Below average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Culver West Health Center during CMS and state inspections, most recent first.
The facility failed to complete annual MDS assessments timely for two residents. During interview and record review, the MDS Coordinator stated both annual assessments had been started but were not completed within the required timeframe, and the DON stated MDS assessments should be completed and submitted per CMS guidelines. The facility policy required resident assessments to be completed once every 12 months.
Delayed MDS Transmission: The facility failed to ensure timely MDS completion and transmission for two residents. The MDS Coordinator stated the annual assessments had been started but were not completed at the time of review, and one resident’s annual MDS had been submitted after the required timeframe. The DON stated MDS assessments should be completed and submitted per CMS guidelines, and the facility policy required timely resident assessments and reviews.
Failure to Verify Need for Apixaban for AFib: A resident with persistent AFib and multiple chronic conditions reported repeatedly telling staff he needed apixaban, but the medication had been discontinued and was not on the current eMAR. The MDS nurse confirmed the resident was not receiving any AFib medication and said she would contact the physician; the DON stated nurses should clarify with the PCP when a resident requests a medication that is not currently ordered.
Unsafe Food Storage Temperatures in Kitchen: A Dietary Aid observed Refrigerator 1 at 45 degrees F and Freezer 1 at 10 degrees C, both above the facility’s required storage limits. The Dietary Supervisor confirmed the temperatures were too warm, and facility policy and the Food Code required refrigerated storage at 41 degrees F or lower and freezer storage at 0 degrees F (-17 degrees C) or lower.
A resident who was continent, cognitively intact, and able to walk with assistance was left toileting in bed with a bedpan, urinal, and adult briefs because the bathroom toilet was too low and no commode or raised toilet seat was provided. OT documented partial/moderate assistance with toilet transfers, but therapy only simulated transfers in the rehab gym and did not adequately assess the resident using the toilet in his room. The resident reported repeated requests for equipment, prior difficulty getting off the toilet, and feelings of humiliation, while the DOR, CNA, and DON confirmed the resident should have been toileting in the bathroom with appropriate equipment.
Inconsistent smoking materials policy. A resident with COPD, tobacco use, anxiety, depression, and other diagnoses was assessed as an independent smoker and stated he kept his own cigarettes at bedside. The AD said residents who smoke independently may keep cigarettes but not lighters, while the DON said residents cleared to smoke independently should not keep cigarettes at bedside because of fire hazard. Facility documents were conflicting, with one policy stating smoking materials are not permitted in residents’ possession and another stating residents with independent smoking privileges may keep cigarettes and other smoking articles.
Failure to Update Care Plan After OT Discharge: A resident with ESRD, morbid obesity, muscle weakness, and BPH remained on an active OT care plan even after OT discharged the resident for maximal potential achieved. The MDS Nurse and DOR confirmed the care plan still listed OT five times weekly for ADLs and strengthening, which caused staff confusion about whether therapy services were still being provided.
Failure to provide toileting equipment and support for safe transfers: A continent resident with ESRD, morbid obesity, muscle weakness, and BPH was able to walk and transfer with assistance, but used a bedpan, urinal, and adult briefs because the bathroom toilet was too low and no raised toilet seat or commode was provided. OT documented partial/moderate assistance with toilet transfers, evaluated the resident only on higher rehab surfaces, and discharged him without trialing bariatric equipment. The resident reported repeated requests for equipment, prior difficulty getting off the toilet, and feelings of humiliation from toileting in bed.
Resident not included in medication care planning. A resident with AFIB, CHF, CKD, DM2, anemia, and mobility impairment told staff he had repeatedly requested apixaban, which had been prescribed by his PCP, but the medication had been discontinued and was not on the current MAR. The resident was alert and oriented, and the MDS showed intact cognition. Staff interviews confirmed the resident’s request should have been clarified with the PCP, and the DON stated apixaban had been discontinued indefinitely without justification.
A resident admitted without pressure injuries and assessed as at risk for skin breakdown developed a right heel DTI during the stay. The resident had Parkinson’s disease, weakness, a right hip fracture, impaired cognition, dependence for bed mobility and ADLs, and incontinence. The care plan for the heel injury was not updated to reflect the current wound treatment orders or the change in PRAFO boot use, and staff observed the resident wearing only one PRAFO boot while the other was in the room closet.
A resident with hemiplegia, contractures, and severe cognitive impairment did not receive ordered PROM to the left elbow and left knee during an RNA session, even though the RNA confirmed the order required PROM to the entire arm and leg. In a separate case, an OT evaluation for a resident with COPD, Parkinson’s disease, and weakness identified impaired shoulder ROM but did not include objective measurements or degrees of movement, and the DOR confirmed the assessment was not objective.
A facility had conflicting smoking policies about whether residents with independent smoking privileges could keep cigarettes and other smoking items, creating confusion between staff and residents. In a separate event, a CNA privately arranged and paid for a PTC to transport a resident with TIA, ESRD, dysphagia, hemiplegia, wheelchair dependence, and impaired cognition to a bank without staff awareness, a physician order, or family consent, and the DON confirmed the resident left without adequate supervision.
A resident who was continent, cognitively intact, and able to walk with assistance was found toileting in bed and wearing adult briefs because the bathroom toilet was too low and no commode or raised toilet seat was available. The resident said he had repeatedly asked for equipment, had previously gotten stuck on the toilet, and was told to use a bedpan and urinal instead. OT documented partial/moderate assistance with toilet transfers but practiced only in the rehab gym, did not assess the resident on a regular toilet, and did not provide alternative bariatric equipment before discharging therapy.
A resident with DM, morbid obesity, and ESRD received Lantus and sliding-scale regular insulin, but the chart had no orders or documented monitoring for insulin side effects such as hypoglycemia, vomiting, or lethargy. The DON confirmed that nurses should monitor for low blood sugar symptoms and that no care plan addressed the resident’s insulin medications or diabetes.
A CNA bought and gave a resident protein bars without consulting the dietitian, nurses, or leadership, even though the resident had dysphagia and was ordered a minced and moist diet. The resident had significant medical issues including TIA, ESRD, anarthria, hemiplegia, and impaired cognition, and the DON confirmed the resident should not have been eating protein bars because of the choking risk.
Garbage Dumpster Lid Not Fully Closed: A garbage dumpster in the outdoor refuse area was observed filled with trash bags to the point that the lid could not fully close. A DA stated the lid should be fully closed to prevent pests and vermin, and the DS stated insects or animals could enter if the lid was not fully closed. Facility policy and the Food Code required garbage containers to remain covered with tight-fitting lids.
A CNA engaged in an inappropriate relationship with a resident who had TIA, ESRD, anarthria, dysphagia, hemiplegia, wheelchair dependence, and impaired cognition. The CNA arranged and paid for PTC transport for the resident to go to a bank without notifying staff, visited the resident at GACH while wearing scrubs without an ID badge, bought protein bars despite a minced and moist diet order, and exchanged romantic text messages with the resident. FM and the DON confirmed the contact and the Admin was aware of the concerns.
A resident with COPD, Parkinson’s disease, weakness, and moderate cognitive impairment had a JMA showing a decline in shoulder ROM from WFL to moderately impaired, but key sections of the form were left blank. The DOR confirmed the assessment was incomplete because it did not include the interpretation of findings, therapy recommendations, or plan of care, and the DON stated all portions of the JMA were important to identify ROM changes and support appropriate services.
A CNA entered a room marked for enhanced barrier precautions to transfer a resident with multiple chronic conditions and an indwelling urinary catheter, and touched room surfaces and the resident, including removing blankets, without wearing required PPE. An LVN observed the CNA inside the room without gown, gloves, or mask during high-contact care activities and stated that staff handling the resident should don full PPE. In a later interview, the CNA acknowledged understanding that gown and gloves were required for enhanced barrier precautions and admitted they should have put them on before entering, contrary to the facility’s EBP policy for residents with indwelling devices.
A dependent, cognitively intact resident with multiple comorbidities, including ESRD on dialysis and hemiplegia, was left without an accessible call light overnight when the call cord was dangling out of reach and later found on the floor. The assigned CNA believed a phone charger cord was the call light and did not identify that the actual call light was inaccessible, reporting that the resident was only changed once near the end of the night shift and was more wet than usual. The resident reported needing a change around 12:30 a.m., being unable to call because the call light was on the floor, not being repositioned, and experiencing burning to the buttocks, while the roommate recalled no staff entering the room for several hours. Subsequent observation confirmed the call light on the floor until prompted by the surveyor, despite facility policies requiring call lights to be within reach and routine resident checks each shift.
A resident with multiple cardiac and metabolic conditions, impaired cognition, and dependence for ADLs requested a room change due to another resident across the hall who frequently yelled and screamed, disturbing his rest. The resident and his family reported the noise problem and asked a supervisor for a room change, but were told it was not possible due to other residents needing proximity to the nurses’ station. An LVN stated she informed the DON and DSS of the room change request, while the DSS and DON both reported they were unaware of any such request from this resident. Surveyor observations documented the neighboring resident repeatedly yelling loudly with the door often open and no call light activated. The facility’s own room change and noise control policies required honoring resident room change requests, advance notice, documentation, and referral of room change and noise complaints to appropriate leadership, but these processes were not effectively carried out for this resident.
The facility failed to document required inspections of the nurse call system in resident bathrooms and bathing areas, despite a policy requiring weekly checks so that all components are tested at least monthly. A complaint was received alleging a call light had been non-functional for several weeks, and while maintenance logs showed all call lights working in earlier months, there was no documentation of call system checks for later months. The MM confirmed that call lights and the call system should be checked monthly and documented, but acknowledged the absence of records for those periods, placing the facility at risk for a non-functioning call system.
A nurse failed to review a change in transportation arrangements for a resident dependent on hemodialysis, resulting in the resident missing a scheduled dialysis session and being unnecessarily sent to a hospital, where dialysis was not provided due to recent prior treatment. The resident had complex medical needs and typically used gurney transport, but a switch to wheelchair transport was not properly communicated or acted upon by staff.
A resident with moderate cognitive impairment and no representative was allowed to refuse pneumonia, influenza, and COVID-19 vaccinations by signing consent forms, despite lacking decision-making capacity. Staff did not consult the physician, IDT, or Bioethics Committee as required by facility policy, and the DON confirmed that the resident should not have provided informed consent.
A resident with multiple medical conditions was found to have acetaminophen and Dulcolax accessible at the bedside without a physician's order or assessment for self-administration. Staff confirmed that the required assessment and authorization were not completed, and the medications were not stored securely, contrary to facility policy.
A resident with severe cognitive impairment and multiple medical conditions, who was dependent on staff for personal hygiene, was repeatedly observed with dirty fingernails and reported not receiving nail care. Staff acknowledged the issue, and facility policy required such care to maintain dignity, but the resident's nail hygiene needs were not met.
Two residents experienced deficiencies in catheter care and UTI management, including failure to label a catheter bag with the date and time of change, lack of timely physician notification of abnormal urinalysis results, and a significant delay in administering prescribed antibiotics due to unclear communication and documentation lapses.
A resident with a history of renal dialysis, UTI, and diabetes experienced a nine-day delay in receiving prescribed IM Ertapenem for a UTI. The delay resulted from late urine sample collection, lack of timely physician notification of abnormal lab results, and confusion about medication administration, with no evidence that staff followed facility protocols for prompt intervention.
A resident with multiple chronic conditions and intact decision-making ability repeatedly informed staff of her dislike for eggs and sweet foods in the morning, but these preferences were not documented or reflected in her meal tray ticket. As a result, she continued to be served foods she disliked, contrary to facility policy and dietary procedures.
A resident with multiple medical conditions and moderately impaired cognition was served a smaller portion of fresh green salad than required, as a dietary aide used a one-third cup scooper instead of the specified one-half cup. The Dietary Supervisor confirmed the error during observation, and facility policy requires adherence to standardized recipes and portion sizes.
Staff failed to follow infection control protocols by not donning required PPE while providing care to a resident on enhanced barrier precautions and by not labeling an indwelling catheter bag for another resident, despite facility policies and care plans outlining these requirements. These lapses were confirmed through observation, staff interviews, and record review.
A resident with moderate cognitive impairment and no representative was allowed to refuse pneumonia, influenza, and COVID-19 vaccinations without staff consulting the physician, IDT, or Bioethics Committee, despite facility policy requiring such consultation for residents lacking decision-making capacity.
A resident with severe cognitive impairment and multiple medical conditions was found without a working call light within reach, despite requiring significant assistance with daily activities. The resident was observed in pain and unable to summon help due to the nonfunctional call light and inaccessible call bell. Staff interviews and maintenance logs confirmed the issue, and facility policy was not followed regarding call light accessibility.
A deficiency was identified when 38 resident rooms did not meet the federal minimum square footage per resident, with multiple rooms providing only 77 square feet per resident in two-bed rooms and 73 square feet per resident in three-bed rooms. Despite a waiver request and staff reporting no concerns, the measured room sizes did not comply with regulatory standards for resident living space.
A facility failed to maintain AED machines, resulting in delayed emergency response during a resident's cardiac arrest. The AEDs were non-functional, lacking necessary components and with expired batteries. Staff were not trained to use or maintain the AEDs, and there was no clear responsibility for their upkeep, contributing to the deficiency.
A resident with diabetes, hypertension, and dementia experienced moisture-associated skin damage (MASD), but the family was not notified as required by the facility's policy. The lack of documentation and communication was confirmed through interviews and record reviews, highlighting a failure to adhere to procedures for notifying family members of changes in condition.
A resident with severe cognitive impairment and multiple health issues was found with the call light on the floor, out of reach, leading to a near fall. The care plan required the call light to be within reach, but staff failed to ensure this, posing a risk of falls. Interviews with staff confirmed the importance of call light accessibility and prompt response, as outlined in the facility's policy.
The facility failed to investigate and report allegations of physical abuse involving a resident-to-resident altercation within the required 2-hour timeframe. A resident reported being grabbed by another resident, causing discoloration on her arms. The incident was not reported to the Department of Public Health, Ombudsman, or local law enforcement promptly, as required by the facility's policy.
The facility failed to maintain safe and sanitary conditions in food preparation and storage, leading to potential foodborne illness risks. Staff did not wear hairnets properly, perform hand hygiene, or change aprons when necessary. Additionally, a resident had food and drink items left at their bedside for over 14 hours without proper storage or refrigeration, contrary to facility policies.
The facility failed to provide an appropriate bed for a resident, leading to potential pressure injuries, and did not ensure another resident's call light was within reach, risking delays in care. The deficiencies were confirmed through observations and staff interviews.
The facility failed to provide a homelike environment for a resident who had to store personal belongings in boxes on the floor due to insufficient closet space. The resident's belongings were not properly inventoried upon admission, leading to difficulties in locating his possessions and causing distress.
The facility failed to identify and mitigate environmental hazards for a resident with moderately impaired cognition, who was found with an open bottle of shampoo and body wash on her bedside drawer. The liquid could have been mistakenly ingested, leading to potential poisoning and allergic reactions. Staff did not follow the facility's policy on safety and supervision, resulting in this deficiency.
The facility failed to ensure that a resident received continuous feeding of isosource 1.5 as per the physician's order. The resident's tube feeding was found disconnected and spilling on the floor, leading to potential inadequate nutrition. This was confirmed by staff and the facility's policy on gastrostomy feeding.
A resident with a history of heart disease and neuropathy did not receive prescribed pain medication during a night shift, despite requesting it. The LPN admitted to not administering the medication, and the DON emphasized the importance of pain management for resident comfort and quality of life.
The facility failed to provide a functioning call light system for two residents, leading to potential physical and emotional harm. One resident reported a broken call light for five days and was given an ineffective bell, while another resident's call light was out of reach, delaying care. Staff acknowledged systemic issues with the call light system and delays in repairs.
The facility failed to provide adequate storage and conduct inventory for a resident's personal belongings, resulting in the resident storing items in boxes on the floor and reporting missing items. Staff confirmed that the inventory form was not filled out upon admission, leading to difficulties in tracking and locating the resident's belongings.
The facility failed to provide the required 80 square feet per resident in multiple resident bedrooms, affecting 38 rooms. Observations showed sufficient space for general movement and care, but a CNA reported difficulties using a Hoyer lift due to limited space.
Late Annual MDS Assessments
Penalty
Summary
The facility failed to complete the Annual MDS assessment timely for Resident 4 and Resident 12 according to its policy and procedures titled, Resident Assessment Instrument. During a concurrent interview and record review with the MDS Coordinator, the most recent annual MDS assessments for both residents were reviewed, and the MDS Coordinator stated they had not been completed at the time of review. The MDS Coordinator stated the annual assessments were started on 6/8/2026 and should have been completed within 14 days, by 6/22/2026. The MDS Coordinator also stated the MDS delineates all care services provided to the resident and that not completing it within CMS guidelines could lead to the facility not recognizing a change in the resident's condition. The DON stated MDS assessments should be completed and submitted per CMS guidelines. The facility policy stated the Resident Assessment Coordinator is responsible for ensuring timely and appropriate resident assessments, including once every 12 months.
Delayed MDS Transmission
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) was transmitted to the CMS system within the required timeframe for one of four sampled residents, identified in the report as Resident 12. A review of the facility’s CMS Submission Report dated 7/9/2026 showed that Resident 12’s annual MDS was submitted on 7/9/2026, which was 31 days after the assessment reference date of 6/8/2026. The report also states that Resident 4 and Resident 12’s most recent annual MDS assessments were reviewed during a concurrent interview and record review with the MDS Coordinator on 7/9/2026 at 3:19 PM. During that interview, the MDS Coordinator stated that Resident 4 and Resident 12’s MDS assessments had not been completed at that time. The MDS Coordinator stated the annual assessments were started on 6/8/2026 and should have been completed within 14 days, by 6/22/2026, and submitted within 14 days of the completion date, by 7/6/2026. During a separate interview on 7/9/2026 at 3:25 PM, the DON stated that MDS assessments should be completed and submitted per CMS guidelines. The facility’s policy titled Resident Assessment Instrument, revised 1/2/2026, states the Resident Assessment Coordinator is responsible for ensuring timely and appropriate resident assessments and reviews according to the required schedule.
Failure to Verify Need for Apixaban for AFib
Penalty
Summary
The facility failed to contact and verify with a physician whether a resident with persistent atrial fibrillation could continue apixaban 2.5 mg, resulting in the resident not receiving the medication after 2/2026. The resident had multiple diagnoses including type 2 diabetes mellitus, chronic systolic congestive heart failure, primary pulmonary hypertension, chronic kidney disease, anemia, gait and mobility abnormalities, and muscle weakness. The resident’s history and physical dated 12/23/2025 described the resident as alert and oriented x4, and the MDS dated 4/15/2026 indicated cognition was intact and documented varying levels of assistance needed for personal care tasks. During a facility tour on 7/6/2026, the resident stated he had told several staff members on multiple occasions that he needed apixaban, which had previously been prescribed by his PCP for AFib, but he had been unsuccessful in convincing licensed staff of his need for the medication. On 7/7/2026, the MDS nurse stated the current eMAR showed no apixaban or other AFib medication ordered and said she would call the physician to check whether the resident still needed it. The medication history showed apixaban had been discontinued on 12/21/2025, and the record later showed apixaban 2.5 mg twice daily was resumed on 7/7/2026 at 11:27 a.m. The DON stated licensed nurses should clarify with the PCP if a resident requests a medication not currently ordered, and that discontinuing apixaban indefinitely without justification places a resident at risk of developing blood clots that could lead to stroke.
Unsafe Food Storage Temperatures in Kitchen
Penalty
Summary
The facility failed to ensure safe and sanitary food storage practices in the kitchen when Refrigerator 1 was observed with an internal temperature of 45 degrees Fahrenheit, above the facility’s stated limit of 41 degrees Fahrenheit or lower. During the observation, a Dietary Aid stated that 45 degrees Fahrenheit was too warm for the refrigerator and that food could potentially become contaminated if the refrigerator temperature was too warm. The facility also failed to maintain Freezer 1 at the required temperature when it was observed at 10 degrees Celsius, above the facility’s stated limit of -17 degrees Celsius or lower. The same Dietary Aid stated that 10 degrees Celsius was too warm for the freezer and that food could potentially become contaminated if freezer temperatures were too warm. The Dietary Supervisor later confirmed that both temperatures were too warm, and the facility policy and Food Code reviewed during the investigation stated that refrigerated storage should be maintained at 41 degrees Fahrenheit or lower and freezer storage at 0 degrees Fahrenheit (-17 degrees Celsius) or lower.
Failure to Provide Toileting Equipment and Safe Transfer Support
Penalty
Summary
The facility failed to provide services and equipment to improve toileting and toilet transfer abilities for a resident who was continent and able to walk and transfer with assistance. Resident 5 was admitted and re-admitted with diagnoses including ESRD, morbid obesity, muscle weakness, and benign prostatic hyperplasia with lower urinary tract symptoms. The resident’s MDS showed cognitive intactness, always continent bowel and bladder status, and need for partial/moderate assistance with toileting hygiene and bathing, supervision or touching assistance with walking 150 feet, and set-up or clean-up assistance with sit-to-stand, bed-to-chair transfers, and toilet transfers. During observation, Resident 5 was found lying in bed wearing adult briefs and stated he primarily used a bed pan and urinal for toileting and wore briefs daily because the bathroom toilet was too low and he did not have a commode or raised toilet seat. He stated he was over six feet tall, could not safely transfer on and off the toilet, had previously gotten stuck on the toilet and needed two staff members to assist him off, and had repeatedly asked staff for equipment to elevate the toilet seat or provide a commode that could accommodate his size and weight. He stated staff instructed him to use a bedpan, urinal, and adult brief instead, and he felt humiliated and degraded by toileting in bed and wearing a brief. OT 1 confirmed the resident had been discharged from OT after no longer progressing and documented partial/moderate assistance for toilet transfers, but OT 1 had only simulated transfers in the rehab gym using a chair and therapy mat rather than a regular toilet. OT 1 stated the simulation was not adequate because the surfaces were higher than the toilet in the resident’s room, and acknowledged the resident needed specialized equipment such as a raised toilet seat or commode to safely transfer. OT 1 stated the resident requested to practice toilet transfers during therapy, but she did not investigate his refusal to use the shower chair she suggested, did not offer other bariatric equipment, and discharged him without further attempts to maximize toileting and toilet transfer abilities. The DOR, CNA 2, and DON all stated that a continent resident who can walk should be toileting in the bathroom and that the facility had not provided the necessary equipment or opportunities to support safe toilet transfers.
Inconsistent Smoking Materials Policy
Penalty
Summary
The facility failed to provide a clear and concise policy and procedure regarding the storage of and access to smoking materials, including cigarettes, lighters, and matches, for one sampled resident. Resident 11 was admitted and re-admitted with diagnoses including COPD, chronic pulmonary edema, alcohol abuse with intoxication, major depressive disorder, acute respiratory failure with hypoxia, tobacco use, generalized anxiety disorder, and other psychoactive substance dependence. The resident’s MDS indicated intact cognition and varying levels of assistance needed for activities of daily living. The resident’s smoker’s risk assessment identified the resident as an independent smoker, and the resident stated he kept his own cigarettes with him while in the facility. During interviews, the Activity Director stated residents who demonstrate independent safe smoking abilities may smoke independently without supervision and are allowed to keep their own cigarettes but not lighters. The DON stated residents cleared to smoke independently are not supposed to keep cigarettes at bedside because of safety and fire hazard. The facility’s written smoking policy provided onsite stated residents are not permitted to keep smoking materials, lighters, matches, or related items in their possession and that these items are kept by designated staff, while a separate electronically provided smoking policy stated residents with independent smoking privileges are permitted to keep cigarettes, pipes, tobacco, and other smoking articles in their possession.
Failure to Update Care Plan After OT Discharge
Penalty
Summary
The facility failed to revise Resident 5’s comprehensive care plan after Occupational Therapy discharged the resident from therapy services on 3/22/2026. Resident 5 had been admitted and readmitted with diagnoses including ESRD, morbid obesity, muscle weakness, and benign prostatic hyperplasia with lower urinary tract symptoms. The resident’s MDS dated 6/1/2026 showed the resident was cognitively intact and required varying levels of assistance with toileting hygiene, bathing, dressing, transfers, and walking, while remaining independent with eating, oral hygiene, rolling, and sitting up in bed. Resident 5’s comprehensive care plan, initiated 2/6/2026, identified the need for skilled OT services to address limitations in ADL participation and generalized weakness. The plan included a goal to increase safety during ADLs and reduce the level of assistance needed, with interventions for OT treatment five times a week for four weeks for self-care training, therapeutic exercises, therapeutic activities, and neuromuscular re-education. However, the OT Discharge Summary stated the resident was discharged from OT services due to maximal potential achieved, and the care plan was not updated to discontinue the OT services after that discharge. During interview and record review, the MDS Nurse stated licensed staff updated comprehensive care plans quarterly, upon a change of condition, and as needed, and that Rehab was responsible for initiating, updating, and discontinuing therapy-related services in the care plan. The MDS Nurse reviewed the care plan and stated she was unaware the resident had been discharged from OT and believed OT was still providing services because the care plan listed OT five times a week. The DOR confirmed OT had discharged the resident and stated the OT care plan should have been discontinued, while the DON stated Rehab should discontinue the therapy care plan and create a new RNA care plan for functional maintenance once therapy ended.
Failure to Provide Toileting Equipment and Support for Safe Transfers
Penalty
Summary
The facility failed to provide services and equipment to improve toileting and toilet transfer abilities for one resident who was continent and able to walk and transfer with assistance. The resident was admitted with diagnoses including ESRD, morbid obesity, muscle weakness, and benign prostatic hyperplasia with lower urinary tract symptoms. The MDS indicated the resident was cognitively intact, always continent of bowel and bladder, and required only partial/moderate assistance with toileting hygiene and bathing, supervision or touching assistance with walking 150 feet, and set-up or clean-up assistance with sit-to-stand, bed-to-chair transfers, and toilet transfers. The OT discharge summary documented that the resident required partial/moderate assistance with toilet/commode transfers and that OT discharged him after maximal potential was achieved. During observation, the resident was found lying in bed wearing adult briefs and stated he primarily used a bedpan and urinal for toileting because the toilet in his bathroom was too low and he did not have a commode or raised toilet seat. He stated he was over six feet tall, could not safely transfer on and off the toilet, had previously gotten stuck on the toilet and needed two staff members to assist him off, and had repeatedly requested equipment to elevate the toilet seat or a commode that could accommodate his weight and size. OT confirmed the resident was evaluated only in the rehab gym using a chair and therapy mat, not on a regular toilet, and stated those surfaces were higher than the toilet in the resident’s room. OT stated the resident needed specialized equipment such as a raised toilet seat or commode because the toilet in his room was very low, but OT did not provide or trial bariatric equipment and discharged him without further attempts to maximize toileting and toilet transfer abilities. The DOR and DON stated that continent residents who are able to walk should be toileting in the bathroom and that Rehab determines the equipment needed for safe toilet transfers. CNA 2 also stated the resident used a bedpan and urinal in bed and did not have proper equipment to accommodate his height and weight for safe transfers.
Resident Not Included in Medication Care Planning
Penalty
Summary
The facility failed to provide one sampled resident with the opportunity to make choices about aspects of his care planning that were significant to his overall health and well-being, as required by the facility's Resident Rights policy. Resident 17 was admitted and re-admitted with multiple diagnoses including type 2 diabetes mellitus, chronic systolic congestive heart failure, primary pulmonary hypertension, persistent atrial fibrillation, chronic kidney disease, anemia, gait and mobility abnormalities, and muscle weakness. His history and physical documented that he was alert and oriented x4, and the MDS indicated intact cognition, with varying levels of assistance needed for personal care tasks. During the survey, Resident 17 stated that he had repeatedly told facility staff to give him apixaban, which he had previously been prescribed by his PCP for atrial fibrillation, but he had been unsuccessful in getting the medication restarted. He reported that the last time he received the medication was in 2/2026. Record review showed the apixaban order had been discontinued on 12/21/2025, and the medication was not on the current eMAR when reviewed by the MDS nurse, who stated she would call the physician to check whether the resident still needed it. Later that day, the record showed apixaban 2.5 mg by mouth twice daily was resumed. Interviews with an LVN and the DON confirmed that when a resident requests a medication that is not currently ordered, licensed nurses should clarify with the PCP whether the resident needs it, and that apixaban had been discontinued indefinitely without justification.
Failure to Update Pressure Injury Care Plan and Prevent Right Heel Injury
Penalty
Summary
The facility failed to ensure that a resident who was admitted without pressure injuries and was assessed as at risk for pressure injury development received necessary care and services to prevent a right heel pressure injury from developing. The resident was admitted with diagnoses including Parkinson’s disease, muscle weakness, and a right hip fracture, and the admission assessment showed extensive assistance was needed for bed mobility with no pressure injuries present. The Braden Scale score was 16, placing the resident in the at-risk category, and the admission MDS indicated the resident was moderately cognitively impaired, substantially dependent for bed mobility, dependent for multiple ADLs, always incontinent, and at risk for pressure ulcers. The resident later developed wounds during the stay, including a right hip surgical wound, a stage 3 sacral coccyx pressure ulcer, and then a right heel deep tissue injury. The wound physician progress notes documented the progression from one wound to two wounds and then to a third wound on the right heel. Physician orders for the right heel treatment changed over time and included cleansing with normal saline, applying betadine, hydrogel, xeroform, Santyl ointment, calcium alginate, and collagen sheet dressings with various coverings and schedules. The resident’s care plan for the right heel skin impairment identified the wound as a deep tissue pressure injury and included heel protectors at all times when in bed, along with an older wound treatment that did not match the current physician orders. The care plan did not address that the resident was not wearing both heel protectors or the PRAFO boot, and it did not include the current wound treatment order. During observation, the resident was seen in bed with bare feet and a kerlix wrap around the right heel and ankle, and later was observed wearing only a PRAFO boot on the right foot while the left boot was in the room closet. Staff stated the resident only wore one PRAFO boot on the right foot, and the LVN stated the care plan was not updated when the physician determined the resident only needed the PRAFO boot on the right foot and was not updated with the current wound treatment orders until later.
Failure to Provide Ordered ROM Services and Objective ROM Measurement
Penalty
Summary
The facility failed to provide ordered ROM services for a resident with significant mobility limitations and contractures. The resident had diagnoses including left-sided hemiplegia, contracture of an unspecified joint, and muscle wasting and atrophy, and the MDS showed severe cognitive impairment, dependence for multiple ADLs, and functional ROM limitations in one arm and one leg. A physician order directed RNA staff to provide PROM to both arms and both legs seven times a week. During an observed RNA session, one RNA provided PROM to the resident’s right shoulder, elbow, wrist, hand, hip, knee, and ankle, while another RNA provided PROM to the resident’s left shoulder, wrist, hip, and ankle. The RNA did not provide PROM to the resident’s left elbow, fingers, or knee. In interview, the RNA confirmed the order required PROM to the entire arm and leg and stated she did not assist with ROM to the left elbow and left knee during the session, even though she acknowledged the resident had extremely stiff and contracted joints and that failure to provide the exercises as ordered could result in ROM decline. The facility also failed to objectively measure ROM impairments for another resident during an OT evaluation. That resident had diagnoses including COPD, Parkinson’s disease, and weakness, and the OT evaluation identified impaired ROM in both shoulders but did not include objective measurements or degrees of movement. The DOR confirmed therapists should objectively measure ROM with a goniometer to establish a baseline and stated the evaluation was not objective because it did not include specific shoulder ROM measurements. The DON stated objective documentation was important to establish an accurate baseline and monitor changes in ROM.
Conflicting Smoking Policies and Unsupervised Resident Transport
Penalty
Summary
The facility failed to provide staff with one clear smoking policy regarding whether residents who independently smoked could keep cigarettes, lighters, matches, or other smoking-related items in their possession. Two policies dated 1/12/2026 conflicted with each other: one stated residents were not permitted to keep smoking materials and that cigarettes, matches, lighters, and other materials would be kept by designated staff, while the other stated residents with independent smoking privileges were permitted to keep cigarettes, pipes, tobacco, and other smoking articles in their possession. The report states this created confusion among staff and residents and placed residents, staff, and guests at increased risk for fire-related injuries, hospitalization, and death. The report also identified that a CNA made private transportation arrangements with a private transportation company to take a resident to and from a bank in Pasadena without facility staff awareness, without a physician's order, and without consent from family members or awareness of family members. The resident had diagnoses including TIA, ESRD, anarthria, dysphagia, and right-sided hemiplegia. The resident's MDS indicated use of a wheelchair, total physical assistance for transfers, and moderately impaired cognitive patterns. The resident's history and physical identified the resident as high risk for falls. According to the record and interviews, the CNA used a phone app to arrange and pay for the transportation, did not inform the Admin, DON, or other facility staff, and stated the resident traveled alone without adequate supervision. The DON confirmed the resident left the facility without adequate supervision and that the CNA paid for the transportation to the bank in Pasadena. The facility's therapeutic leave policy required a physician order and a signed Release of Responsibility form for therapeutic leave, and the safety and supervision policy stated resident safety and supervision were facility-wide priorities.
Failure to Provide Toileting Equipment and Safe Toilet Transfer Support
Penalty
Summary
The facility failed to provide services and equipment to improve toileting and toilet transfer abilities for a resident who was continent, cognitively intact, able to walk with assistance, and required only partial/moderate assistance with toileting hygiene and toilet transfers. The resident had diagnoses including ESRD, morbid obesity, muscle weakness, and benign prostatic hyperplasia with lower urinary tract symptoms. The MDS indicated the resident was always continent of bowel and bladder, and the OT discharge summary documented partial/moderate assistance with toilet/commode transfers. During observation, the resident was found lying in bed wearing adult briefs and stated he primarily used a bed pan and urinal for toileting because the toilet in his bathroom was too low and he did not have a commode or raised toilet seat. He stated he was over six feet tall, could not safely transfer on and off the toilet, had previously gotten stuck on the toilet and needed two staff members to assist him off, and had repeatedly asked staff for equipment to elevate the toilet seat or provide a commode that could accommodate his size and weight. He stated staff instructed him to use a bedpan, urinal, and adult brief instead. OT confirmed the resident had been discharged from therapy after reaching maximal potential and that the toilet transfer practice had been simulated only in the rehab gym using a chair and therapy mat, not on a regular toilet or a surface matching the toilet height in the resident's room. OT stated the resident requested to practice toilet transfers, but OT did not investigate his refusal to use the suggested shower chair, did not offer alternative bariatric equipment, and discharged him without further attempts to maximize toileting and toilet transfer abilities. The DOR and DON stated that residents who are continent and able to walk should be walking to the bathroom for toileting and that Rehab should assess safe toilet transfers and provide necessary equipment, while the facility policy stated it was committed to maintaining and improving ADLs to the highest practicable level.
Failure to Monitor Insulin and Care Plan for Diabetes
Penalty
Summary
The facility failed to provide appropriate monitoring of insulin for one resident who was admitted with diagnoses including diabetes mellitus, morbid obesity, and ESRD. The resident’s record showed orders for Lantus insulin 5 units at bedtime and regular insulin by sliding scale before meals. A review of the resident’s physician orders on 7/9/2026 found no orders to monitor for hypoglycemia, vomiting, or lethargy, and the June and July 2026 MARs showed the resident was receiving regular insulin and Lantus insulin without documented evidence that nursing staff monitored for side effects of insulin. During a concurrent interview and record review, the DON stated the resident was taking Lantus and regular insulin and that nurses should monitor for signs and symptoms of low blood sugar, with such monitoring documented on the MAR. The facility also failed to initiate a comprehensive care plan that addressed the resident’s diabetes or insulin administration. During the same interview, the DON stated there was no care plan addressing the resident’s insulin medications and that there should be a care plan including insulin administration and monitoring for signs and symptoms of hypoglycemia. The facility’s policy for comprehensive person-centered care plans stated that care plans are to be developed and implemented for each resident and include measurable objectives, timeframes, identified problem areas, risk factors, and treatment goals.
Failure to Follow Ordered Minced Diet
Penalty
Summary
The facility failed to ensure a CNA followed and verified a physician’s order for a minced and moist diet for one resident with dysphagia. The resident was admitted with diagnoses including TIA, ESRD, anarthria, dysphagia, and right-sided hemiplegia, and the MDS indicated the resident used a wheelchair, required total physical assistance for transfers, and had moderately impaired cognitive patterns. A physician’s order dated 4/8/2026 downgraded the resident’s diet from soft bite-sized to minced and moist because of dysphagia, and the care plan identified a swallowing problem with goals to avoid aspiration injury and choking episodes. During the investigation, the resident’s family member stated that the CNA used personal money to buy protein bars and brought protein bars and water bottles to the resident while the resident was at the facility. The CNA confirmed buying the protein bars without consulting the facility dietitian, licensed nurses, or leadership, and stated the resident ate the protein bars despite being aware the resident was on a minced diet. The DON also stated the CNA purchased bottled water and protein bars for the resident and that the resident should not have been receiving or eating protein bars because of the resident’s diet and choking risk. Speech therapy notes also stated it was not optimal to upgrade the resident to a regular or soft and bite-sized diet due to prolonged oral phase and previous weight loss with an upgraded diet.
Garbage Dumpster Lid Not Fully Closed
Penalty
Summary
The facility failed to ensure that one of two garbage dumpsters had a lid that was completely closed and covered. During a concurrent observation and interview in the outdoor garbage area, a garbage dumpster was found filled with trash bags to the point that the lid could not fully close. A Dietary Aid stated the dumpster lid should be fully closed to prevent pests and vermin. During a later interview, the Dietary Supervisor stated insects or animals could travel inside the dumpster if the lid is not fully closed. Facility policy and procedures for Miscellaneous Areas - Garbage and Trash stated that all food waste must be placed in sealed, leak-proof, non-absorbent, tightly closed containers and disposed of as necessary, and that adequate, clean, vermin-proof areas must be provided for storage of garbage and rubbish. The facility's Trash Removal policy stated the trash cart remains covered at all times, and the Food Code stated outside receptacles must have tight-fitting lids or covers.
Inappropriate staff-resident relationship and unsupervised outing
Penalty
Summary
The facility failed to ensure CNA 1 followed the employee code of conduct by engaging in an inappropriate relationship with Resident 99. Resident 99 was admitted with diagnoses including TIA, ESRD, anarthria, dysphagia, and right-sided hemiplegia, and the MDS indicated the resident used a wheelchair, required total physical assistance for transfers, and had moderately impaired cognitive patterns. The facility’s Employee Handbook required employees to avoid actual or potential conflicts of interest and to disclose relevant circumstances to supervision. CNA 1 arranged and paid for a private transportation company to take Resident 99 from the facility to a bank in Pasadena and back, without informing the Admin, DON, or other staff. CNA 1 confirmed the resident traveled alone and stated the resident was transported without adequate supervision. The DON confirmed the resident left the facility without adequate supervision and that CNA 1 paid for the transportation. The facility’s Therapeutic Leave Policy required residents on therapeutic leave to sign the Release of Responsibility form, and the record review found no documented evidence that Resident 99 signed in or out for out-of-pass leave in April 2026. CNA 1 also visited Resident 99 at GACH 1 on multiple occasions while the resident was hospitalized, wore scrubs without an identification badge, and stated the visits were to help feed the resident. CNA 1 bought protein bars for Resident 99 despite a physician order for a minced and moist diet related to dysphagia, and the DON stated the resident should not have been receiving protein bars. FM 1 reported observing CNA 1’s continued contact with Resident 99 and read text messages on the resident’s phone, including a message from a contact with CNA 1’s first name stating, “Hi [NAME], how are you today? I can't wait to see you. I miss you.” The DON stated the relationship involved romantic text messages, visits at the hospital, and purchasing bottled water and protein bars, and the Admin acknowledged awareness of the email from FM 1 and the visits to GACH 1.
Incomplete Joint Mobility Assessment Documentation
Penalty
Summary
The facility failed to keep the medical record complete for one sampled resident by leaving portions of the Joint Mobility Assessment (JMA) blank. Resident 10 had diagnoses including COPD, Parkinson’s disease, and weakness, and the record showed the resident was initially admitted and later re-admitted to the facility. The resident’s admission record also reflected moderate cognitive impairment and significant assistance needs for multiple activities of daily living. A JMA dated 9/9/2025 documented that both shoulders were within functional limits and indicated Occupational Therapy should evaluate and treat the resident. A later JMA dated 4/2/2026 showed both shoulders were moderately impaired, reflecting a decline from the prior assessment. However, the sections for review of rehabilitative needs, therapy evaluation orders, whether skilled therapy intervention was needed, and additional comments/notes were left blank. During observation, Resident 10 sat in a wheelchair with both elbows bent on the armrests and did not attempt to move both shoulders or raise both arms overhead when asked. The Director of Rehabilitation confirmed the later JMA was incomplete and stated the evaluating therapist must complete all sections to interpret the findings, indicate whether the resident maintained, improved, or declined in ROM, and document recommendations and plan of care. The Director of Nursing also stated it was important that all portions of the JMA be completed to identify ROM changes and provide appropriate services.
Failure to Use PPE for Resident on Enhanced Barrier Precautions
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to follow the facility’s Enhanced Barrier Precautions (EBP) requirements for personal protective equipment (PPE) while providing care to a resident on EBP. The resident was an older male admitted with multiple chronic conditions, including COPD, dysphagia, CHF, HTN, glaucoma, atrial fibrillation, emphysema, asthma, GERD, gout, chronic kidney disease, oxygen dependence, and BPH. Physician orders documented an indwelling urinary catheter for BPH and chronic kidney disease and a specific order for enhanced barrier precautions related to the urinary catheter. The resident’s MDS showed moderately impaired cognition and dependence on staff for toileting, personal hygiene, and transfers, and the care plan identified the resident as being on enhanced standard precautions due to risk for acquiring or being a source of MDRO, with an intervention that nursing staff would render EBP procedures per the facility infection control plan. During an observation conducted outside the resident’s room, surveyors and an LVN saw the CNA already inside the room, touching room surfaces and the resident in bed, including removing blankets, without wearing gloves, gown, or mask, despite EBP signage on the room. The LVN stated that anyone handling the resident should put on gown, mask, and gloves before entering the room, and then instructed the CNA to exit and don PPE. At the time, the CNA was in the process of preparing to transfer the resident from bed to chair and to prepare the resident for lunch, which are high-contact resident care activities. In a subsequent interview, the CNA acknowledged that when a sign indicates enhanced barrier precautions, they are supposed to put on a gown and gloves before entering the room if performing any care with the resident. The CNA confirmed they were going into the room to transfer the resident from bed to chair and prepare the resident for lunch and admitted they should have put on the gown and gloves before entering. The facility’s EBP policy, reviewed in 1/2026, specified that gown and gloves are required for high-contact resident care activities such as transferring, providing hygiene, changing linens, assisting with toileting, and device care for residents with indwelling medical devices, including urinary catheters, even when contact precautions do not otherwise apply.
Failure to Maintain Accessible Call Light Resulting in Prolonged Incontinence Episode
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a working and accessible call light system was available to a dependent resident, resulting in the resident remaining in a wet diaper for several hours and experiencing a burning sensation to the buttocks. Resident 1, an adult male with hemiplegia and hemiparesis of the right side, ESRD on dialysis, HTN, hyperlipidemia, prior cerebral infarction, generalized weakness, dysphagia, aphasia, and anemia, had intact cognition per the H&P. The MDS indicated he was dependent for toileting, personal hygiene, and transfers, and his care plan required the call light to be within reach, needs to be attended to promptly, and encouragement to call for help. Facility policy on call lights required the system to be demonstrated, kept within reach, and functioning, and policy on routine resident checks required at least one check per 8‑hour shift with documentation. On the night in question, CNA 2 was assigned to Resident 1 for the 11:00 p.m. to 7:00 a.m. shift. CNA 2 reported that upon starting the shift, Resident 1 was asleep and what CNA 2 believed to be the call light cord coming out of the wall was actually a phone charger cord. CNA 2 stated that Resident 1 usually called between 1:00 a.m. and 2:00 a.m. but did not call that night, and that Resident 1 was only changed at 6:30 a.m., at which time he was more wet than usual. CNA 2 also stated that when entering the room in the morning, the call light was seen dangling on the right side of the bed, out of the resident’s reach, and acknowledged that this may have been why the resident did not call during the night. Resident 2, the roommate, reported that the night was quiet between 2:00 a.m. and 6:00 a.m. and did not recall anyone coming into the room during that time, although he had seen staff come in and change Resident 1 on other nights when the call button was used. During an interview, Resident 1 communicated via a board that no one came to check on him between 12:30 a.m. and 6:30 a.m., that he needed to be changed at 12:30 a.m. but his call light was on the floor, and that he did not sleep much because his bottom was burning. He stated he was not repositioned and that he had told all shifts about his bottom burning, and he reported that CNA 2 changed him at 6:30 a.m. and that this was the only change since the previous night. Later observation in Resident 1’s room with CNA 1 showed the call light on the floor on the right side of the bed, out of reach, until the surveyor prompted CNA 1 to retrieve and pin it to the bed linen. The DON stated that the call light should always be in reach. These observations, interviews, and record reviews demonstrate that the facility did not ensure the call light was accessible and did not perform routine checks consistent with policy, leading to Resident 1 remaining in a wet diaper for several hours and experiencing a burning sensation to the buttocks.
Failure to Act on Resident’s Room Change Request Related to Ongoing Noise Disturbance
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to request a room change and to provide appropriate notice and follow-through on that request. One male resident with multiple complex medical conditions, including heart failure, atrial fibrillation, diabetes mellitus, peripheral vascular disease, and general anxiety disorder, was admitted in November and had impaired cognition and dependence on staff for toileting and transfers per his MDS. This resident was housed across the hall from a female resident who had encephalopathy, delusional disorder, anxiety disorder, insomnia, bipolar disorder, chronic kidney disease, and other conditions, and who was known to yell and scream. The facility’s policy stated that room changes would be made when the facility deemed it necessary or when requested by the resident, with documentation in the medical record and involvement of Social Services for inquiries. According to interviews, the male resident and his family member reported that he had complained about the female resident’s constant yelling and screaming, which made it difficult for him to sleep. The family member stated that a supervisor was asked for a room change and responded that a room change was not possible because other residents needed to be closer to the nursing station. The resident himself stated that he had requested a room change about three weeks prior and that no one followed up with him. The LVN reported that multiple residents, including this resident, had complained about the yelling and that the resident requested a room change about two weeks earlier, with the family member calling about one week later to follow up. The LVN stated she informed the DON and the Director of Social Services of the room change request. In contrast, the Director of Social Services stated she was not aware of any complaints from the current room regarding the yelling and screaming and was not aware of any room change request from this resident. The DON stated that any staff member could receive a room change request and that such requests should be reported to the DON and Social Services, but the DON was not aware that this resident had complained or requested a room change. Observations on the survey date documented the female resident repeatedly yelling loudly from her room, sometimes with the door open and without the call light activated, while the male resident’s door was open or slightly open across the hall. The failure of the LVN and/or facility to ensure that the resident’s room change request was effectively communicated, acted upon, and documented resulted in the resident remaining in a room across from a resident who was frequently yelling, contrary to the facility’s room change and noise control policies and the resident’s right to request a room change.
Failure to Document Required Nurse Call System Checks
Penalty
Summary
The facility failed to follow its policy for routine testing and documentation of the nurse call system in resident bathrooms and bathing areas, resulting in missing documentation of required inspections. A complaint was received by the California Department of Public Health alleging that a call light had not been working for four weeks. Review of the maintenance logs for July, August, and September 2025 showed entries indicating all call lights were working, but there was no documentation of call system checks for November and December 2025. During an interview, the Maintenance Manager stated that call lights and the call system are supposed to be checked monthly and documented, and acknowledged that there was no documentation for those two months. The facility’s policy, revised in January 2025, required weekly checking of a proportionate number of nurse call buttons, buzzers, cords, and lights so that each part of the system is checked at least monthly, including verification that the signal lights over residents’ doors, the audible signal at the nurses’ station, and the annunciator lights function properly. This deficient practice placed the facility at risk for a non-functioning call system, as the required testing and documentation process was not followed or recorded for the specified months.
Failure to Review Updated Dialysis Transportation Results in Missed Treatment
Penalty
Summary
A registered nurse failed to review and act upon a change in the transportation method for a resident dependent on hemodialysis, resulting in the resident missing a scheduled dialysis session. The resident, an older adult with multiple complex medical conditions including end stage renal disease, osteomyelitis, heart disease, diabetes, and a stage 4 pressure ulcer, was typically transported to dialysis via gurney due to early morning appointments and personal preference. However, after a change in insurance and transportation arrangements, the Director of Social Services scheduled wheelchair transport and communicated this change through the facility's electronic medical record system. On the day of the scheduled dialysis, the nurse on duty did not review the updated communication regarding the new wheelchair transport arrangement. When the transportation staff arrived with a wheelchair instead of a gurney, the nurse was unaware of the change and the transport staff left without the resident. Subsequent attempts to contact the transportation company were unsuccessful, and the resident ultimately missed the dialysis session. The resident was then sent to a general acute care hospital, where dialysis was not provided because the resident had already received treatment the previous day during a prior hospital visit. The facility's policy required that all pertinent information regarding dialysis care, including transportation details, be documented and available to all caregivers. Despite this, the failure to review and act on the updated transportation method led to a missed dialysis session and unnecessary hospital transfer for the resident.
Failure to Consult IDT or Bioethics Committee for Vaccination Consent in Cognitively Impaired Resident
Penalty
Summary
Staff failed to consult with a physician, the Interdisciplinary Team (IDT), or the facility's Bioethics Committee regarding vaccination decisions for a resident who lacked both decision-making capacity and a representative. The resident, who had diagnoses including adult failure to thrive, anemia, and cholelithiasis, was assessed as moderately cognitively impaired and dependent on staff for daily activities. Documentation showed that the resident did not have the capacity to understand or make medical decisions, as confirmed by both the History and Physical and the BIMS score. Despite this, vaccination consent forms for pneumonia, influenza, and COVID-19 were signed as refusals by the resident, without appropriate consultation or surrogate decision-making. The Director of Nursing acknowledged that the resident should not have signed the informed consent forms and that the required process of involving the physician, IDT, or Bioethics Committee was not followed. Facility policy required treatment consent for non-routine care and outlined the use of the Bioethics Committee to support residents' healthcare decision-making rights, but these procedures were not implemented in this case.
Failure to Assess and Authorize Resident Self-Administration of Medications
Penalty
Summary
The facility's interdisciplinary team failed to ensure that a resident had a physician's order and a proper assessment for self-administration of medications left at the bedside. During a record review, it was found that the resident, who had diagnoses including atrial fibrillation, hypertension, neuropathy, osteoarthritis, and difficulty walking, was cognitively intact according to the Minimum Data Set. However, the resident required setup assistance for eating and oral hygiene. Observation of the resident's room revealed bottles of extra strength acetaminophen and Dulcolax in the bedside drawer, accessible while the resident was not present. Interviews with nursing staff confirmed that the resident did not have a physician's order to self-administer these medications, nor had an assessment been completed to determine the resident's capability to do so safely. The facility's policy requires that residents be assessed for cognitive and physical ability and have physician approval before self-administering medications, with such medications stored securely. The medications were not stored in a locked container, and staff acknowledged that this practice was not in accordance with facility policy.
Failure to Provide Routine Nail Hygiene for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment and multiple medical diagnoses, including hyperlipidemia, anemia, a history of falls, a left arm fracture, and pneumonia, did not receive routine personal hygiene care, specifically nail hygiene. The resident was dependent on staff for personal hygiene, as documented in the Minimum Data Set and medical records. During observations, the resident was seen with black residue under the fingernails on multiple occasions, including while eating breakfast with his hands. The resident reported that staff had not offered to clean or cut his fingernails. Interviews with facility staff confirmed that the resident's nails were dirty and unkempt, and that this was recognized as a dignity issue and a potential source of infection. The facility's policy required that residents be groomed according to their wishes, including nail care, to promote dignity and quality of life. Despite these requirements, the resident did not receive the necessary nail hygiene assistance, resulting in a failure to maintain the resident's dignity and personal hygiene needs.
Deficient Catheter Care and Delayed UTI Response
Penalty
Summary
Two residents experienced deficiencies in care related to urinary catheter management and timely response to urinary tract infection (UTI) symptoms and laboratory findings. For one resident with a history of neuromuscular bladder dysfunction and recurrent UTIs, the indwelling catheter bag was not labeled with the date and time of the last change, as observed by a licensed vocational nurse. The nurse confirmed that labeling is necessary to track changes and prevent complications such as obstruction or infection. Review of the resident's treatment records and facility policy revealed no documentation of when the catheter bag was last changed, and the policy did not specify routine intervals for changing bags. Another resident, dependent on staff for personal care and with a history of renal dialysis, UTI, and diabetes, reported symptoms of dysuria and voiding hesitancy. A physician ordered a urinalysis and culture, but the urine sample was not collected promptly, and the results indicating infection were not immediately communicated to the physician. There was no documentation of a change in condition evaluation or physician notification when the urinalysis returned positive for bacteria. The resident's antibiotic treatment was delayed by nine days due to confusion over the administration route and lack of timely clarification with the physician, despite the presence of symptoms and abnormal laboratory findings. Interviews with nursing staff, the medical director, and the director of nursing confirmed that facility procedures require prompt collection of urine samples, immediate notification of abnormal lab results, and timely initiation of physician-ordered treatments. However, these procedures were not followed, resulting in delayed care and increased risk of complications for the residents involved. Facility policies reviewed also emphasized the need for immediate documentation and communication regarding changes in resident condition and abnormal laboratory values.
Delay in Antibiotic Administration for UTI Due to Lapses in Communication and Protocol
Penalty
Summary
A resident with a history of renal dialysis, urinary tract infection (UTI), and diabetes mellitus experienced a significant delay in receiving prescribed antibiotic treatment for a UTI. The resident first reported symptoms of dysuria and voiding hesitancy, prompting a physician's order for a urinalysis with culture and sensitivity. The urine sample was collected two days after the order, and laboratory results indicating infection were available three days later. However, there was no documented evidence that the abnormal urinalysis results were communicated to the physician or that a change of condition was initiated at that time. The facility received the culture and sensitivity results and obtained a physician's order for Ertapenem, an intramuscular antibiotic, to be administered daily for seven days. Despite this, the first dose of the antibiotic was not given until four days after the order was received. Documentation showed that the delay was due to concerns about a penicillin allergy and confusion regarding the route of administration, but there was no evidence that the physician was notified of these issues or the delay in starting the medication. Interviews with facility staff, including the Registered Nurse Supervisor, Medical Doctor, and Director of Nursing, confirmed that the facility's processes for timely collection of samples, prompt notification of abnormal lab results, and immediate initiation of ordered antibiotics were not followed. The facility's policies required prompt action in response to changes in condition and abnormal laboratory findings, but these procedures were not adhered to, resulting in a nine-day delay from the onset of symptoms to the administration of the prescribed antibiotic.
Failure to Honor Resident Food Preferences in Meal Planning
Penalty
Summary
The facility failed to assess and honor the individual food preferences of a resident with multiple medical diagnoses, including congestive heart failure, COPD, atrial fibrillation, peripheral neuropathy, and a history of repeated falls. Despite the resident having intact cognition and the ability to make decisions, documentation and interviews revealed that her stated dislikes for eggs and sweet foods in the morning were not reflected on her meal tray ticket. The resident reported repeatedly informing staff of her preferences, yet she continued to be served foods she disliked, such as eggs and sweet rolls, which she ate only to avoid hunger. Record reviews showed that the Dietary Supervisor was responsible for visiting new residents to document food preferences and updating these preferences in the resident's health records and meal tray tickets. However, the resident's meal tray ticket did not indicate her specific dislikes, and the last nutritional screening was completed several months prior. Facility policy required quarterly reviews of food preferences, but there was no evidence that the resident's preferences were updated or considered in her meal planning, resulting in a failure to meet her nutritional needs and preferences.
Incorrect Food Portion Served to Resident During Meal Service
Penalty
Summary
The facility failed to serve the correct food portion to a resident during meal service. Specifically, a dietary aide was observed using a one-third cup scooper to serve fresh green salad instead of the required one-half cup scooper, as specified in the facility's Spring Cycle Menu Spreadsheet for that week. The Dietary Supervisor confirmed during the observation that the incorrect scooper was being used and acknowledged that using the wrong portion size could result in residents not receiving the appropriate amount of food. The facility's policy and procedures require standardized recipes and appropriate yields to be maintained and used in preparation. The resident involved had a history of hemiplegia, hemiparesis, essential primary hypertension, and muscle weakness, and was noted to have moderately impaired cognition according to the Minimum Data Set. The resident was admitted and readmitted to the facility with these diagnoses and was determined to have the capacity to understand and make decisions. The dietary aide responsible for serving the meal had participated in a recent in-service education session, as documented in the facility's meeting minutes.
Failure to Follow Infection Control Protocols for PPE Use and Catheter Bag Labeling
Penalty
Summary
Facility staff failed to observe proper infection control measures for two residents. In the case of one resident on enhanced barrier precautions (EBP), a Certified Nurse Assistant (CNA) was observed providing activities of daily living (ADL) care without donning the required personal protective equipment (PPE), specifically a gown, despite signage indicating the need for PPE before entering the room. The CNA stated unawareness of the requirement to continuously wear PPE while providing care to a resident on EBP, and only removed PPE after care was completed. Interviews with the infection prevention nurse and Director of Nursing confirmed that staff are expected to don PPE during physical contact with residents on EBP to prevent the spread of infection. For another resident with an indwelling catheter due to neurogenic bladder and a history of urinary tract infections, the facility failed to ensure the catheter bag was labeled with the date and time of the last change. During observation and interview, a Licensed Vocational Nurse (LVN) confirmed the absence of a label and stated that labeling is necessary to track when the bag was last changed, which is important for monitoring potential complications such as obstruction or infection. The resident's care plan included monitoring for infection and practicing good infection control, but the treatment administration record did not indicate when the catheter bag was last changed. Facility policy and procedures for both PPE use and urinary catheter care were reviewed. The PPE policy outlined the purpose and objectives for gown use, including preventing the spread of infections and exposure to bodily fluids. The urinary catheter care policy indicated that indwelling catheters or drainage bags are not to be changed on routine, fixed intervals, but did not address labeling requirements. These observations and interviews demonstrate lapses in adherence to established infection prevention and control protocols.
Failure to Consult IDT or Bioethics Committee for Vaccination Consent in Incapacitated Resident
Penalty
Summary
The facility failed to ensure that staff consulted with a physician, the Interdisciplinary Team (IDT), or the facility Bioethics Committee regarding vaccination decisions for a resident who lacked both decision-making capacity and a representative. The resident, who had diagnoses including adult failure to thrive, anemia, and cholelithiasis, was assessed as moderately cognitively impaired and dependent on staff for daily activities. Documentation showed that the resident did not have the capacity to understand or make medical decisions, as indicated by both the history and physical and a BIMS score of 10. Despite this, the resident's vaccination consent forms for pneumonia, influenza, and COVID-19 were signed as refusals by the resident, without appropriate consultation with the physician, IDT, or Bioethics Committee. The Director of Nursing confirmed that the resident should not have signed the informed consent due to lack of capacity and that the required consultations did not occur. Facility policies required obtaining treatment consent for non-routine care and outlined the use of the Bioethics Committee to support residents' healthcare decision-making, but these procedures were not followed in this case.
Failure to Provide Accessible and Functional Call Light for Resident
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment and multiple complex medical conditions, including an indwelling urethral catheter, hematuria, difficulty walking, type II diabetes mellitus, obstructive and reflux uropathy, benign prostatic hyperplasia, cerebral infarction, and Parkinson's disease, was found without a functioning call light within reach. The resident required significant assistance with activities of daily living and was dependent for toileting hygiene. During observation, the resident was seen in pain and attempted to use the call light, which was not operational. The call bell was found on top of the bedside drawer, out of the resident's reach. Interviews with staff confirmed that the call bell should be accessible to residents at all times to ensure timely assistance, especially in emergencies. The maintenance supervisor was unaware of how long the call light had been nonfunctional, and maintenance logs showed previous notifications about the issue. Facility policy requires that call lights be accessible to residents when in bed, but this was not followed in this instance, resulting in the resident's inability to summon help when needed.
Resident Room Size Below Federal Minimum Requirements
Penalty
Summary
The facility failed to provide the required minimum square footage per resident in multiple resident bedrooms, as mandated by federal regulations. Specifically, 38 rooms did not meet the standard of at least 80 square feet per resident in multiple occupancy rooms or 100 square feet for single occupancy rooms. Record review showed that several two-bed rooms measured only 154 square feet (77 square feet per resident), and several three-bed rooms measured 220 square feet (73 square feet per resident). The facility had submitted a waiver request acknowledging these deficiencies, stating that the rooms were used for higher acuity residents and asserting that the arrangement did not adversely affect resident health or safety. Observations conducted over several days indicated that residents had sufficient space to move freely within their rooms, and there was adequate space for beds, side tables, and care equipment. Staff interviews during the survey revealed no concerns regarding room size. However, the documented measurements confirmed that the rooms did not meet the federal minimum space requirements, resulting in a deficiency related to inadequate living and working space for residents and caregivers.
Failure to Maintain AED Machines Leads to Delayed Emergency Response
Penalty
Summary
The facility failed to maintain essential lifesaving equipment, specifically the automated emergency defibrillator (AED) machines, at designated nursing stations. During an emergency resuscitation attempt for a resident, the facility staff discovered that the AED machines were not functional. The AED machines lacked necessary components such as AED pads, and one of the machines did not turn on. Additionally, the batteries for both AED machines were expired, and there were no backup batteries available. This deficiency resulted in delayed lifesaving measures during the resident's emergency resuscitation attempts. The resident involved in the incident was admitted with diagnoses including pneumonia, weakness, and paroxysmal atrial fibrillation. The resident's Physician Orders for Life-Sustaining Treatment (POLST) indicated that resuscitation should be attempted. However, during the emergency, the facility staff were unable to use the AED machines effectively due to their non-functional state. The paramedics, who arrived after the emergency call, confirmed that the AED pads were expired, and the machines were not operational, leading to the resident being pronounced deceased. Interviews with facility staff, including certified nursing assistants, licensed vocational nurses, the director of staffing development, and the director of nursing, revealed a lack of training and awareness regarding the use and maintenance of AED machines. The staff were not trained to use or maintain the AEDs, and there was no clear responsibility assigned for their upkeep. The facility's policy and procedure documents did not include AED maintenance as part of the emergency equipment checks, contributing to the oversight and deficiency in maintaining lifesaving equipment.
Failure to Notify Family of Resident's Change of Condition
Penalty
Summary
The facility failed to notify a resident's family member about a change of condition (COC) as required by their policy and procedures. The resident, who had been initially admitted in 2011 and readmitted in 2024, had diagnoses including diabetes, hypertension, and dementia. A skin assessment on August 6, 2024, revealed moisture-associated skin damage (MASD), but the family member was not informed of this condition. Interviews with the family member and facility staff confirmed the lack of notification, and a review of records showed no documentation of the MASD in the change of condition or nursing progress notes. The facility's policy, revised in September 2023, mandates that licensed nurses notify the primary physician, family, and responsible party of any non-life-threatening change of condition. However, the Treatment Nurse and Director of Nursing acknowledged that the family was not informed, which could prevent them from participating in the resident's care plan. The deficiency violated the family member's right to be informed about the resident's care and had the potential to result in inadequate care and services.
Failure to Ensure Call Light Accessibility
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, as required by the facility's policy and procedures. The resident, who was admitted with multiple diagnoses including chronic obstructive pulmonary disease, respiratory failure, bronchiectasis, weakness, difficulty walking, and Alzheimer's disease, was observed in bed with the call light on the floor behind the bed. The resident expressed a need for assistance with a diaper change and was unable to locate the call light, which led to an attempt to get up and nearly resulted in a fall. The resident's care plan indicated a risk for falls due to balance problems, impaired cognition, and noncompliance with using the call light. The care plan specified that the call light should be kept within reach and that staff should respond promptly to requests for assistance. During an observation, a CNA confirmed that the call light was on the floor and acknowledged the danger posed by the call light being out of reach, as residents might try to get up and potentially fall. Interviews with facility staff, including a CNA, an LVN, and the DON, revealed that all staff were aware of the importance of keeping call lights within reach and responding to them promptly. The DON admitted not knowing how the call light ended up behind the bed but emphasized the necessity of having call lights accessible to residents to prevent falls and ensure timely assistance. The facility's policy on call light answering, revised recently, reiterated the requirement for call lights to be within reach and answered quickly.
Failure to Timely Report Allegations of Abuse
Penalty
Summary
The facility failed to investigate and report allegations of physical abuse involving a resident-to-resident altercation within the required timeframe. Resident 1, who had intact cognition and was independent with activities of daily living, reported that another resident, Resident 2, had grabbed her arms, causing discoloration. This incident was not reported to the Department of Public Health, Ombudsman, or local law enforcement within the mandated 2-hour window as per the facility's policy and procedures titled Abuse and Crime Reporting effective 9/11/2023. Licensed Vocational Nurse 1 (LVN 1) was informed of the incident by Resident 1 around 3 A.M. and texted the administrator but did not report the incident to the police, SSA, or the Ombudsman. The administrator received the text around 6 A.M. and subsequently notified the police at 9:30 A.M., the Ombudsman at 10:03 A.M., and the Department of Public Health at 10:00 A.M., all of which were beyond the required 2-hour reporting window. The facility's Director of Staff Development confirmed that the abuse should have been reported immediately within 2 hours to ensure the safety of the resident and prevent additional emotional harm. The failure to report the incident promptly had the potential to place Resident 1 at risk for further abuse and delayed the onsite inspection by the Department of Public Health. The facility's policy clearly stated that any employee with a reasonable suspicion of a crime against a resident must report the incident within 2 hours to the appropriate authorities. The administrator acknowledged that the incident should have been reported within the required timeframe to ensure immediate investigation and resident safety.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain safe and sanitary conditions in food preparation and storage, leading to potential foodborne illness risks for residents. During a kitchen tour, it was observed that staff did not wear hairnets properly, leaving hair exposed, which could contaminate food. Additionally, staff did not perform hand hygiene or change aprons when transitioning from handling dirty dishes to clean dishes, increasing the risk of cross-contamination. Interviews with staff confirmed these practices were against the facility's policies and could lead to infections among residents. In another instance, a resident was found with multiple food and drink items left at their bedside for over 14 hours without proper storage or refrigeration. The resident confirmed that the items had been there since the previous night. The Infection Prevention Nurse and Director of Nursing acknowledged that such practices could lead to food spoilage and potential health risks for the resident. The facility's policy stated that food meant for refrigeration should not be stored in residents' rooms unless being consumed immediately. The facility's policies and procedures were reviewed, indicating that food services employees must follow hygiene and sanitary practices to prevent foodborne illnesses. These policies included wearing hairnets, performing hand hygiene, and changing aprons when necessary. The failure to adhere to these policies was observed and confirmed through staff interviews, highlighting significant lapses in maintaining food safety standards in the facility.
Failure to Provide Appropriate Bed and Ensure Call Light Accessibility
Penalty
Summary
The facility failed to provide an appropriate bed for a resident, leading to potential pressure injuries. The resident, who was admitted with type 2 diabetes and morbid obesity, had intact cognition and required assistance for hygiene, dressing, and toileting. Despite the resident's complaints about the bed being too short and causing pressure on his feet, the issue was not addressed by the staff, including the social worker and maintenance personnel. The resident's height was documented as 73 inches, which exceeded the length of the bed, leading to discomfort and potential pressure ulcers as confirmed by the Licensed Vocational Nurse and Director of Nursing. Additionally, the facility failed to ensure that another resident's call light was within reach, which is crucial for communication and timely assistance. This resident, who had epilepsy, asthma, schizophrenia, and hemiplegia, was observed lying in bed with the call light hanging against the wall, out of reach. The resident expressed difficulty in reaching the call light due to her condition. The Certified Nurse Assistant confirmed that the call light should be within reach to prevent delays in care, which could lead to poor outcomes or unnecessary hospitalization. The Director of Nursing emphasized the importance of having the call light within reach for all residents to ensure timely care and prevent potential medical complications. The facility's policy on answering call lights also mandates that the call light should be easily accessible to residents when they are in bed. The failure to adhere to this policy was evident in the case of the resident with multiple medical conditions, highlighting a significant lapse in ensuring resident safety and communication.
Failure to Provide Homelike Environment Due to Improper Inventory of Resident's Belongings
Penalty
Summary
The facility failed to provide a homelike environment for Resident 38, who was observed storing personal belongings in boxes on the floor. Resident 38, who has type 2 diabetes and morbid obesity, was admitted to the facility and has intact cognition but requires assistance with hygiene, dressing, and toileting. During an interview, Resident 38 expressed frustration about missing clothes and the lack of assistance from staff in organizing his belongings. Certified Nurse Assistant 1 confirmed that there was not enough space in the closet, leading to the resident's belongings being stored in boxes, which is not a homelike environment. The CNA also mentioned that an inventory of the resident's belongings should be done upon admission, but this was not completed for Resident 38, leading to difficulties in locating his possessions. Further interviews with staff, including a Licensed Vocational Nurse, Social Worker, Registered Nurse, and the Director of Nursing, revealed that the facility's policy requires an inventory of residents' belongings upon admission. However, this procedure was not followed for Resident 38, resulting in the misplacement of his belongings and contributing to a non-homelike environment. The facility's policy on personal property emphasizes the importance of documenting and investigating any complaints of missing items, but this was not adhered to in this case, causing distress to the resident.
Failure to Identify and Mitigate Environmental Hazards
Penalty
Summary
The facility failed to assess and identify environmental hazards and risk factors for accidents for one of the residents. Resident 35, who has a history of diabetes mellitus, chronic obstructive pulmonary disease (COPD), pneumonia, and congestive heart failure (CHF), was found with an open one-gallon bottle containing a strawberry pink-colored liquid on her bedside drawer. The resident, who has moderately impaired cognition, stated that the bottle was not hers and she did not know what the liquid was. The liquid was later identified by a Licensed Vocational Nurse (LVN) as shampoo and body wash used by the facility for bathing residents. The LVN acknowledged that the bottle should have been tightly capped and not left at the bedside, as a confused or wandering resident could mistakenly ingest it, leading to potential poisoning and allergic reactions. The Director of Nursing (DON) confirmed that staff are required to observe and assess the environment for safety when entering and exiting residents' rooms. The facility's policy on safety and supervision of residents emphasizes the importance of preventing accidents by considering environmental hazards and individual resident risk factors. However, this policy was not followed in the case of Resident 35, leading to the identified deficiency.
Failure to Ensure Continuous Tube Feeding for Resident
Penalty
Summary
The facility failed to ensure that Resident 65 received continuous feeding of isosource 1.5 as per the physician's order. Resident 65, who was admitted with diagnoses including moderate protein-calorie malnutrition, dysphagia, and gastro-esophageal reflux disease, had a physician's order for continuous feeding via a gastrostomy tube at 65 cc per hour. However, during an observation, the tube feeding was found to be disconnected from the resident and spilling on the floor, indicating that the resident was not receiving the prescribed nutrition. This was confirmed by a Licensed Vocational Nurse who acknowledged that the feeding pump was running but not connected to the resident's g-tube, which could lead to inadequate nutrition and calories for the resident. Further interviews with the Quality Assurance and Director of Nursing confirmed that the tube feeding needs to be connected to the resident's g-tube to ensure adequate nutrition and calories. The facility's policy and procedures for gastrostomy feeding also indicated that the feeding formula should be connected to the tube. The failure to connect the feeding tube as ordered had the potential to cause inadequate nutrition for Resident 65, which could lead to weight loss and dehydration.
Failure to Provide Timely Pain Management
Penalty
Summary
The facility failed to ensure timely pain management for Resident 33, who was admitted with diagnoses including atherosclerotic heart disease, autonomic neuropathy, and heart failure. Despite having an active physician order for Oxycodone HCL 10 mg every 6 hours as needed for pain, the medication was not administered during the 11 PM to 7 AM shift on 4/16/24. Resident 33 reported requesting the pain medication at 3 AM but did not receive it, resulting in unnecessary pain. The Medication Administration Record and Individual Resident's Controlled Drug Record confirmed that no pain medication was given during that shift. Licensed Vocational Nurse 3 admitted to not administering the pain medication as requested, acknowledging that it should have been given to ensure the resident's comfort. The Director of Nursing emphasized the importance of pain management for resident comfort, quality of life, and functionality. The facility's policy on pain management, which requires staff to assess and manage pain using a consistent approach, was not followed in this instance, leading to the deficiency.
Deficient Call Light System
Penalty
Summary
The facility failed to provide a functioning call light system for two residents, leading to potential physical and emotional harm. Resident 37, who had multiple diagnoses including Type 2 Diabetes, lung transplant, heart failure, and major depressive disorder, reported a broken call light for five days. Despite informing staff, the resident was given a bell that staff could not hear effectively, causing frustration and anger. The maintenance supervisor acknowledged the issue, citing an old call light system and delays in obtaining parts for repairs. The Director of Nursing confirmed that malfunctioning call lights were reported but could not specify the time required to fix them, acknowledging the potential health consequences of delayed assistance. Resident 29, diagnosed with epilepsy, asthma, schizophrenia, and hemiplegia, was found with a call light out of reach. The resident, who required substantial assistance and was unable to move independently, stated she could not reach the call light. A Certified Nurse Assistant confirmed that the call light should have been within reach and acknowledged that its unavailability could delay care and result in poor outcomes. The Director of Nursing reiterated the importance of ensuring call lights are reachable to prevent delays in care, which could worsen the resident's medical condition. The facility's policies and procedures emphasized the importance of maintaining functional call light systems and ensuring they are within residents' reach. However, the observations and interviews revealed that these policies were not effectively implemented, leading to deficiencies in resident care. The maintenance log and staff interviews highlighted systemic issues with the call light system and delays in addressing reported malfunctions, contributing to the residents' inability to promptly alert staff to their needs.
Failure to Provide Adequate Storage and Inventory for Resident Belongings
Penalty
Summary
The facility failed to provide adequate storage and conduct inventory for personal belongings for Resident 38, resulting in a non-homelike environment. Resident 38, who has type 2 diabetes and morbid obesity, was observed storing personal belongings in several boxes on the floor. The resident complained about missing personal items, including sweatpants, and stated that staff were unhelpful in locating these items. Certified Nurse Assistant 1 confirmed that there was insufficient closet space, leading to belongings being stored in boxes, and acknowledged that the inventory form was not filled out upon admission. This was corroborated by Licensed Vocational Nurse 1, who found no admission inventory in the resident's medical chart. Further interviews revealed that the facility's policy requires an inventory of residents' belongings upon admission, but this was not followed for Resident 38. The Social Worker and Director of Nursing both emphasized the importance of this inventory for tracking and investigating missing items. The failure to complete the inventory form and provide adequate storage led to Resident 38 feeling upset and reporting lost belongings, which compromised the resident's sense of a homelike environment.
Deficiency in Room Size Requirements
Penalty
Summary
The facility failed to provide at least 80 square feet per resident in multiple resident bedrooms for 38 out of the 38 resident rooms. Specifically, 30 rooms consist of 2 beds each, providing only 77 square feet per resident, and 8 rooms consist of 3 beds each, providing only 73 square feet per resident. This deficiency was identified through observation, interview, and record review. The facility had previously submitted a Request for Room Size Waiver, indicating that the room sizes would not interfere with daily nursing care or the safety of the residents. However, the waiver did not meet the federal regulation requirements of 80 square feet per resident for multiple resident rooms and 100 square feet for single resident rooms. During multiple observations, it was noted that residents had ample space to move freely inside the rooms, and there was sufficient space for beds, side tables, and resident care equipment. However, during an interview with a Certified Nurse Assistant (CNA), it was revealed that the limited space in the rooms made it difficult to use a Hoyer lift for residents whose beds were close to the window. This indicates that while the rooms appeared to have enough space for general movement and care, specific care activities requiring more space were hindered by the room sizes not meeting federal regulations.
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What surveyors actually found near you
We read the 7,176 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
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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) |
|---|---|---|---|---|
| Mar Vista Country Villa Healthcare & Wellness | 0.2 mi | ★★★★★ | 2 | 0 |
| Vista Del Sol Care Center | 0.6 mi | ★★★★★ | 26 | 0 |
| Meadowbrook Behavioral Health Center | 0.7 mi | ★★★★★ | 16 | 0 |
| Marina Pointe Healthcare & Subacute | 1.7 mi | ★★★★★ | 22 | 0 |
| Overland Terrace Healthcare & Wellness Centre, Lp | 2 mi | ★★★★★ | 25 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.