Above 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 El Encanto Healthcare Center during CMS and state inspections, most recent first.
A facility failed to follow its AD policy for four residents when AD paperwork was incomplete or missing from the chart. One resident with DM, HTN, and intact cognition had an AD acknowledgement form missing the facility rep’s signature and date; another resident with dementia had an incomplete AD form that did not show who discussed the AD policy or whether a POLST or AD was desired; a third resident’s chart lacked the AD even though the POLST showed an executed AD; and a fourth resident’s chart lacked both the POLST and AD acknowledgement form after admission.
Missing Language-Appropriate Communication Boards for Non-English Speaking Residents: Two residents who spoke Mandarin and Cantonese did not have communication boards or books at bedside in their preferred languages. One resident had severely impaired cognition and needed assistance with ADLs, while the other had impaired cognition and was dependent for multiple ADLs. Staff and the ADON confirmed the lack of communication tools, and the ADON stated translation was sometimes done using a personal mobile phone or family members.
Bed rail use was not implemented or documented correctly for three residents. One resident had a PO for bilateral 1/2 side rails at the HOB, but only 1/4 rails were observed. Another resident had no active PO and no completed consent for bedside rails, yet 1/4 rails were in place on both sides of the bed. A third resident had a PO for bilateral 1/2 siderails, but the consent form did not identify the person giving consent or the staff verifying it.
Improper Food Labeling and Use of Expired Juice: A tray of juice boxes in the kitchen cooler lacked delivery and use-by/best-by or expiration labels, and an open container of cranberry juice was found past its use-by date. The DS and ADON stated that food items and beverages should be labeled with required dates to ensure safe consumption, and the facility policy required dating of deliveries, opened packages, and beverages.
Unlabeled outside food was found at the bedside of two residents, and the facility did not follow its policy for food brought by family or visitors. One resident with DM and ESRD had a sealed container of mixed nuts left by family without a name or received date, and another resident with dementia had multiple unlabeled food items, including cookies and coffee cake, at the bedside. Staff and the ADON stated the items should have been labeled with the resident’s name and date information.
Failure to Monitor Target Behaviors for Psychotropic Medication Use: A resident admitted with a history of falls, anxiety disorder, and impulse disorder was ordered Abilify for psychosis with constant yelling and Trileptal for impulse control with verbal and physical aggression. The care plan directed staff to monitor and record behaviors in the MAR and/or nursing notes, but an LVN stated the resident’s yelling and aggressive behaviors were not consistently monitored, and the facility’s behavior management policy required behavior occurrences to be documented every shift.
A resident with osteoarthritis, DM, and Afib was discharged home with HH PT/OT, RN, and HHA services, but the MDS was coded as discharged to home or community instead of home under care of an organized HH service organization. The MDS coordinator and ADON stated the assessment should have been coded accurately to reflect the services provided and for accurate reporting to CMS.
Missing Care Plan for Quetiapine Use: A resident with dementia, severely impaired cognition, and dependence for multiple ADLs had an active order for quetiapine fumarate, but no individualized care plan was developed to address the medication use. During record review, the LVN and ADON stated the resident needed a resident-centered plan with measurable goals and monitoring for side effects, and the facility policy required a comprehensive care plan with time-oriented objectives.
A resident receiving IV Ertapenem for a UTI had a left-hand IV dressing with dry blood at the insertion site and no visible date or nurse initials. The resident said the IV site was painful, and staff confirmed the dressing was not labeled as required by the facility’s P&P for peripheral catheter dressing changes.
A resident with anxiety, depression, and impaired cognition remained on Celexa 10 mg every other day after the pharmacy consultant recommended considering discontinuation. The physician accepted the recommendation with a modification to contact psychiatry, but the ADON stated the psychiatry referral was missed and the pharmacist’s recommendation was not acted upon. The ADON also noted the resident had no ongoing episodes of sadness with crying during several months reviewed and that Celexa should have been discontinued or reduced.
Failure to implement EBP for a resident with a GT was cited when staff observed the resident receiving enteral feeding without EBP signage or a PPE cart outside the room. The resident had dysphagia, a GT, was non-verbal, unable to understand or make self-understood, and required staff assistance. An LVN, IPN, and ADON all stated residents with GT should be on EBP and that gowns and gloves should be used during care, while the facility policy identified feeding tubes as an indication for EBP.
A resident with hemiplegia, dementia, and severe cognitive impairment was transferred from the facility to a GACH via 911 for AMS, increased respirations, and desaturation, and then admitted to an LTACH for further evaluation and therapy. LTACH records documented that the resident’s discharge goal was return to a SNF and that a psychiatric consult found the resident calm, quiet, and manageable. When the LTACH requested readmission, the facility’s ACD and DON declined, initially citing unresolved behavioral issues, despite having received the psychiatric consult report and having multiple available female beds in semi-private rooms. This refusal conflicted with the facility’s bed-hold and return policy, which required allowing residents to return after hospitalization to their previous room if available or to the first available semi-private bed when they still required facility services and remained Medicare/Medicaid eligible.
A resident with dementia, hemiplegia, and hemiparesis was transferred to a GACH via 911 for AMS, increased respirations, and desaturation following a physician’s telephone order. Despite facility policy requiring a Notice of Transfer or Discharge (NTD) to be provided to the resident and RP and sent to the LTC ombudsman as soon as practicable before transfer, no NTD was found in the medical record, and staff acknowledged that the NTD was not completed or faxed to the ombudsman.
Two residents with significant mobility and cognitive impairments did not have accessible or functioning call lights. In one case, a call light was placed out of reach, and in another, a call light was nonfunctional for two days despite staff being informed. Facility policy required prompt response and functioning call lights, but these were not followed, resulting in delayed or unmet care needs.
The facility did not accurately post daily nurse staffing information, failing to display the actual hours worked by RNs, LPNs, and CNAs for multiple shifts. Observations and interviews confirmed that required staffing details were incomplete and not posted in visible areas, contrary to facility policy.
Surveyors observed that expired and unlabeled food items were not removed from storage, and multiple food items lacked required labeling with use by or expiration dates. Staff confirmed these practices were not in line with facility policy. Additionally, a malfunctioning convection steamer with missing rails caused a staff injury and delayed meal service, with maintenance staff aware of the issue but repairs not completed. Facility policies require proper food labeling and equipment maintenance, which were not followed in these instances.
A resident with hyperlipidemia and type 2 diabetes was discharged home after dialysis, but the MDS assessment was incorrectly coded as a discharge to a short-term general hospital. Review of records and staff interviews confirmed the error, resulting in inaccurate reporting to CMS.
A resident with significant mobility and cognitive impairments, requiring two-person assistance for all ADLs, was left in the care of a single CNA during personal care. The resident slid off the bed during a diaper change and fell, leading to an emergency room visit. Staff interviews and documentation confirmed that two-person assistance was required but not provided at the time of the incident.
A resident with an indwelling Foley catheter, admitted with chronic kidney disease, urinary retention, and dementia, was observed with unsecured catheter tubing despite care plan and facility policy requiring it to be secured to the leg. Both an LVN and the ADON confirmed the tubing should have been secured to prevent injury, and the facility's policy also specified the use of leg straps for this purpose.
A resident receiving oxygen therapy via nasal cannula was found to have tubing that was not labeled with the date of last change, contrary to facility policy requiring labeling and dating for infection control. Staff confirmed the omission during interviews, and record review showed the resident had multiple chronic conditions requiring respiratory care.
A resident with severe cognitive impairment and multiple medical conditions was found with bilateral one-fourth siderails in use without a physician's order or informed consent. Staff confirmed that required documentation was missing, and facility policy mandates these steps before siderail installation, especially when used as a restraint.
A resident with severe cognitive impairment and full dependence on staff was observed lying in bed with ripped and damaged padded side rails, despite care plan and physician orders requiring intact pads for safety and skin protection. Facility policy required staff to report and document defective equipment, but this was not done, resulting in the continued use of damaged side rail pads.
A nurse administered Zofran to a resident for nausea without verifying a current physician order in the MAR, contrary to facility policy requiring staff to check orders before giving medications. The medication was given after the resident vomited, and the error was discovered when the nurse attempted to document the administration and found no active order.
A resident with a history of fracture and dementia exhibited unusual pain behaviors during care, which were reported by a CNA to an LVN. The LVN and RN checked on the resident but did not perform or document a full assessment of the lower extremities, missing signs of pain and swelling. Later, the resident was found to have a tibial fracture, and staff interviews confirmed that required documentation and assessment were not completed according to facility policy.
The facility failed to ensure call lights were within reach for two residents, potentially delaying necessary care. One resident with severe cognitive impairment had their call light caught between the bed and bedrails, while another resident with a history of falls had their call light on the floor. Staff interviews confirmed the expectation for call lights to be accessible, aligning with the facility's policy.
The facility failed to include Advance Directive forms in the medical records of two residents, risking care against their wishes. One resident, with intact cognition, had preferences for no resuscitation and no tube feeding, while the other, with impaired cognition, lacked an AD Acknowledgement Form. Staff confirmed the absence of these forms, which are essential for guiding care decisions in emergencies.
The facility failed to provide adequate communication devices for two residents who spoke Cantonese/Mandarin, leading to potential communication barriers and unmet needs. One resident lacked a communication board, and staff were not always available to speak the resident's language. Another resident had a limited communication board, and staff relied on body language, which was insufficient. The facility's policy required communication boards, but no additional interpretation services were available, affecting the residents' quality of life.
The facility failed to label and date opened food containers and did not discard expired refrigerated food, as required by its P&P. Additionally, two staff members with facial hair did not wear beard nets in the kitchen, contrary to the facility's policy, increasing the risk of food contamination.
The facility failed to ensure its binding arbitration agreements included a convenient venue for three residents, risking unjust arbitration. A resident with dementia, another with metabolic encephalopathy, and a third with renal dialysis dependence had agreements lacking details on a neutral arbitrator and venue, contrary to facility policy.
A facility failed to complete a quarterly MDS assessment on time for a resident with dementia and malnutrition. The assessment was not completed as of the required date, and the MDS Coordinator acknowledged missing the deadline. Facility policy mandates submission within 14 days of the MDS Completion Date.
A resident with hearing difficulties and severe cognitive impairment did not have a specific care plan developed to address their needs. Despite being assessed for hearing issues and requiring maximal assistance, the facility failed to create a person-centered care plan, as observed during staff interactions where the resident indicated hearing problems.
A resident with lung cancer and dysphagia had an IV site that was not labeled with the date of insertion, contrary to professional standards and facility policy. This oversight was confirmed by the MDS Coordinator, who noted the importance of labeling for infection control. The facility's policy required labeling to ensure timely changes of the IV site.
A facility failed to follow its Enhanced Barrier Precaution (EBP) protocol when a nurse did not wear personal protective equipment (PPE) while taking the blood pressure of a resident in an EBP room. The nurse admitted to not wearing a gown and gloves, which are required for close contact activities to prevent the spread of multidrug-resistant organisms (MDRO). The Infection Prevention Nurse confirmed the necessity of PPE in such situations, as outlined in the facility's policy.
The facility did not post actual nurse staffing data at the beginning of each shift in the lobby and nursing station on two occasions. Observations showed that the Posted Nurse Staffing Information (PNSI) forms were incomplete, and interviews with the DON and RN Supervisor confirmed the oversight. The facility's policy requires posting staffing numbers within two hours of each shift's start, which was not followed.
Missing and Incomplete Advance Directive Documentation
Penalty
Summary
The facility failed to follow its Advance Directives policy for four sampled residents when required advance directive documents were missing or incomplete in the medical record. Resident 13 was admitted with diagnoses including type 2 DM, HTN, and generalized muscle weakness, and was described as alert, conversant, and cognitively intact for daily decision making; however, the resident’s AD Acknowledgement Form was not fully completed because the facility representative’s signature and date were missing. The SSA stated it was unsure whether the incomplete form was valid. Resident 58 was admitted with difficulty walking, low back pain, and dementia, and the H&P stated the resident did not have capacity to understand and make decisions due to dementia. The resident’s AD Acknowledgement Form did not identify who the AD policy was discussed with, did not indicate whether a POLST had been completed, did not show whether the resident or family understood the right to formulate an AD and accept or refuse medical or surgical treatment, and did not indicate whether the resident or family wanted to initiate an AD or POLST. The SSA stated staff would not know if Resident 58 had an AD because the form was not completed. Resident 39’s chart did not contain the resident’s AD, although the POLST indicated the resident had executed an AD dated 1/10/2023 that was available and reviewed by the facility. Resident 63 was admitted with a left femur fracture, ESRD, and HTN, and staff found no copy of the resident’s POLST or AD acknowledgement form in the chart. LVN 2 stated these documents should be completed upon admission and placed in the chart, and the ADON stated they should be in the chart upon admission or within 48 hours so staff could identify the resident’s end-of-life wishes and preferences.
Missing Language-Appropriate Communication Boards for Non-English Speaking Residents
Penalty
Summary
The facility failed to ensure that non-English speaking residents were provided with communication boards or devices in a language they understood. For Resident 5, the record showed admission with diagnoses including DM and major depressive disorder, and the MDS identified Mandarin as the preferred language, a need or desire for an interpreter, severely impaired cognition, and assistance needs with oral hygiene, toileting, and upper body dressing. During observation and interview, Resident 5 was in bed, did not speak or understand English, and did not have a communication board or book with Mandarin pictures and descriptions at the bedside. For Resident 41, the record showed the resident was Cantonese speaking only, with the son assisting with translation, and the care plan identified impaired cognition and communication with an intervention to provide a communication board as needed. The MDS identified Cantonese as the preferred language and showed the resident was dependent on staff for multiple ADLs including eating, oral hygiene, toileting, showering, lower body dressing, footwear, and personal hygiene. During observations, Resident 41 was awake in bed speaking in the resident’s own language to a relative, and there was no communication tool at the bedside. During interviews, the ADON stated that non-verbal, alert and oriented residents and non-English speaking residents should have a communication board or book at bedside to communicate needs. The ADON also stated there was no communication tool at Resident 41’s bedside and that staff used personal mobile phones for translation when no interpreter was available, and family members were contacted for language interpretation. The MDS Coordinator confirmed Resident 41 spoke Cantonese and required an interpreter to translate information into Cantonese. The facility policy stated that nonverbal and non-native speaking residents should always have communication boards available at bedside, and that if required, a communication board would be provided in the language of the non-native speaking resident.
Bed Rail Use Not Implemented or Documented Correctly
Penalty
Summary
The facility failed to implement its policy and procedure on the use of bed rails/siderails for three sampled residents. For one resident admitted with a history of falling, anxiety disorder, and muscle weakness, the physician order called for bilateral 1/2 side rails at the head of the bed for mobility and improved function, but observation showed only 1/4 side rails in place on the bed. The Assistant Director of Nursing stated the resident could entrap in the side rails if both rails on the right side were up and that this would become a restraint because it would prevent the resident from getting out of bed. For another resident admitted with profound intellectual disabilities and epilepsy, the record showed the resident did not follow commands and was not capable of giving informed consent or participating in the treatment plan. There was no active physician order for bedside rails, and the Consent for Bedside Rail Use was not completed. Despite this, observation showed 1/4 bedside rails up on both sides of the bed. The MDS Coordinator stated the resident should not have bedside rails because the consent needed to be completed before installation, and that the resident was unable to make decisions and the facility needed to call the responsible party for consent. For the third resident, admitted with hypertension and diabetes mellitus, the physician order indicated bilateral one-half siderails as an enabler to aid in bed mobility. The Consent for Bedside Rail Use stated bedside rail was ordered for left and right upper 1/2 partial rail for mobility aid to improve functional ability when in bed, but it did not include the name of the person giving consent or the name of the staff verifying the consent. The LVN and ADON stated the consent should be complete and accurately document both names to ensure the risks and benefits of siderail use were explained and understood.
Improper Food Labeling and Use of Expired Juice
Penalty
Summary
Safe food storage and sanitary food storage were not maintained in the kitchen when a tray containing 15 small paper packages of cranberry juice and 14 juice boxes of apple juice was found inside the kitchen cooler refrigerator without delivery dates, used by/best by dates, or expiration dates labeled. During the observation, the Dietary Supervisor stated that all food items should be labeled with delivery dates, open dates, used by/best by dates, and expiration dates to ensure food remained safe for consumption. In a separate observation, one large open plastic container of cranberry juice, about one-fourth full, was found in a rack next to the reach-in refrigerator with an open date of 6/18/2026 and a used by date of 6/21/2026, which was beyond the date listed. The Dietary Supervisor stated that food items beyond the used by/best by or expiration dates should be discarded and not served to residents. The Assistant Director of Nursing also stated that food products received and delivered should be labeled with delivery/received date, open date, preparation date, and used by/best by date to ensure food remained safe for consumption. The facility policy titled Food Labeling and Dating Policy stated that deliveries should be inspected upon arrival, manufacturer dates checked, bulk items without manufacturer dates labeled with receiving date, and opened packages and beverages labeled with opening date and discard date or manufacturer guidelines.
Unlabeled Outside Food at Residents’ Bedside
Penalty
Summary
The facility failed to implement its policy and procedure titled, Foods Brought by Family/Visitors, by not labeling outside food left at the bedside of two residents. Resident 7 was admitted with diagnoses including type 2 diabetes mellitus and end stage renal disease, and records indicated the resident had capacity to understand and make decisions and intact cognition for daily decision making. During multiple observations, a sealed plastic container of mixed nuts was found at Resident 7’s bedside without a resident name or received date, and the resident stated the nuts had been brought by family two to three weeks earlier. CNA 2 and LVN 4 both stated the container should have been labeled with the resident’s name and received date. Resident 58 was admitted with diagnoses including UTI and dementia, and the H&P stated the resident did not have the capacity to understand and make decisions due to dementia. During observation, several outside food items were found at the bedside without labels, including two clear containers of cookies, a zip-lock bag with four cookies, and a bag of coffee cake. CNA 2 stated the foods were not labeled and should have been. The ADON stated staff should label residents’ outside food with the date and time received and the resident’s name, and the facility’s policy stated food brought by family or visitors and left with the resident to consume later should be labeled with the resident’s name, the item, and the use-by date.
Failure to Monitor Target Behaviors for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that Resident 6’s target behaviors were monitored for the use of psychotropic medications as outlined in the facility’s Behavior Management policy. Resident 6 was admitted with diagnoses including a history of falling, anxiety disorder, impulse disorder, and hyperlipidemia. The order summary directed staff to administer Abilify 15 mg daily for psychosis manifested by responding to internal stimuli, constantly yelling, getting up unassisted for no reason, being at risk for falls, and striking out at staff. However, the order summary did not include an order for staff to monitor the resident’s responding to internal stimuli and constant yelling for the use of Abilify. Resident 6 also had an order for Trileptal 150 mg every 12 hours for impulse control related to being easily agitated and becoming verbally and physically aggressive. The care plan for Abilify directed staff to monitor and record episodes of behavior in the MAR and/or nursing notes, and the care plan for Trileptal gave the same direction. During interview and record review, an LVN stated that the resident’s constant yelling for Abilify was not monitored and that the resident’s verbally and physically aggressive behavior for Trileptal was not monitored on the morning shift of 6/26/2026 and 6/30/2026. The facility’s Behavior Management policy stated that occurrences of behaviors for which psychotropic medications are in use would be entered with hash marks on the MAR every shift.
Inaccurate MDS Discharge Status Coding
Penalty
Summary
The facility failed to ensure Resident 57’s MDS reflected an accurate discharge status assessment. Resident 57 was admitted with diagnoses including osteoarthritis, DM, and Afib, and had a physician order to discharge home with HH services including PT/OT for therapeutic exercises, ADL training, and gait, RN for medication management and overall safety evaluation, and HHA for bathing. The discharge summary documented that Resident 57 was discharged home with family or caregiver and home health. The MDS for Resident 57 was coded as discharged to home or community, but during interview and record review, the MDS coordinator stated this was incorrect because it should have been coded as discharged home under care of an organized home health service organization. The MDS coordinator stated the MDS should be coded accurately and specifically for the services provided for accurate reporting to CMS. The ADON also stated the MDS assessment should be coded correctly to reflect the resident’s overall current health status and for accurate reporting of information to CMS.
Missing Care Plan for Quetiapine Use
Penalty
Summary
The facility failed to develop and implement a specific, comprehensive, individualized person-centered care plan for Resident 26 to address the resident’s use of quetiapine fumarate. Resident 26 was admitted with diagnoses including dementia and a personal history of other mental and behavioral disorders, and the history and physical stated the resident did not have the capacity to understand and make decisions. The MDS indicated severely impaired cognition, maximal assistance was needed for eating, oral hygiene, personal hygiene, and bed-to-chair transferring, and the resident was dependent for toileting hygiene. The physician order dated 5/26/2026 showed an active order for quetiapine fumarate 25 mg by mouth at bedtime for senile degeneration of brain paranoia. During record review and interview, the resident’s care plans were reviewed and no care plan was developed for the quetiapine fumarate use. The LVN stated there should have been a care plan with a goal for fewer behavioral episodes and that the licensed nurse who received the order should have developed it. The ADON stated there should be a specific, resident-centered care plan for medication use so staff could monitor for side effects and know what to do if adverse effects occurred. The facility policy stated the care plan should be comprehensive and include measurable goals and time-oriented objectives to meet the resident’s medical, nursing, mental, and psychosocial needs.
Unlabeled IV Dressing on Resident Receiving IV Antibiotic Therapy
Penalty
Summary
The facility failed to implement its Policy and Procedure titled, Peripheral Catheter Dressing Change, when it did not label the IV dressing for a resident receiving IV therapy. The resident was admitted with diagnoses including UTI and dementia, had an active order for IV Ertapenem 1 gram every 24 hours for 11 days, and was ordered to have the IV site and dressing restarted every 72 hours and as needed for complications. The resident’s history and physical stated the resident lacked capacity to understand and make decisions due to dementia, and the MDS indicated moderately impaired cognition and varying levels of assistance needed for daily care. During observation, the resident’s left hand IV dressing had dry blood at the insertion site and no date was labeled on the dressing. The resident stated the IV site was painful. The MDS Coordinator reviewed pictures of the site and stated the tape was coming off and the dressing date could not be read. The MDSC stated the nurse should place the nurse’s initial and date on the sticker after changing the IV site, and that it was not acceptable to have an IV dressing without a date or initials because staff would not know when it was changed. The ADON stated the IV dressing should be dry, clean, intact, and labeled with a date and the nurse’s initial for infection control. The facility policy stated the licensed nurse should label the IV dressing with the date, time, and nurse’s initials.
MRR Recommendation Not Acted Upon for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a medication regimen review irregularity identified by the pharmacy consultant was acted upon for one resident. The resident was admitted with diagnoses including a history of falling, anxiety disorder, and depression. The resident’s order summary showed Celexa 10 mg by mouth every other day for depression manifested by verbalization of sadness with episodes of crying, and the MDS indicated moderately impaired cognition with dependence or need for extensive assistance from staff for multiple activities of daily living. The pharmacy consultant’s consultation report stated that the resident had received Celexa 10 mg every other day since 11/2025 and only once since 7/2025, and recommended considering a trial discontinuation of Celexa. The resident’s physician accepted the recommendation with a modification to reach out to psychiatry, but the ADON stated the referral to psychiatry was missed and the pharmacist’s recommendation was not acted upon. The ADON also stated the resident had no episodes of verbalization of sadness with crying during several months reviewed, and that Celexa should have been discontinued or reduced because the resident did not have ongoing depressive symptoms.
Failure to Implement Enhanced Barrier Precautions for Resident with Feeding Tube
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when the facility failed to ensure a safe and sanitary environment to help prevent the development and transmission of communicable diseases for one sampled resident. Resident 59 was admitted and later readmitted with diagnoses including dysphagia, encounter for attention of gastrostomy, and UTI. The resident’s H&P stated the resident did not follow commands, and physician admission orders indicated the resident was incapable of giving informed consent and/or participating in the treatment plan. Enteral orders showed the resident received Fibersource HN via GT at 50 cc per hour over 24 hours due to dysphagia. The PRDA documented the resident had a GT, was unaware of safety needs, had short- and long-term memory impairment, was non-verbal, unable to make self-understood, unable to understand others, and required staff assistance for transfers. During observations inside the resident’s room, the resident was in bed receiving Fibersource HN via GT, and there was no EBP signage or PPE cart outside the room. An LVN stated residents with GT should be on EBP due to low immune system and that staff should wear gloves and gowns when providing care to residents with GT. The IPN reviewed the pictures and stated they showed no EBP sign outside the room, and that staff should initiate EBP for the resident upon admission and/or within 24 hours after assessments. The IPN stated residents with GT should be placed on EBP to prevent transmission of infection to other residents, staff, and visitors, and that there should be an EBP sign outside the room and a shared PPE cart. The ADON stated the staff did not think gowns were used when providing care because there was no EBP sign outside the room, and stated the facility should initiate EBP after assessing the resident’s skin. The facility policy stated EBP were for residents with feeding tubes and that staff should wear gowns and gloves while performing care for EBP residents.
Failure to Readmit a Hospitalized Resident to First Available Semi-Private Bed
Penalty
Summary
The facility failed to permit a resident to be readmitted to the first available bed in a semi-private room following hospitalization and transfer to a long-term acute care hospital (LTACH), as required by its own bed-hold and return policy. The resident had a history of hemiplegia and hemiparesis following cerebral infarction and dementia, with documentation showing severe cognitive impairment and a lack of capacity to make decisions. The resident was originally admitted and later readmitted to the facility, then transferred to a general acute care hospital (GACH) via 911 for altered mental status, increased respirations, and oxygen desaturation, and subsequently admitted to an LTACH for further evaluation and therapy. At the LTACH, documentation indicated that the resident’s discharge goal/plan included transfer back to a SNF, and a psychiatric consultation noted that the resident was calm, quiet, and manageable with the current treatment plan. The LTACH case manager reported that a psychiatric consultation report addressing behavioral issues was completed and sent to the facility. Despite this, when the LTACH inquired about readmission, the facility’s Admission Coordinator Director and DON stated that the facility refused to readmit the resident, initially citing that behavioral issues had not been addressed or evaluated in the LTACH records. Further review showed that the facility had multiple available female beds in semi-private rooms on the dates in question. The DON acknowledged that the facility received the psychiatric consultation report from the LTACH and still refused readmission, and also stated that the resident should be accepted for readmission if there were no behaviors that would endanger the health or safety of the resident or others, and that the facility could provide the care and meet the resident’s needs. The facility’s written policy on bed-holds and returns required that residents be allowed to return to their previous room if available, or to the first available semi-private bed, provided they still required facility services and were eligible for Medicare or Medicaid services, and that residents be evaluated based on their current condition following hospitalization. The facility did not follow this policy in the resident’s case.
Failure to Provide Required Transfer/Discharge Notice and Ombudsman Notification
Penalty
Summary
The deficiency involves the facility’s failure to complete the required transfer/discharge notification process for one sampled resident when the resident was transferred to a general acute care hospital. The resident had a history of hemiplegia, hemiparesis following cerebral infarction, and dementia, and was documented as lacking capacity to understand and make decisions, with an MDS showing severely impaired cognitive skills and need for partial/moderate assistance with most ADLs. On the day of transfer, a physician’s telephone order directed that the resident be transferred to a hospital via 911 due to altered mental status and desaturation, and progress notes documented that the resident was transferred by 911 for altered mental status, increased respirations, and desaturation. Record review showed that there was no Notice of Transfer or Discharge (NTD) in the resident’s medical record related to this hospital transfer. In a telephone interview, the RN who received the transfer order stated that they should have completed the NTD form and faxed it to the ombudsman after the resident was transferred. The ADON, after reviewing the medical record, confirmed that no NTD form could be found and stated that the NTD is important to inform the resident and family of the transfer or discharge and to fax to the ombudsman prior to transfer or discharge. The facility’s policy titled “Transfer or Discharge, Facility-Initiated” indicated that the NTD should be given as soon as practicable but before transfer or discharge when an immediate transfer is required by urgent medical needs, that notice is to be provided to the resident, representative, and LTC ombudsman when practicable, and that nursing notes will include documentation of appropriate orientation and preparation of the resident prior to transfer or discharge.
Failure to Ensure Call Lights Were Accessible and Functional
Penalty
Summary
The facility failed to ensure that call lights were within reach and functioning properly for two residents, resulting in the potential for delayed or unmet care needs. For one resident with hemiplegia, impaired vision, and severe cognitive impairment, the call light was observed to be placed on a rolling table approximately three feet away from the bed, making it inaccessible. Both the LVN and ADON confirmed that the call light was not within reach and should have been placed closer to the resident's functional side to allow for timely assistance, as outlined in the resident's care plan. Another resident, assessed as high risk for falls due to impaired mobility and vision, reported that their call light had not been working for two days despite notifying staff. The resident stated that no staff responded to the call light and had to leave the room to seek assistance. The facility's policy required staff to ensure call lights were functional and to answer them promptly, but this was not followed, as evidenced by the resident's experience and staff interviews.
Failure to Accurately Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post accurate nurse staffing information reflecting the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care for three consecutive days. Observations and interviews revealed that the required staffing information for the night and day shifts was not completed and was not posted in visible areas such as the nurses' station. The Case Manager acknowledged that the staff posting was incomplete and stated that actual hours would be posted the following day, rather than as required. Further interviews with the Assistant Director of Nursing confirmed that staffing hours should be posted at the beginning of each shift and should reflect actual hours worked. Record review showed that the posted nurse staffing information was not completed for all three shifts on the specified dates. The facility's policy and procedure require that within two hours of the beginning of each shift, the number of licensed and unlicensed nursing staff and their actual hours worked be posted in a prominent location accessible to residents and visitors.
Deficient Food Storage, Labeling, and Equipment Maintenance in Dietary Services
Penalty
Summary
The facility failed to adhere to its own food storage and handling policies by not removing expired food items from the refrigerator and failing to label food items with the required information, such as the food item name and use by or expiration date. During multiple kitchen observations, surveyors found expired prunes, puree food, and sandwiches in the refrigerator, as well as numerous unlabeled or undated items including grapes, fruit cups, applesauce, peppers, fortified milk, sweetener, thickener, raw chicken, and pastrami meat. Staff interviews confirmed that these items should have been labeled and expired food should have been discarded, as per facility policy. Staff acknowledged that the lack of proper labeling and removal of expired food could result in serving unsafe food to residents. Additionally, the facility failed to maintain a functional convection steamer in the kitchen. During an observation, a staff member was injured when a tray of green beans fell from the steamer due to missing supporting rails. The equipment had been known to be in disrepair, and maintenance staff were aware of the issue but had not yet completed repairs. This malfunction led to delays in meal preparation and service, as food had to be remade and staff were diverted to address the injury. Review of the facility's policies and procedures confirmed that all food items are required to be labeled and dated, and that equipment must be maintained in good working order with regular inspections. The observed deficiencies in food labeling, storage, and equipment maintenance were not in accordance with these established policies, as confirmed by staff and policy review.
Inaccurate MDS Discharge Coding for Resident
Penalty
Summary
The facility failed to ensure the accurate coding of a resident's discharge destination in the Minimum Data Set (MDS) assessment. Specifically, a resident who was admitted with diagnoses including hyperlipidemia and type 2 diabetes mellitus was discharged home per their request after dialysis treatment. However, the MDS assessment incorrectly documented the discharge destination as a short-term general hospital. This error was identified during a review of the resident's admission record, physician's order, and discharge summary, all of which confirmed the resident was discharged home. Interviews with the MDS Coordinator and the Assistant Director of Nursing confirmed that the resident was not discharged to a hospital, and both acknowledged the necessity for accurate MDS coding. The facility's policy and procedure on the MDS and Resident Assessment Instrument (RAI) process indicated that all members of the Interdisciplinary Team share responsibility for the accurate completion of the RAI, with the RN MDS Coordinator responsible for reviewing and signing off on the assessment. Despite these procedures, the MDS was not coded accurately, resulting in incorrect information being reported to CMS.
Failure to Provide Required Two-Person Assistance During ADLs Resulted in Resident Fall
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including osteoarthritis, osteoporosis, morbid obesity, generalized muscle weakness, and lack of coordination, was not provided adequate supervision during activities of daily living (ADLs). The resident was assessed as being dependent on staff for all ADLs and required the assistance of two or more staff members for tasks such as turning, repositioning, and personal care. Despite this documented need, a certified nursing assistant (CNA) provided care alone, during which the resident slid off the bed while being turned for a diaper change. The CNA was unable to prevent the fall due to the resident's weight and called for assistance after the incident occurred. Interviews with staff, including the CNA involved, a licensed vocational nurse (LVN), and the assistant director of nursing (ADON), confirmed that the resident should have received two-person assistance for all ADLs to ensure safety and prevent falls. Documentation and care plans also indicated the requirement for two-person assistance. The facility's policy on ADL support emphasized providing appropriate care and assistance for residents unable to perform ADLs independently. The failure to follow these protocols resulted in the resident falling from the bed and being sent to the emergency room, although no fractures were found.
Failure to Secure Foley Catheter Tubing as Required by Care Plan and Policy
Penalty
Summary
A deficiency was identified when a resident with chronic kidney disease, urinary retention, and dementia, who was admitted with an indwelling Foley catheter, was observed to have the catheter tubing unsecured on their thigh. The resident's care plan specifically required the catheter tubing to be secured to the leg to prevent pulling or trauma. During observation, the resident was seen in a wheelchair with the Foley catheter tubing not secured, and the attending LVN confirmed this was not in accordance with proper procedure. Interviews with both the LVN and the Assistant Director of Nursing confirmed that all indwelling catheters should be properly secured to prevent injury during movement or transfers. Review of the facility's policy and procedure for catheter care also indicated that leg straps should be used to attach catheter tubing to the resident's leg to avoid tension. The failure to secure the catheter tubing as required by the care plan and facility policy constituted the deficiency.
Failure to Label Nasal Cannula Tubing for Oxygen Therapy
Penalty
Summary
A deficiency was identified when a resident with a history of congestive heart failure, cirrhosis of the liver, and obstructive sleep apnea was observed receiving oxygen therapy via nasal cannula (NC) at 2 liters per physician order. During observation and interview, it was noted that the NC tubing in use was not labeled with a date to indicate when it was last changed. The Certified Nurse Assistant confirmed that the tubing was not labeled, and the Assistant Director of Nursing stated that NCs and other respiratory tubing should be labeled with the date for infection control purposes. A review of the facility's policy and procedure for oxygen administration indicated that nasal cannula tubing should be labeled and dated, and changed every 7 days by licensed nurses. The failure to label the NC tubing as required by facility policy was observed and confirmed through staff interviews and record review, resulting in a deficiency related to safe and appropriate respiratory care and infection control practices for the resident.
Failure to Obtain Physician Order and Informed Consent for Siderail Use
Penalty
Summary
The facility failed to obtain a physician's order and informed consent prior to the installation of bilateral one-fourth siderails/bedrails for a resident. The resident, who had diagnoses including hemiplegia, hemiparesis, and diabetes mellitus, was severely cognitively impaired and dependent on staff for all activities of daily living. During observation, the resident was found in bed with both siderails up, and review of the medical record confirmed that neither a physician's order nor informed consent had been documented before the siderails were installed. Interviews with facility staff, including the Minimum Data Set Coordinator and the Assistant Director of Nursing, confirmed that the required physician's order and informed consent were missing. The facility's policies and procedures specify that informed consent and a physician's order are necessary before siderails are used, especially when they may function as a physical restraint. The absence of these steps placed the resident at risk for entrapment and injury associated with siderail use.
Damaged Side Rail Pads Not Replaced for Dependent Resident
Penalty
Summary
The facility failed to ensure that both side rail pads on a resident's bed were free from damage, wear, and tear. Observation revealed that the resident, who was admitted with diagnoses including unspecified dementia and senile degeneration of the brain, was lying in bed with half-length bilateral side rails that had ripped and damaged pads. The resident's care plan required the use of padded side rails as an enabler for bed mobility and to minimize the risk of bruising or skin tears, with instructions for nursing staff to periodically check the side rails for safety and refer to maintenance as needed. A physician's order also specified the use of padded side rails to prevent skin injury. Record review indicated that the resident was severely cognitively impaired and fully dependent on staff for all activities of daily living. During an interview, the ADON acknowledged that the side rail pads needed to be changed and should not be ripped or damaged to maintain the resident's safety and dignity. The facility's policy required staff to report any defective equipment to supervisors and document it in the maintenance request log, but this was not followed in this instance.
Medication Administered Without Physician Order
Penalty
Summary
A licensed vocational nurse (LVN) administered Zofran 4 mg to a resident without first verifying the presence of a current physician's order in the Medication Administration Record (MAR). The LVN obtained the medication from the medication cart, which was labeled with the resident's name, and gave it to the resident after the resident experienced a small amount of emesis. After administering the medication, the LVN attempted to document the administration in the MAR but discovered there was no active order for Zofran for the resident. Interviews with the LVN, Assistant Director of Nursing (ADON), and Director of Nursing (DON) confirmed that facility policy requires staff to check the MAR and verify physician orders before administering any medication. The facility's policy and procedure on Medication Administration states that medications are to be administered only as prescribed and in accordance with written orders from the attending physician. The failure to follow this process resulted in the administration of medication without a physician's order.
Incomplete Assessment and Documentation of Resident's Change in Condition
Penalty
Summary
The facility failed to follow its own policy and procedure for charting and documentation by not completing a thorough assessment and documentation of a resident's change in condition. The resident, who had a history of a right femur fracture, dementia, and difficulty walking, was observed by a CNA to be moaning and expressing pain when repositioned, which was unusual for this resident. The CNA reported these observations to the LVN, who, along with an RN, checked on the resident but did not perform a full assessment of the resident's lower extremities or document any findings related to possible pain or swelling. The LVN did not note any abnormalities or changes in the resident's condition in the medical record at that time. Subsequent documentation revealed that the resident continued to exhibit signs of pain and was later found to have swelling in the right knee. A radiology report confirmed a fracture of the proximal lateral tibia. Interviews with staff confirmed that the LVN did not evaluate or document the condition of the resident's legs, and the facility's policy required documentation of all changes in a resident's condition. The lack of complete assessment and documentation resulted in incomplete information regarding the resident's condition.
Inaccessible Call Lights for Residents
Penalty
Summary
The facility failed to ensure that the call lights were within reach for two residents, leading to potential delays in receiving necessary care. Resident 20, who was admitted with metabolic encephalopathy and Parkinson's disease, had severely impaired cognition and required maximal assistance with daily activities. The care plan for Resident 20 included keeping the call light within reach, but during an observation, the call light was found hanging on the side of the bed, caught between the bed and bedrails, making it inaccessible. Similarly, Resident 27, who had osteoarthritis and a history of falls, was observed with the call light on the floor by the wall, out of reach. Despite having intact cognition and requiring moderate assistance, the resident's care plan also specified that the call light should be within reach. Interviews with staff, including LVNs and the DON, confirmed that the call lights should be accessible to residents to ensure their needs are promptly met. The facility's policy also stated that call lights should be repositioned within residents' reach at all times.
Failure to Include Advance Directives in Medical Records
Penalty
Summary
The facility failed to ensure that the Advance Directive/Preferred Intensity of Care Documentation form (AD) was included in the medical records of two residents, which could lead to care being provided against their wishes. Resident 35, who was admitted with renal dialysis dependence and a leg fracture, had an AD form indicating a preference for no resuscitation and no tube feeding. Despite having intact cognition and the ability to communicate, the AD form was missing from the medical record, as confirmed by the Admission Coordinator. This omission meant that staff might not be aware of the resident's treatment preferences during an emergency. Similarly, Resident 2, admitted with dementia, hypertension, and type 2 diabetes, also lacked an AD Acknowledgement Form in their medical record. The resident's cognition for daily decision-making was severely impaired, making the presence of the AD form crucial for guiding care decisions. Both a Licensed Vocational Nurse and the facility's Case Manager confirmed the absence of the form, and the Director of Nursing acknowledged the necessity of having the AD form in the resident's chart to honor their wishes. The facility's policy mandates recording residents' wishes in their medical records to ensure their rights are respected.
Communication Barriers for Non-English Speaking Residents
Penalty
Summary
The facility failed to provide appropriate communication devices for two residents, leading to potential communication barriers and unmet needs. Resident 20, who was admitted with metabolic encephalopathy and Parkinson's disease, spoke Cantonese/Mandarin and was at risk for social isolation. The care plan for Resident 20 included the use of a communication board and translation services, but during an observation, it was noted that no communication board was present in the room, and Cantonese/Mandarin-speaking staff were not always available. This lack of effective communication tools hindered the ability of staff to meet Resident 20's needs. Similarly, Resident 34, who preferred to communicate in Mandarin, faced challenges due to limited communication options. Although an English-Chinese communication board was available, it did not cover all necessary care areas, and staff primarily relied on body language to communicate. This inadequacy was confirmed by interviews with staff, who acknowledged the difficulty in understanding and meeting Resident 34's needs due to the language barrier. The facility's policy indicated that communication boards should be available for non-verbal and non-native speaking residents, but the implementation was insufficient. Staff interviews revealed that there were no additional interpretation services available, which further exacerbated the communication challenges faced by non-English speaking residents. This deficiency in communication support had the potential to delay care and affect the quality of life for the residents involved.
Food Storage and Safety Deficiencies
Penalty
Summary
The facility failed to adhere to its Policy and Procedure (P&P) regarding the proper labeling and dating of opened food containers, as well as the storage of refrigerated food. During an observation, it was noted that a bottle of salad dressing, a carton of milk, and several canisters of seasonings were opened without being labeled with the date of opening. Additionally, a tray of nourishments containing yogurt, prunes, and cottage cheese was found in the refrigerator with a date of 6/12/2024, which should have been discarded after three days according to the facility's P&P. Interviews with the Dietary Supervisor and another staff member confirmed that the lack of labeling and failure to discard expired food could lead to foodborne illnesses. Furthermore, the facility did not comply with its Hair Net Policy for kitchen workers. During an observation, two staff members with facial hair were seen working in the kitchen without wearing beard nets. The Dietary Supervisor acknowledged this oversight and stated that beard nets are necessary to prevent hair from contaminating the food. The facility's P&P clearly requires kitchen workers with facial hair to wear beard nets, but this policy was not followed, increasing the risk of food contamination.
Deficient Arbitration Agreements in LTC Facility
Penalty
Summary
The facility failed to ensure that its binding arbitration agreements included the selection of a venue convenient to both the facility and the resident or the resident's responsible party for three sampled residents. Resident 16, who was admitted with diagnoses including dementia, hypertension, and diabetes, had an arbitration agreement signed by their responsible party that did not specify a neutral arbitrator or a convenient venue. The facility's policy required that the venue be agreed upon by both parties and be convenient for the resident, but this was not reflected in the agreement. Similarly, Resident 20, who was admitted with metabolic encephalopathy and Parkinson's disease, signed an arbitration agreement that also lacked information about a neutral arbitrator and a convenient venue. Despite Resident 20's lack of capacity to understand and make decisions, the agreement was signed without these critical details. Resident 35, who was cognitively intact and admitted with renal dialysis dependence and a leg fracture, also had an arbitration agreement that did not provide for a convenient venue. These omissions in the arbitration agreements placed the residents at risk for unjust arbitration processes.
Failure to Timely Complete Quarterly MDS Assessment
Penalty
Summary
The facility failed to ensure that a quarterly Minimum Data Set (MDS) assessment was completed within the required time frame for a resident diagnosed with dementia and malnutrition. The resident was admitted on September 16, 2022, and the quarterly MDS assessment was not completed as of June 8, 2024. This delay in completing the MDS assessment was identified during a review of the resident's admission record and the Center for Medicare and Medicaid Services (CMS) Submission Report, which indicated that the assessment was completed more than 14 days after the assessment reference date. During an interview and record review with the MDS Coordinator, it was confirmed that the quarterly MDS for the resident was missed and not submitted on time. The facility's policy and procedure for the MDS and Resident Assessment Instrument Process requires that all assessments be submitted within 14 days of the MDS Completion Date, and quarterly assessments are due every quarter unless the resident is no longer in the facility. The MDS Coordinator acknowledged the importance of timely completion and submission of the MDS to provide accurate information to CMS.
Failure to Develop Care Plan for Resident with Hearing Difficulties
Penalty
Summary
The facility failed to develop a specific and individualized person-centered care plan for a resident with hearing difficulties. The resident, who was admitted with diagnoses including metabolic encephalopathy and Parkinson's disease, was assessed to have severely impaired cognition and required maximal assistance with daily activities. Despite these assessments, the facility did not initiate or develop a care plan to address the resident's hearing difficulties, as observed during interactions with staff where the resident indicated difficulty hearing. During observations and interviews, it was noted that the resident primarily spoke Cantonese and had trouble hearing in both ears. Licensed Vocational Nurses communicated with the resident by speaking loudly, but there was no documented care plan to guide staff in addressing the resident's hearing impairment. The facility's policy requires the development of a comprehensive care plan upon admission and during changes in condition, but this was not adhered to in the case of this resident.
Failure to Label IV Site
Penalty
Summary
The facility failed to adhere to professional standards of practice by not labeling and dating the intravenous (IV) site for a resident, which is essential for infection control. The resident, who was admitted with diagnoses including dysphagia and lung cancer, had a peripheral IV line inserted on their left hand for continuous infusion of 0.9% Normal Saline at a rate of 60 ml/hr. During an observation, it was noted that the IV dressing lacked a label indicating the date of insertion, which is a critical step to ensure timely changes of the IV site to prevent infection. The Minimum Data Set Coordinator confirmed that the IV site was not labeled and emphasized the importance of labeling for infection control, stating that the IV access should be changed every 72 hours. The facility's policy on Short Peripheral Catheter Insertion, revised in 2015, also required the dressing to be labeled with the date and time of insertion, catheter gauge and length, and the nurse's initials. The failure to label the IV site as per the facility's policy and professional standards posed a risk of infection for the resident.
Failure to Follow Enhanced Barrier Precaution Protocol
Penalty
Summary
The facility failed to adhere to its Policy and Procedure on Enhanced Barrier Precaution (EBP) for infection control, specifically in the case of Resident 35. During an observation, Licensed Vocational Nurse 7 (LVN 7) entered Resident 35's EBP room without donning personal protective equipment (PPE) and proceeded to take the resident's blood pressure. LVN 7 acknowledged the failure to wear a gown and gloves, which are required when in close contact with residents in EBP rooms, as per the facility's policy. This oversight was identified as a potential risk for the transmission of multidrug-resistant organisms (MDRO) to other residents. The Infection Prevention Nurse (IPN) confirmed that EBP is implemented to reduce the transmission of MDROs, with signs posted outside rooms of residents who require such precautions. These residents may have conditions such as open wounds, gastrostomy tubes, foley catheters, or be on dialysis. The IPN emphasized that taking blood pressure is considered a close contact activity, necessitating the use of PPE. A review of the facility's undated P&P on Enhanced Barrier Precaution reiterated the requirement for staff to wear gowns and gloves during tasks with a high risk of MDRO contamination.
Failure to Post Nurse Staffing Information
Penalty
Summary
The facility failed to post actual nurse staffing data at the beginning of each shift daily in two sampled locations, the lobby and nursing station, on specific dates. On 6/18/2024, during an observation at 10:24 am, it was noted that the Posted Nurse Staffing Information (PNSI) form did not reflect the actual number of nursing staff present for the morning shift. This oversight was confirmed during an interview with the Director of Nursing (DON) on 6/20/2024, who acknowledged that the PNSI form should be completed at the start of each shift to inform residents and visitors of the staffing levels. Further observations on 6/20/2024 at 11:35 am revealed that the PNSI form at the nursing station was also incomplete, lacking the actual number of staff working. The Registered Nurse Supervisor (RN Sup 1) admitted responsibility for updating the form and confirmed that it was not completed for that day. The facility's policy, revised in 8/2022, mandates that the charge nurse or designee must compute and post the staffing numbers within two hours of each shift's start. The failure to adhere to this policy potentially affected the transparency of staffing information available to residents and their families.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near City Of Industry
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Beacon Healthcare Center | 2.2 mi | ★★★★★ | 15 | 0 |
| Garden View Post Acute Rehabilitation | 3.3 mi | ★★★★★ | 20 | 0 |
| West Haven Healthcare | 3.5 mi | ★★★★★ | 17 | 0 |
| West Covina Healthcare Center | 3.5 mi | ★★★★★ | 20 | 0 |
| Clara Baldwin Stocker Home For Women | 3.5 mi | ★★★★★ | 25 | 0 |
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