed in sealed containers, and a review of Food Code 2017 stated that refuse and waste handling units kept outside the food establishment shall be kept covered with tight-fitting lids or doors.
Missing COVID-19 Vaccination Documentation and Education for Staff
Penalty
Summary
The facility failed to provide documented COVID-19 2025 to 2026 vaccination status and evidence that education on the benefits and potential side effects of the vaccine was provided for all employees, including physicians. During a concurrent interview and record review on 12/10/2025 at 8:10 a.m. with the Infection Prevention Nurse (IPN), the facility's COVID Staff Vaccination Status roster was reviewed and found to be undated. The IPN stated there was no documented evidence that all staff received education on benefits and side effects or that the 2025 to 2026 COVID-19 booster vaccine was offered. The IPN also stated the roster did not include physicians, although it should include everyone with direct access to residents. During an interview on 12/12/2025 at 7:55 a.m. with the Director of Nursing (DON), the DON stated all staff need to be educated and offered the current COVID-19 booster. Review of the facility policy and procedure titled, Covid-19 Vaccine Immunization for Residents and HCP, revised 9/2025, showed the policy was intended to guide the facility in meeting immunization requirements for educating and administering COVID-19 vaccine and boosters to healthcare personnel (HCP), that HCP were to be provided education regarding the benefits of COVID vaccination and booster potential side effects and adverse events, that the facility keeps a line listing of resident and HCP COVID-19 vaccination status, and that HCP includes physicians.
Failure to Notify Physician of Missed Dialysis Treatment
Penalty
Summary
The facility failed to inform the physician when a scheduled dialysis treatment was missed for Resident 39. Resident 39 was admitted with diagnoses including sepsis, osteomyelitis, end stage renal disease, and dependence on renal dialysis. The admission record and H&P indicated the resident had capacity to understand and make decisions, while the MDS dated 11/20/2025 indicated moderate cognitive impairment and significant assistance needs with activities of daily living. During interview and record review, Registered Nurse Supervisor 1 stated Resident 39 had orders for dialysis every Tuesday, Thursday, and Saturday at 8:00 a.m., but there was no documentation showing the resident received dialysis on Tuesday 11/25/2025. RNS 1 stated there was also no documentation that the physician was notified of the missed dialysis session. The DON stated it was important for the physician to be notified of a missed dialysis session so the physician could intervene and determine the next step.
Late NOMNC Delivery Before End of Skilled Coverage
Penalty
Summary
The facility failed to ensure that one sampled resident received the Notice of Medicare Non-Coverage (NOMNC) at least 48 hours before the last covered date of skilled services. Resident 63 was initially admitted and later readmitted with diagnoses including a wedge compression fracture of the lumbar vertebra and COPD. The resident’s H&P dated 9/23/2025 indicated the resident had the capacity to understand and make decisions, and the MDS dated 9/24/2025 indicated no cognitive impairment, with assistance needs for eating, oral hygiene, showering, toileting, and upper and lower body dressing. Resident 63 was discharged home on [DATE], and the NOMNC reviewed during the survey was dated 10/10/2025. During interview and record review, the MDSC stated the resident’s inpatient skilled nursing services end date was 10/14/2025 and that the resident signed receiving the notice on 10/14/2025. The MDSC stated the resident should have received the NOMNC at least 48 hours prior to 10/14/2025. The DON stated residents should receive the NOMNC at least 2 days before discharge of skilled services so they are informed of changes to care and their right to appeal, and the facility policy stated termination of skilled coverage is issued at least 2 days before Medicare coverage ends or as soon as the decision is made.
Inaccurate MDS Coding for Insulin Administration
Penalty
Summary
The facility failed to ensure that one resident's MDS assessment was coded accurately. Resident 3 was admitted with a diagnosis of DM and, on the MDS dated 11/28/2025, was documented as having severe cognitive impairment and as having received insulin injections for three days during the last 7 days or since admission. A review of Resident 3's MAR for 11/2025 showed no insulin injections were administered, and the physician orders for 11/2025 did not include any insulin orders. During a concurrent interview and record review, the MDSC stated the resident did not have orders for insulin and did not receive insulin injections, and that the MDS was inaccurately coded and should be amended. The DON stated assessments should be accurate and reflect the residents' plan of care and orders.
Missing Active BLS Certification for LVN
Penalty
Summary
The facility failed to ensure that one of five employees, an LVN, had an active BLS certification on file. During a concurrent interview and record review with the DSD, the LVN's employee file was reviewed and it was stated that the LVN did not have an active BLS certification on file. During an interview with the DON, it was stated that all nursing staff, including CNAs, LVNs, and RNs, are required to have active, not expired, BLS certifications so their skills remain up to date with current standards. The DON stated that if nursing staff do not have active BLS certifications, there is a risk they will provide ineffective CPR. The facility's policy titled Emergency Procedure - Cardiopulmonary Resuscitation stated personnel have completed training on the initiation of CPR and BLS, including defibrillation, for victims of sudden cardiac arrest, and that the facility is to obtain and/or maintain American Red Cross or American Heart Association BLS/CPR certification for key clinical staff members who will direct resuscitative efforts, including non-licensed personnel.
Missed Scheduled Dialysis Session
Penalty
Summary
The facility failed to ensure that Resident 39 received dialysis as ordered. Resident 39 was admitted with diagnoses including sepsis, osteomyelitis, end stage renal disease, and dependence on renal dialysis. The resident’s H&P dated 11/19/2025 indicated the resident had the capacity to understand and make decisions, while the MDS dated 11/20/2025 indicated moderate cognitive impairment and varying levels of assistance needed with activities of daily living, including setup assistance for eating and oral hygiene, moderate assistance for dressing, maximal assistance for toileting hygiene, and dependence for bathing. During interview and record review, Resident 39 stated they missed a dialysis session one time. The RNS reviewed the record and stated the resident had orders for dialysis every Tuesday, Thursday, and Saturday at 8:00 a.m., but there was no documentation showing the resident received scheduled dialysis on Tuesday 11/25/2025, and it was possible the resident missed dialysis. The RNS stated a missed dialysis session puts the resident at risk for fluid overload. The DON stated that for a resident dependent on dialysis, receiving dialysis as scheduled is important because it is the only way to expel toxins from the body, and missing a session places the resident at risk for health deterioration or death.
Annual Performance Evaluations Not Completed
Penalty
Summary
The facility failed to ensure that two of five employees, CNA 2 and RNA 1, received annual performance evaluations. During a concurrent interview and record review with the DSD, the employee files for CNA 2 and RNA 1 were reviewed and it was stated that neither employee had received a performance evaluation in the last twelve months. The DSD stated performance evaluations should be completed every year and filed in the employee record, and the DON later stated that evaluations should be completed once a year or every twelve months. A review of the facility policy titled Performance Evaluations, revised 12/11/2025, indicated that a performance evaluation is to be completed at the end of the 90-day probationary period and at least annually thereafter.
Incomplete antibiotic stewardship screening for resident on IV antibiotic
Penalty
Summary
The facility failed to implement its antibiotic stewardship program for one sampled resident who was receiving Ceftriaxone sodium solution 2 grams IV daily for a right foot infection. The resident was admitted with diagnoses including sepsis, osteomyelitis, ESRD, and dependence on renal dialysis. The admission H&P stated the resident had the capacity to understand and make decisions, while the MDS indicated moderate cognitive impairment and varying levels of assistance needed for eating, oral hygiene, dressing, toileting hygiene, and bathing. The resident’s Physician Order Summary showed the antibiotic order began with a start date of 11/19/2025. During interview and record review, the Infection Prevention Nurse stated the Individual Surveillance Form for Possible Infection dated 11/18/2025 was incomplete and did not indicate whether the Ceftriaxone use met McGeer’s guidelines for a true infection or whether the physician was notified. The IPN stated the form is used to determine if the antibiotic meets criteria and to prevent the growth of antibiotic resistant organisms, and that a complete screening is done for all residents on antibiotics. The DON stated all residents on antibiotics should be screened using McGeer’s criteria on admission, including residents prescribed antibiotics from the hospital, and if criteria were not met the physician should be notified; if the physician continued the antibiotic, documentation of that notification should be present.
Failure to Complete Neurological Checks per Protocol After Unwitnessed Falls
Penalty
Summary
The facility failed to ensure that neurological checks were completed as indicated in their policy for two residents following unwitnessed falls. For one resident with diagnoses including acute respiratory failure, congestive heart failure, and dementia, the care plan required neuro checks after an unwitnessed fall. However, the neurological assessments were not performed at the required intervals, as the checks were completed every 30 minutes twice, every hour twice, and then every three hours three times, instead of following the specified protocol. Similarly, another resident with diagnoses of pneumonia, meningitis, and mobility abnormalities also experienced an unwitnessed fall. The neurological assessments for this resident were completed at incorrect intervals, deviating from the facility's protocol. The DON confirmed during interview and record review that the neuro checks for both residents were not completed at the correct frequencies as required by the facility's policy and procedure, which mandates specific intervals for neurological assessments following unwitnessed falls.
Inaccurate Nursing Documentation for Resident Care
Penalty
Summary
The facility failed to ensure that nursing progress notes for one resident were accurate and properly documented. Specifically, a review of the resident's admission record showed the individual was admitted with diagnoses including acute respiratory failure, congestive heart failure, and dementia with severely impaired cognition. The resident was later sent to a general acute care hospital and subsequently expired. Upon review of the resident's daily nurse notes, it was found that entries made on a certain date were actually late entries for a previous date, but the nurse did not indicate that they were late entries or specify the actual date and time the events occurred. During interviews, the registered nurse acknowledged forgetting to document the entries as late and to include the correct timing. The Director of Nursing confirmed that documentation is required to be complete and accurate. The facility's policy also states that all services and changes in a resident's condition must be documented objectively, completely, and accurately. The failure to properly document late entries resulted in an inaccurate depiction of the care and services provided to the resident.
Failure to Notify Physicians of BiPAP Refusals
Penalty
Summary
The facility failed to notify the primary care doctors of two residents when they refused to wear their BiPAP masks as ordered. Resident 1, who was admitted with obstructive sleep apnea and had intact cognition, refused to wear the BiPAP mask on multiple occasions in January 2025. Despite these refusals being documented in the Medication Administration Record, there was no evidence that the physician was notified of these refusals. Licensed Vocational Nurse 1 confirmed that the physician should have been notified and that the lack of documentation meant there was no evidence of such notification. Resident 2, who had moderately impaired cognition and required substantial assistance with activities of daily living, also refused to wear the BiPAP mask since admission. The resident expressed discomfort with the fit of the mask, stating it was not like the one used at home. Although the refusal was documented, there was no indication that the physician was notified. Licensed Vocational Nurse 2 acknowledged the importance of notifying the physician due to potential respiratory issues or sleep disturbances. The Director of Nursing confirmed that refusals should be documented and the physician notified, as per the facility's policy.
Failure to Provide Timely Incontinent Care
Penalty
Summary
The facility failed to provide adequate care for a resident who was unable to perform activities of daily living, specifically in maintaining personal hygiene. The resident, who had moderate cognitive impairment and was diagnosed with bipolar disorder, COPD, and bilateral hip osteoarthritis, was left in a wet diaper for over five hours. This situation arose when the resident initially refused a diaper change at 9:30 am, requesting the CNA to return later. The CNA, after attending to other residents and taking a lunch break, did not return to check on the resident until after lunch, at which point the resident's call light was on. Upon returning, the CNA found the resident's diaper to be extremely wet, acknowledging that this could lead to skin breakdown and discomfort. The CNA admitted that she should have informed the charge nurse of the resident's refusal and arranged for another staff member to assist before going to lunch. The Director of Nursing confirmed that CNAs are expected to notify the charge nurse in such situations to prevent prolonged exposure to wet conditions, which can cause skin issues and discomfort. The facility's policy emphasizes treating residents with respect, kindness, and dignity, ensuring equal access to quality care.
Medication Management Deficiencies
Penalty
Summary
The facility failed to ensure timely refilling of Norco, a controlled medication for severe pain, for a resident. The resident, who was admitted with diagnoses including bipolar disorder, COPD, and bilateral hip osteoarthritis, had an active order for Norco 7.5-325 mg to be taken every six hours as needed. However, there was a gap in availability from November 24, 2025, to December 3, 2025, during which the resident did not receive the medication. Instead, the resident was given tramadol and repositioned for comfort while waiting for authorization from the physician. The Licensed Vocational Nurse (LVN) acknowledged the importance of documenting the process in the resident's health records to ensure follow-up and continuity of care, which was not done in this case. Additionally, the facility failed to remove a discontinued medication from the medication cart. A discontinued Hydrocodone-Acetaminophen tablet for another resident was found in the cart, despite the order to discontinue it on January 27, 2025. The LVN responsible stated that discontinued medications should be removed immediately to prevent medication errors. The facility's policy requires that discontinued medications be destroyed or returned to the pharmacy, but this was not adhered to, as evidenced by the presence of the medication in the cart.
Failure in Hand Hygiene Practices by CNA
Penalty
Summary
The facility failed to implement proper infection control practices when a Certified Nursing Assistant (CNA) did not perform hand hygiene between caring for different residents. Specifically, the CNA was observed adjusting a splint for one resident and then immediately touching another resident's call light and blanket without sanitizing her hands. The CNA admitted to not using the alcohol-based hand sanitizer and instead used alcohol pads, which is not in accordance with the facility's infection control policy. Resident 1, who was involved in this incident, had been admitted to the facility with diagnoses including bipolar disorder, chronic obstructive pulmonary disease (COPD), and bilateral hip osteoarthritis. The resident also had moderate cognitive impairment as indicated by the Minimum Data Set (MDS). The facility's policy requires staff to perform hand hygiene before and after direct contact with residents to prevent the spread of infection. Interviews with the Infection Preventionist nurse and the Director of Staff Developer confirmed that all staff were educated on the importance of hand hygiene, emphasizing the 'gel in and gel out' practice.
Failure to Ensure Safe Discharge Planning for Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure a safe discharge plan for a resident with cognitive impairment and the inability to make medical decisions. The resident was taken from the facility against medical advice by a significant other, who was not authorized to make medical decisions on behalf of the resident. The facility was aware of the significant other's intention to remove the resident five days prior but did not develop a discharge plan or notify the resident's physician of the situation. As a result, the resident's whereabouts were unknown for two days, and he was later found in a homeless encampment under unsafe and unsanitary conditions. The resident, who was non-ambulatory, incontinent, and required medication for multiple medical conditions, was found without necessary care or provisions. The facility did not assess the resident's medical condition upon locating him, nor did they call emergency medical services to evaluate his need for hospitalization. Instead, the facility allowed the resident and the significant other to sign an AMA form without ensuring the resident's safety or ability to care for himself outside the facility. Interviews with facility staff revealed that they were aware of the significant other's intentions but failed to take appropriate actions to prevent the unauthorized removal. The facility's policies and procedures for discharge and AMA situations were not followed, leading to the resident being placed in a potentially life-threatening situation without proper care or support.
Removal Plan
- Facility staff went to a homeless encampment at a park, located two miles from the facility. The DON drove by the local area park again where Resident 1 and his Responsible Party were found. The DON confirmed that this was Resident 1. Resident 1 was not in any distress and had no signs of diminished cognitive response. Resident 1 was sitting in a wheelchair, his breathing was even and unlabored, he was asked his full name and date of birth, and he was able to respond appropriately. The DON called 911 and the paramedics arrived while the DON remained at the park. The paramedics asked Resident 1 if they could assess him, and he refused. The paramedics offered to take the Resident 1 to the hospital, he and the significant other refused. The paramedics informed the ADM and the DON that they could not force Resident 1 to go to the hospital against and they had a right to refuse. Resident 1 refused transport with the paramedics and refused an offer to return to the facility. The facility offered Resident 1 and the significant other supplies, but Resident 1 and the significant other told facility representatives to stop bothering them. The DON attempted to notify the Resident 1's Physician. The Physician was notified that Resident 1 refused to come back to the facility or go to the hospital to be evaluated.
- The facility reviewed Resident 1's medical records, which were available during Resident 1's admission and confirmed the significant other was listed as his Responsible Party in his previous hospital records and his facility history and physical. The facility also confirmed that Resident 1 and the significant other once resided at the same address. The significant other refused to provide any identifying information to the paramedics or facility representatives because the significant other said that information was personal. The significant other introduced herself to the paramedics as Resident 1's wife and caretaker.
- The facility Social Services Director, DON and Minimum Data Set nurse reviewed documents for all residents discharged in the past months. No deficient practices were identified. No other residents left the facility AMA in the past 3 months.
- The Continuous Quality Improvement Nurse Consultant in-serviced all licensed nurses who were present and the Interdisciplinary Team on the facility's policy and procedure pertaining to the discharge process, discharge planning, AMA, and care for residents with cognitive impairment and physical limitations. In-services were done with licensed nurses who were present on all shifts. Staff who were not present for the in-services will be in-serviced via phone and will be asked to sign the in-service form upon return to the facility. If unable to in-service via phone, staff will be in-serviced upon returning to work. Staff will not be returned to the floor until in-serviced.
- The DON and CQI Nurse Consultant reviewed all current residents' records for presence of information about the responsible party, including contact information and followed up to request information for any residents missing this information. No discrepancies were found.
- The facility will initiate discharge planning with the resident or resident's representative if the resident has no capacity to make decisions during initial social service assessment and discuss the discharge process and plan during the initial IDT care conference within one week of admission if the resident or representative agree and are available.
- When a resident or resident's representative expresses the desire to leave the facility, the social service will call for a discharge plan meeting to discuss the resident's post discharge needs unless the plan is already in place. If a resident or representative expresses the desire or intention to leave facility AMA and the physician determines the resident is not ready for discharge and will not issue a discharge order, the facility will present the resident or the representative with information regarding the risks and the consequences of leaving and request that they sign an AMA form. The Physician will be notified regarding the AMA.
- In the event that a resident leaves the facility without notice, the facility staff will assess the resident for any signs of injury or change of condition once located. The facility may transfer the resident to the emergency department for further evaluation if needed and the resident will be returned to the facility if the resident or the representative agrees. The facility will involve emergency services personnel as necessary.
Resident Removed from Facility by Unauthorized Person
Penalty
Summary
The facility failed to ensure the safety and supervision of a resident with severe cognitive impairment and multiple medical conditions, resulting in the resident being taken out of the facility by an unauthorized person. The resident, who was non-ambulatory and dependent on staff for activities of daily living, was removed by a significant other who had no documented contact information and had previously refused to sign admission documents or provide contact details. The facility was unaware of the resident's whereabouts for two days until he was found in a homeless encampment, exposed to poor weather and unsanitary conditions without necessary medications or care. The resident's medical history included metabolic encephalopathy, post-stroke hemiplegia, functional quadriplegia, hypertension, dysarthria, benign prostatic hypertrophy, urinary tract infection, hypothyroidism, generalized weakness, and a history of repeated falls. Despite these conditions, the facility did not have a responsible person listed for the resident, only a contact person with no contact information. The resident's care plan indicated a need for retraining in skills for community return, but there was no effective communication or intervention to prevent the unauthorized removal. Interviews with facility staff revealed a lack of communication and monitoring regarding the significant other's intentions to take the resident out of the facility against medical advice (AMA). The facility's weekend receptionist, who remotely opened the front door for the resident and the significant other, was not informed of the situation. The Director of Nursing acknowledged awareness of the significant other's intentions but failed to notify the resident's physician or implement a care plan to address the risk. The facility's policy on safety and supervision was not effectively followed, leading to the resident's unsafe removal and subsequent exposure to hazardous conditions.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, leading to potential food contamination risks. During an observation, it was noted that several opened food items, including Simply thick easy mix, horseradish sauce, bread, and hamburger buns, were not labeled with the date they were opened. This oversight was acknowledged by a staff member, who confirmed that these items should have been dated. Additionally, the dry storage area was found to be unclean, with a banana peel observed on top of kitchen supplies, which a dietary aide agreed to remove. Further deficiencies were identified in the storage temperatures of the residents' refrigerator and freezer. The refrigerator was found to be operating at 42 degrees Fahrenheit, and the freezer at 8 degrees Fahrenheit, both above the recommended temperatures for safe food storage. The Activities Director acknowledged these issues and indicated that maintenance would be notified to address the temperature discrepancies. The facility's policies and procedures, as well as federal guidelines, emphasize the importance of maintaining proper food storage temperatures to prevent foodborne illnesses.
Failure to Obtain Consent and Physician Orders for Bed Placement as Restraints
Penalty
Summary
The facility failed to ensure that three residents were assessed for the use of physical restraints, received informed consent, and had a physician order for their beds being placed against the wall. This practice was observed for three residents, all of whom had severely impaired cognition and were dependent on staff for various activities of daily living. The placement of beds against the wall was considered a form of restraint as it restricted the residents' freedom of movement, and there was no documentation of informed consent or physician orders for this arrangement. During observations, the beds of the three residents were noted to be against the wall, and interviews with the Registered Nurse Supervisor and the Director of Nursing confirmed that this setup could be considered a restraint. The facility's policy on the use of restraints requires informed consent, a restraint assessment, and a physician order, none of which were present in the cases of these residents. The policy also emphasizes the need for a pre-restraining assessment to explore less restrictive interventions, which was not conducted for these residents.
Inaccurate MDS Coding for Two Residents
Penalty
Summary
The facility failed to accurately assess and code the Minimum Data Set (MDS) for two residents, leading to potential deficiencies in care planning and service provision. For Resident 1, the facility did not correctly code Section GG 0115 of the MDS to reflect the resident's functional limitations in the range of motion (ROM) of both arms. Despite the Occupational Therapy Joint Mobility Assessment indicating moderate to severe ROM loss in both arms, the MDS was incorrectly coded to show no ROM limitations. This discrepancy was confirmed by the MDS Nurse, who acknowledged that the incorrect coding could lead to inaccurate care planning. Resident 1 was admitted with diagnoses including cataracts, rheumatoid arthritis, and contracture of the upper arm. Observations and interviews revealed that Resident 1 had significant difficulty moving both arms, particularly the right arm, which was consistent with the findings of the Joint Mobility Assessment. The resident expressed reliance on staff for all daily care, highlighting the importance of accurate MDS coding to ensure appropriate care and services. For Resident 25, the facility failed to document the diagnosis of anxiety disorder in the MDS, despite the resident being prescribed and taking antianxiety medication. The resident's medical records, including the Order Summary Report and psychiatric visit progress reports, indicated a diagnosis of generalized anxiety disorder and the use of buspirone for treatment. Interviews with facility staff confirmed the resident's diagnoses, including anxiety, yet the MDS did not reflect this, potentially impacting the monitoring and care provided to the resident.
Medication Availability and Administration Deficiencies
Penalty
Summary
The facility failed to ensure the availability of essential medications for three residents, leading to deficiencies in medication administration. Resident 5 was supposed to receive magnesium oxide as per the physician's order, but the medication was not in stock, and the LVN was confused about the strength on the bottle. This oversight could potentially affect the resident's magnesium levels, leading to muscle cramps and weakness. The Director of Nursing acknowledged that missing doses could result in abnormal magnesium levels, affecting the heart and causing muscle weakness. Resident 28 did not receive lactulose solution for bowel management due to the facility running out of the medication. The LVN noted that the absence of this medication increased the risk of bowel impaction, potentially leading to emergency situations or hospitalization. Additionally, Resident 28 was administered aspirin in a manner inconsistent with the physician's order, as the chewable tablet was swallowed instead of chewed, which could delay its effectiveness in preventing heart complications. Resident 202 was not administered gabapentin for neuropathic pain because the medication was not delivered by the pharmacy. The LVN reported that the resident experienced significant pain, rated at 9 out of 10, and refused an alternative pain medication. The delay in medication delivery was attributed to an error in entering the medication as house stock. The DON confirmed that untreated pain could lead to discomfort and affect the resident's ability to perform daily activities.
Deficiencies in Psychotropic Medication Management
Penalty
Summary
The facility failed to ensure proper management of psychotropic medications for two residents, leading to deficiencies in medication administration and informed consent. For one resident, the facility did not specify a duration for the PRN Lorazepam order, failed to implement non-pharmacological interventions before administering the medication, and did not conduct behavior monitoring or obtain informed consent. This resident had a history of major depressive disorder, chronic pain syndrome, and cancer, and required significant assistance with daily activities. Another resident was administered Mirtazapine for major depressive disorder without updated informed consent reflecting the increased dosage and changed behavior monitoring. This resident, diagnosed with dementia, major depressive disorder, and anxiety, was unable to make medical decisions independently. The facility's failure to obtain new informed consent and monitor the resident's behavior for medication effectiveness was confirmed by a registered nurse supervisor. The facility's policies required monitoring for effectiveness and adverse reactions of psychotropic medications, attempting alternative behavior management before medication use, and obtaining informed consent for specific dosages. However, these policies were not followed, as evidenced by the lack of specified duration for PRN medications, absence of non-pharmacological interventions, and outdated informed consent documentation.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5% during medication administration, resulting in a 13.33% error rate. This deficiency was observed in the cases of three residents. For one resident, the facility did not have magnesium oxide in stock, which was prescribed to treat low magnesium levels. The Licensed Vocational Nurse (LVN) was confused about the strength of the available magnesium oxide and did not administer it, potentially affecting the resident's magnesium levels and causing muscle cramps and weakness. Another resident did not receive their prescribed lactulose solution due to it being out of stock, which was necessary for bowel management. Additionally, the resident was given aspirin in a form that was not chewed as required, which could delay its effectiveness. The LVN acknowledged the error and the potential risk of heart complications due to the improper administration of aspirin. A third resident did not receive gabapentin for neuropathic pain because the medication was not available. The resident reported significant pain, and the LVN noted that the medication request was delayed due to an administrative error. This oversight left the resident in pain, which could lead to increased blood pressure and affect their mood.
Infection Control and Medication Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper implementation of Enhanced Barrier Precautions (EBP) for a resident with a gastrostomy tube, as there were no physician orders or documentation for EBP. A Certified Nurse Assistant (CNA) was observed providing care to the resident without wearing an isolation gown, despite a sign indicating the need for gown and gloves for high-contact care. The CNA admitted to forgetting to use the gown, and the Registered Nurse Supervisor confirmed the absence of physician orders for EBP, emphasizing the need for such orders to ensure proper care under physician supervision. Additionally, the facility did not maintain a clean and sanitary environment for medication storage. A red incinerator bin with an open lid containing liquid was found in a medication cart, posing a risk of contamination to nearby medications. The Licensed Vocational Nurse (LVN) responsible for the cart was unaware of when the bin was placed there and acknowledged the risk of contamination and infection control issues. The Director of Nursing (DON) also recognized the potential for spillage and contamination due to the open bin. The facility's policies and procedures for infection prevention, physician services, and medication storage were reviewed, indicating the need for a safe and sanitary environment and proper documentation and implementation of care practices. However, these policies were not followed, leading to the deficiencies observed during the survey.
Failure to Provide Simultaneous Feeding Assistance
Penalty
Summary
The facility failed to ensure that a resident received feeding assistance at the same time as another resident, resulting in an undignified dining experience. Resident 23, who was admitted with diagnoses including age-related cataract, vision loss, hearing loss, and unspecified osteoarthritis, was dependent on staff for eating due to severely impaired cognition. The resident was on a regular diet with mechanical soft texture. During an observation, it was noted that Resident 23 was waiting for feeding assistance while Resident 17, who also had severely impaired cognition and was dependent on staff for eating, was being assisted by a Certified Nurse Assistant (CNA). Resident 17 was on a regular diet with pureed texture. The CNA stated that there was insufficient staff to assist both residents simultaneously, leading to one resident having to wait while the other was being fed. Interviews with the Director of Staff Development (DSD) and the Director of Nursing (DON) confirmed that the staff needed to be sensitive to residents requiring feeding assistance and that it was a dignity issue if residents did not eat at the same time. The facility's policy on Resident Rights emphasized treating all residents with kindness, respect, and dignity, which was not upheld in this instance.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light device was within reach for a resident, which had the potential to prevent the resident from receiving necessary care and services. The resident, who was admitted with diagnoses including cataracts, rheumatoid arthritis, and contracture of the upper arm, had severely impaired vision, difficulty hearing, and severely impaired cognition. The resident required assistance with various daily activities and was assessed as having a high fall risk. During an observation, the resident's call light was found on the floor, out of reach, and the resident was unable to locate it due to her impaired vision. Licensed Vocational Nurse 1 confirmed that the call light was out of reach and stated that it should always be in the resident's hands to ensure accessibility. The Director of Nursing also stated that call lights should always be accessible and within reach to allow residents to call for assistance. The facility's policy indicated that call lights should be within easy reach of residents to ensure their needs and requests are met. This deficiency was identified through observation, interview, and record review, highlighting a failure to accommodate the resident's needs and preferences effectively.
Inaccurate PASARR Screening for Resident with Mental Disorder
Penalty
Summary
The facility failed to ensure that a resident's Preadmission Screening and Resident Review (PASARR) accurately reflected the presence of a mental disorder, which is a federal requirement to ensure appropriate placement and services. The resident, identified as Resident 19, was admitted with diagnoses of major depressive disorder and post-traumatic stress disorder (PTSD). Despite these diagnoses, the PASARR Level I screening inaccurately indicated that the resident did not have a mental disorder, which should have triggered a Level II PASARR for a comprehensive evaluation. During interviews and record reviews, it was confirmed by the MDS nurse that the resident's PASARR Level I screening was incorrect and should have indicated the presence of a mental disorder, the prescription of psychotropic medications, and the experience of symptoms. The Director of Nursing also acknowledged that Level II PASARR is necessary for residents with mental disorders to ensure they receive the appropriate assistance. The facility's policy on PASARR, revised in May 2023, outlines the federal requirement to evaluate all applicants for serious mental disorders and ensure they receive the necessary services in the most appropriate setting.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for two residents, leading to potential delays in care and services. Resident 25, who was admitted with major depressive disorder, generalized muscle weakness, and a gastrotomy tube, was found to have severely impaired cognition and was dependent on staff for all activities of daily living. However, during a review of Resident 25's care plans, it was discovered that there was no care plan addressing the resident's activities, as confirmed by the registered Nurse Supervisor. Resident 1, admitted with cataracts, rheumatoid arthritis, and contracture of the upper arm, was identified as having severely impaired vision, difficulty hearing, and severely impaired cognition. Despite these conditions, Resident 1's care plan did not address the severe visual impairments. Observations revealed that Resident 1 was unable to see the television positioned close to her face and could not locate or reach the call light due to her visual impairment. The Minimum Data Set Nurse confirmed that a care plan with specific goals and interventions should have been developed for Resident 1's visual deficits, but none was in place. The Director of Nursing acknowledged the importance of developing and implementing care plans to guide resident care and treatment, emphasizing that the absence of such plans could impede continuity of care. The facility's policy and procedure on care plans, revised in March 2022, mandates the development and implementation of comprehensive, person-centered care plans with measurable objectives and timetables to meet residents' needs. However, the facility failed to adhere to this policy for Residents 1 and 25, resulting in deficiencies related to their care.
Failure to Update Care Plan for Tube Feeding
Penalty
Summary
The facility failed to revise a person-centered care plan for Resident 149, who was receiving artificial nutrition through a gastrostomy tube. The care plan, created on January 5, 2024, indicated that Resident 149 was to receive Diabeticsource 1.2 at 75 ml per hour for 10 hours daily, which was discontinued on June 27, 2024. However, a new physician's order was placed on June 27, 2024, for Glucerna 1.2 at 60 ml per hour for 20 hours daily. Despite this change, the care plan was not updated to reflect the new order, leading to a discrepancy between the care plan and the current physician's orders. Resident 149, who has diagnoses of dysphagia, cerebral palsy, and unspecified abnormal physiological development, was observed on October 15, 2024, receiving Glucerna 1.2 at 60 ml per hour. The MDS nurse confirmed that the care plan was not updated with the current feeding order, and the director of nursing emphasized the importance of accurate care plans for ensuring continuity of care. The facility's policy requires care plans to be revised as residents' conditions change, but this was not adhered to in Resident 149's case.
Failure to Provide ROM Services Leads to Decline in Resident's Mobility
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent a decline in range of motion (ROM) for a resident identified as having ROM limitations in both legs and a decline in ROM of both hips. The resident, who was admitted with diagnoses including rheumatoid arthritis and contracture of the upper arm, had been discharged from physical therapy services after reaching her highest practical level of function. However, the recommended Restorative Nursing Aide Program to apply splints was not fully implemented, as there were no orders for ROM exercises for the legs. Observations and interviews revealed that the resident was not receiving assistance with leg exercises, and staff assumed that ROM exercises were being provided by others. The Restorative Nursing Aide and Certified Nursing Assistant both confirmed that they did not perform ROM exercises, and the Director of Rehabilitation acknowledged that a therapy evaluation should have been ordered when a decline in ROM was noted. The resident's Joint Mobility Assessments indicated a worsening of ROM in both hips, knees, and ankles over time, yet no additional therapy services were initiated. The facility's policies and procedures required that any changes in ROM be addressed through evaluations and communication with the interdisciplinary team. Despite these guidelines, the resident did not receive the necessary ROM services to prevent further decline, leading to a significant reduction in mobility and potential risk for contracture development.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure the proper removal and storage of medications, leading to several deficiencies. In the medication room, an expired bottle of Folic Acid and discontinued Inbrija capsules for a resident were found. The Director of Nursing (DON) acknowledged that the expired Folic Acid should have been removed to prevent it from being administered, and the discontinued Inbrija should have been discarded immediately after the order was placed for discontinuation. The improper storage of these medications increased the risk of medication errors and misuse. Additionally, the facility did not store Brimonidine tartrate ophthalmic solution according to manufacturer requirements. The medication was found in the refrigerator alongside another resident's Latanoprost, which requires refrigeration. However, Brimonidine should be stored at room temperature. The DON confirmed that the Brimonidine was improperly stored, which could have rendered it ineffective and unsafe for treating the resident's glaucoma. Furthermore, an insulin Glargine prefilled pen for another resident was labeled with two different opened dates, contrary to the manufacturer's requirements. This discrepancy posed a risk of administering expired insulin, potentially compromising the resident's treatment for high blood sugar levels. The DON stated that the facility staff is required to label medication containers with an opened date and follow the standard for insulin expiration, which was not adhered to in this case.
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 5,881 citations issued within 25 miles in the last 12 months — including the 22 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 Signal Hill
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Long Beach Post Acute | 0.7 mi | ★★★★★ | 18 | 0 |
| Villa Serena Healthcare Center | 1.1 mi | ★★★★★ | 16 | 0 |
| Ocean Ridge Post Acute | 1.2 mi | ★★★★★ | 23 | 0 |
| Coral Cove Post Acute | 1.2 mi | ★★★★★ | 45 | 0 |
| Colonial Care Center | 1.3 mi | ★★★★★ | 35 | 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.