Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Extended Care Hospital Of Westminster during CMS and state inspections, most recent first.
Unnecessary Psychotropic Medication Use Without Documented Nonpharmacological Interventions: Multiple residents with schizophrenia-related diagnoses and no decision-making capacity had orders for psychotropic medications including antipsychotics, antidepressants, mood stabilizers, and anxiolytics. Behavior logs documented repeated episodes such as paranoia, depressed mood, restlessness, anxiety, and akathisia, but the records did not show that nonpharmacological interventions were attempted or included in the care plans. The DON, ADON, and MDS Coordinator acknowledged the missing documentation.
PASARR Level II recommendations were not followed up or incorporated into the care plans for three residents. One resident with paranoid schizophrenia lacked documented neuropsychology and sleep specialist consultations, another resident with bipolar schizophrenia and a language barrier lacked documented interpreter services, and a third resident with insomnia and paranoid schizophrenia lacked documented sleep specialist consultation. The TRC MDS Coordinator, TRC Program Director, and DON acknowledged the missing documentation.
Menu Recipes Not Followed for Altered-Texture Diets: Facility staff did not follow standardized recipes for altered-texture menu items. A dietary staff member prepared pureed peas and carrots by blending in peas, and the DSS confirmed the recipe was not followed. Separate tray observations showed minced and moist peas and carrots containing peas when only carrots should have been served, and minced and moist meatloaf served with gravy instead of the required thick ketchup.
Food safety practices were not followed for 87 of 93 residents receiving meals from the kitchen. A Diet Aide was observed in the food prep area with uncovered facial hair despite the facility dress code requiring beard restraint. The ice machine was visibly coated with reddish-brown material, and two opened dry pasta packages in storage were not dated, which the DSS verified.
Infection Control Failures in Environmental Cleaning, Laundry Practices, Legionella Prevention, and Hand Hygiene: The facility had multiple infection control lapses, including damaged and uncleanable surfaces in a resident bathroom, hallways, and the laundry room; uncovered clean towels and improperly stored clean PPE gowns in the laundry area; no eye protection available for staff sorting soiled laundry; and damaged laundry equipment. The facility also lacked staff education on Legionnaire’s disease and had a Legionella policy without the required temperature range. During resident care, an LVN touched a resident’s pump, gown, and blanket, then continued GT care without hand hygiene or changing gloves.
Incomplete psychotropic medication informed consents were found for two residents with no decision-making capacity. One resident’s consents for Geodon and Seroquel did not include the diagnosis supporting the meds, and another resident’s consents for Zoloft and Zyprexa did not include the manifested behaviors or expected benefits. The ADON verified the omissions during record review, and the DON was informed.
Homelike Environment Not Maintained: Yellow stains were observed on ceiling tiles in multiple areas, including outside the dining room and activities room, and the lobby ceiling had cracks and peeling paint. The Maintenance/Housekeeping Supervisor verified the observations during interview.
The facility failed to keep care plans current for three residents. Two residents had physician-ordered pain management plans that included nonpharmacological interventions, but their care plans only listed medication administration and did not include the ordered NPIs. Another resident was using a wheelchair alarm for fall prevention, but the care plan still reflected a discontinued lap buddy and did not include the current alarm intervention. Staff acknowledged the care plans were not updated to match the residents’ current orders and care needs.
Failure to Monitor and Report Psychotropic Medication Side Effects: A resident with paranoid schizophrenia was prescribed Zoloft and Zyprexa, with orders to monitor psychotropic side effects each shift. Staff observed a persistent left-hand tremor, but the MAR and record did not show the tremor was documented, assessed, or reported to the physician, and an LPN/CNA noted the shaking had been present for a long time.
A resident with immobility and no capacity to make decisions was ordered to have an LAL mattress set to alternating pressure for skin management, with staff instructed to verify the mode each shift. Surveyors observed the mattress in static mode while the resident was lying in bed, and an LVN confirmed it should not have been in static mode. The DON acknowledged the setting was not accurate per the resident’s needs or physician’s order.
Failure to Notify Physician and Responsible Party of Significant Weight Loss: A resident with no decision-making capacity had significant wt loss after readmission, with weights dropping from 124 lbs. to 110 lbs. The facility’s nutritional update documented a 9-lb. loss in 10 days and noted further wt loss was not clinically indicated, but the record did not show that the physician or resident’s representative was notified. An LVN and the DON both verified the wt loss met the facility’s criteria for significant change and that notification should have occurred.
Appropriate GT care was not provided for two residents. An LVN was observed giving multiple diluted meds via GT by pushing them with a syringe plunger instead of using gravity flow, despite facility P&P requiring gravity flow. In another case, a resident’s enteral formula bottle and water bag remained in use beyond 24 hours even though facility P&P required open-system enteral feeding sets to be changed at least every 24 hours; the RN and DON acknowledged the findings.
A resident’s suction canister, suction tubing, and opened Yankauer were observed in the room without labels showing when they were last changed. The tubing contained yellowish fluid, and the IP confirmed the items were unlabeled. The resident had an order for suctioning PRN for excessive saliva/drooling and lacked capacity to understand and make decisions.
Inadequate Competency for GT Medication Administration: An LVN was observed administering multiple medications via GT to a resident by pushing them through the enteral syringe plunger instead of using gravity flow as required by facility P&P. The LVN confirmed the technique and stated she should have stopped to check GT patency when the medications were flowing slowly. Review of the nurse's skills checklist showed concerns with gastric/NG medication administration, and the DON acknowledged the findings.
Unsecured Over-the-Counter Medications in Accessible Storage Area: An unlocked medication storage room in the administrative office building contained multiple OTC medications, including aspirin, loratadine, artificial tears, and arthritis pain meds, stored openly on a counter and in an open box. The Central Supply Staff stated that several office and housekeeping staff had access to the building, and the DON verified that the medications were not secured and were accessible to unauthorized personnel.
Food safety and sanitation guidelines were not followed for 87 of 93 residents receiving meals from the kitchen. A Diet Aide was observed in the food prep area with uncovered facial hair despite the facility dress code requiring beard restraint, the ice machine had visible reddish-brown material on the evaporator grid, and two opened packages of dry pasta in dry storage were not dated.
A facility failed to ensure residents in the TRC were offered suitable alternate meal choices when they refused a planned meal. The facility policy required a nourishing food substitution, but LPT 1 and the DSS stated that residents who did not eat their meals were offered only a nutritional supplement drink instead of an alternate meal of choice.
Incomplete Advance Directive Documentation: The facility failed to keep A/D records accurate for a resident who had no capacity to make decisions. The POLST Section D indicated no advance directive, and the Advance Directive Acknowledgement did not show a DPOA for healthcare, even though the chart contained a copy of the resident’s active DPOA for healthcare. The SSD stated the forms were not updated to reflect the resident’s legal decision maker.
The facility failed to ensure its Facility Assessment included a plan to maximize recruitment and retention of direct care staff and a contingency plan for staffing needs. During interview and document review, the Administrator verified the Facility Assessment did not reflect the current CMS guidance and stated he was not aware of it. The assessment also did not show the required staffing resources for resident care, including weekends, or the active involvement of direct care staff in developing the assessment.
Three residents were placed on bed exit alarms without documented informed consent, despite facility policy requiring consent from the resident or responsible party. Nursing staff and the DON confirmed that informed consent was never obtained for the use of these alarms, even for residents lacking decision-making capacity due to dementia.
CNAs were observed feeding two fully dependent residents at the same time by alternating spoonfuls and beverages, contrary to facility policy requiring individualized attention during meals. Multiple residents with severe cognitive impairment and total dependence on staff for eating were affected, and staff interviews confirmed this was a routine practice. Facility leadership acknowledged that this practice did not align with training or policy.
Several residents were administered antipsychotic medications without documentation of attempted nonpharmacological interventions, and staff failed to accurately monitor or document orthostatic blood pressure as required by physician orders and facility policy. In multiple cases, blood pressure readings were either identical across different positions or taken hours apart, and abnormal readings were not reassessed or reported. Staff interviews confirmed gaps in understanding and documentation, and the facility's policies for monitoring side effects and obtaining informed consent were not consistently followed.
A resident with severe cognitive impairment and limited English proficiency did not receive individualized cultural music or TV programming in their primary language, as required by their care plan and activity assessments. Despite staff awareness of the resident's preferences and needs, observations and interviews confirmed that only English-language TV was provided in the room and no radio was available, resulting in a lack of culturally appropriate activities.
The facility did not provide staff supervision or safety equipment for four residents who smoked in the designated area, and did not assess their ability to smoke safely unsupervised. Additionally, a resident who experienced two falls did not have all care plan interventions implemented, including missing blood pressure monitoring in different positions and incomplete placement of floor pads. The resident's change in neurological status, specifically speech, was not communicated to the physician as required.
Two residents receiving GT feedings had formulas at their bedsides with labels that did not match physician orders, including incorrect feeding rates and missing times. Unopened feeding formula bags were also stored at the bedside instead of in a temperature-controlled utility room, contrary to facility policy. Nursing staff and the DON confirmed these practices did not follow established procedures for enteral feeding safety and labeling.
Two residents did not receive pain management in accordance with physician orders and facility policy. One resident was given Tylenol for moderate pain when the order specified use only for mild pain, and staff did not contact the physician for an appropriate order. Another resident received PRN Tylenol for moderate to severe pain without documentation or implementation of non-pharmacological interventions prior to medication administration, as required by policy.
The facility did not ensure that nurses and nurse aides were competent in obtaining and evaluating orthostatic hypotension, as evidenced by the lack of specific training, competency assessments, and proper documentation. Several residents experienced significant drops in blood pressure that were not properly identified or reported, and staff interviews revealed inconsistent knowledge and practices regarding orthostatic hypotension monitoring.
A nurse failed to administer a complete dose of a medication to a resident, leaving significant residue in the medication cup, and did not follow proper procedure to ensure the full dose was given. Additionally, the facility did not accurately reconcile and document the removal and administration of controlled substances for a resident, resulting in discrepancies between medication removal records and the MAR. The DON confirmed these findings.
Surveyors found that medications for oral and external use were stored together without separation, daily temperature monitoring of the medication refrigerator was not consistently documented, and enteral formulas and supplements were kept in a utility room without temperature monitoring. Staff confirmed these deficiencies during interviews.
Surveyors found that food in the kitchen was not properly labeled or dated, the heated plate lowerator was unclean with utensils and debris present, the walk-in freezer had significant ice build-up, and the dishwasher drainpipe lacked the required air gap for backflow prevention. These deficiencies were confirmed by staff and affected the majority of residents receiving food from the kitchen.
The facility did not consistently follow its policies for the storage and handling of food brought in by family or visitors, as staff gave conflicting accounts of procedures and used an unmonitored employee refrigerator for storage. Staff interviews revealed a lack of training and awareness regarding safe food handling of outside food, and facility leadership could not provide documentation of staff education on this topic.
Staff failed to follow hand hygiene protocols while assisting multiple residents with meals and during medication administration. CNAs were observed feeding more than one resident at a time and touching bibs without performing hand hygiene between residents. An LVN administered oral medications and then prepared a nebulizer treatment for a resident without hand hygiene in between, despite facility policy requiring it. Staff interviews confirmed these lapses in infection control practices.
Several residents, including those lacking decision-making capacity, did not have informed consents for psychotropic medications renewed every six months as required, and consent forms often lacked specific details such as dose, frequency, and indication. The process for obtaining consent did not consistently involve direct communication between the prescribing physician and the responsible party, and facility policies were not updated to reflect current regulations. These deficiencies were confirmed by interviews and record reviews with nursing staff and the DON.
The facility did not create care plans for 23 residents who smoked, nor for two residents involved in repeated disputes over their shared room door. Despite documentation and staff awareness of these issues, no individualized care plans were developed to address the residents' needs or manage the ongoing conflicts.
The facility did not follow its posted menu by serving mashed potatoes instead of roasted red potatoes to residents on regular diets, and this change was not communicated in advance as required by policy. The substitution was confirmed during a trayline observation, and facility staff acknowledged the menu should have been followed.
A facility failed to provide necessary psychiatric services for a resident with senile dementia and psychosis, as ordered by a physician. Despite a documented order for psychiatric evaluation and treatment, the resident was neither scheduled nor seen for these services. Interviews with the resident, an LVN, and the DON confirmed the oversight.
The facility failed to complete post-fall assessments for two residents, leading to potential delays in identifying neurological changes. One resident had an unwitnessed fall with no neuro checks documented, while another had incomplete neuro assessments after a fall. The DON acknowledged these lapses in following the facility's policy.
The facility failed to meet sanitary requirements in the kitchen, including improper drying of a blender, unclean kitchen hood, unsanitary ice machine, heavily marred cutting boards, and dirty or damaged utensils. These issues were confirmed by the Dietary Supervisor and had the potential to cause foodborne illnesses.
The facility failed to maintain its infection control program, including inaccurate infection surveillance documentation, improper storage of soiled and clean linens, and staff not performing proper hand hygiene during medication administration. These deficiencies were confirmed by the Infection Preventionist and observed during inspections.
The facility failed to offer PCV15/PCV20 immunizations to sampled and nonsampled residents in accordance with CDC recommendations. The Infection Preventionist admitted that the type of vaccine administered depended on the physician's order and was not aware of the current CDC guidelines, leading to the deficiency.
A resident with suspected mental illness did not receive a timely Level II Mental Health Evaluation due to the facility's failure to conduct a new Level 1 PASRR screening after the resident's isolation period. The delay resulted in the resident not receiving necessary specialized services for over a year.
The facility failed to coordinate hospice care, administer Lantus solution as ordered, and complete a fall risk assessment after an unwitnessed fall. These deficiencies were confirmed by the LVN, Social Services Director, and DON, posing risks to the residents' well-being.
The facility failed to attempt alternatives before using elevated side rails for a resident with limited mobility, impaired cognition, and a high risk for falls. The medical record showed no evidence of attempted alternatives, and staff confirmed this oversight.
The facility failed to have an RN on duty for at least eight consecutive hours a day, as required. Document reviews and interviews revealed multiple instances where RNs did not work the required hours, and the recorded hours did not match the actual hours worked. The Administrator confirmed the discrepancy and acknowledged the lack of an RN staffing waiver.
The facility failed to provide necessary pharmacy services, as discrepancies were found in the documentation and handling of discontinued controlled medications. Observations revealed that the quantities documented did not match the actual quantities, and some medications were not documented at all. Both the SNF DON and TRC DON acknowledged these findings.
A resident was administered Norvasc despite having a pulse rate below the physician-prescribed parameter. The resident's medical record indicated that Norvasc should be held if the pulse rate was less than 60 beats per minute, but it was given when the pulse rate was 56 beats per minute. This was confirmed by the DON during a review.
The facility failed to ensure that three residents were free from unnecessary psychotropic medications. Two residents were not properly monitored for orthostatic blood pressures while on Seroquel, and another resident did not have required monthly behavior summaries completed for multiple psychotropic medications. These deficiencies were confirmed by facility staff and had the potential to result in adverse consequences.
The facility failed to ensure safe and secure medication storage, including improperly labeled insulin pens, unreported removal of a medicated patch, expired sanitizing wipes, and an unlocked medication cart. These deficiencies compromised medication safety and security.
The facility failed to ensure that a TSH blood test was completed for a resident as ordered by the physician. The resident, who lacked decision-making capacity, had a physician's order for a TSH test every three months. However, the test due in April 2024 was not completed, as confirmed by the DON.
The facility failed to maintain accurate medical records for two residents. One resident was transferred to an acute care hospital without documentation of the change of condition, and another resident's POLST form lacked information on advance directives.
Unnecessary Psychotropic Medication Use Without Documented Nonpharmacological Interventions
Penalty
Summary
The facility failed to ensure five sampled residents were free from unnecessary psychotropic medication use because nonpharmacological interventions were not documented as being implemented when behavior episodes occurred, and the related interventions were not included in the residents’ plans of care. The deficiency involved Residents 5, 10, 25, 68, and 81, all of whom had no capacity to understand and make decisions according to their H&P examinations. The facility’s Psychotropic Medication Use policy stated that behavioral and other non-pharmacological approaches are to be used unless contraindicated, and that the clinical rationale for psychotropic use must document attempted behavioral interventions. For Resident 5, the record showed orders for clozapine, sertraline, Depakote, and gabapentin for paranoid thoughts, depressed mood, labile mood, and anxiety-related behaviors. The behavior monitoring log documented repeated episodes of paranoia, withdrawn behavior, irritability, yelling, mood swings, anxiousness, and restlessness across multiple shifts. However, the medical record did not show documented evidence that nonpharmacological interventions were implemented for those episodes, and the care plan did not include nonpharmacological interventions for the behaviors. The ADON acknowledged that staff should have provided nonpharmacological interventions when the behaviors occurred before psychotropic medications were administered. For Resident 10, the record showed an order for Lexapro for depressed moods/anxiety related to paranoid schizophrenia, and the behavior monitoring log documented repeated behavior episodes across many shifts in May 2026. The medical record did not show documented evidence that nonpharmacological interventions were implemented, and the care plan lacked nonpharmacological interventions addressing the behaviors. For Resident 25, the record showed orders for lithium, clozapine, haloperidol, and Zoloft for mania, self-hitting-related behaviors, restlessness, and anxiety/depressed mood. The behavior monitoring log documented multiple episodes of hyperactivity, telling peers to hit him, restlessness, and anxiety-related depressed mood, but the record did not show nonpharmacological interventions were implemented and the care plan lacked them. The TRC MDS Coordinator and DON acknowledged these findings. For Resident 68, the record showed orders for Seroquel, Geodon, and Ativan for anxiety, difficulty sleeping, depressed mood, and akathisia. The behavior monitoring log documented one episode each for depressed mood and paranoid ideation, and 29 episodes related to Ativan use. The documentation did not show whether nonpharmacological interventions were attempted or implemented. For Resident 81, the record showed an order for Zoloft for depressed mood related to paranoid schizophrenia, and the behavior monitoring log documented four episodes of depressed mood manifested by staying in bed. The record did not show whether nonpharmacological interventions were attempted or implemented. The ADON and DON acknowledged the findings for Residents 68 and 81.
PASARR Recommendations Not Incorporated Into Care Plans
Penalty
Summary
The facility failed to ensure that recommendations from PASARR Level II determinations were followed up and incorporated into the care plans for three sampled residents. Facility policy stated that PASARR recommendations, including specialized services, were to be included in the comprehensive person-centered care plan, but the records reviewed did not show that this occurred for Residents 10, 25, and 81. Resident 10 had a history of paranoid schizophrenia and was documented as having no capacity to understand and make decisions. The PASARR Individualized Determination Report stated that the resident required nursing facility services and a special treatment program, with recommended specialized services including neuropsychology consultation and a sleep specialist consultation. The care plan acknowledged PASARR screening, but it did not include those consultations, and the medical record did not show that either consultation was completed. Resident 25 had a history of bipolar schizophrenia, no capacity to understand and make decisions, and needed an interpreter to communicate with health care staff. The PASARR report recommended interpretation services, but the care plan did not include them and the medical record did not show that interpretation services were provided. Resident 81 had diagnoses including insomnia and paranoid schizophrenia and was also documented as having no capacity to understand and make decisions. The PASARR report recommended a sleep specialist consultation, but the care plan did not include it and the medical record did not show that the consultation was completed. The TRC MDS Coordinator and the DON acknowledged the findings for Residents 10 and 25, and the TRC Program Director and the DON acknowledged the findings for Resident 81.
Menu Recipes Not Followed for Altered-Texture Diets
Penalty
Summary
The facility failed to ensure that standardized menu recipes were followed for altered-texture diets. Review of the facility’s policies showed that standardized recipes adjusted to appropriate yield were to be maintained and used in food preparation. The facility’s recipe documents for glazed meatloaf and peas and carrots specified altered-diet instructions, including that pureed and minced and moist diets were to omit peas in the vegetable preparation and that the meatloaf should be served with thick ketchup ladled over the altered meat. The facility’s diet extension document also showed that the pureed diet was to receive pureed carrots and the minced and moist diet was to receive mashed carrots. During observation, the dietary staff member preparing the pureed peas and carrots made 24 servings by placing cooked peas and carrots into a blender, adding water from the cooking process and thickener, and did not refer to the recipe during preparation. The Dietary Services Supervisor confirmed that peas were incorrectly included in the pureed vegetable and that the recipe should have been followed. In a separate observation, a minced and moist diet tray contained minced peas and carrots, and the DSS confirmed that the vegetable serving should have contained carrots only and that peas should have been omitted. In another observation, a minced and moist diet tray contained minced meatloaf with gravy on top, and the DSS confirmed that the recipe called for thick ketchup to be ladled over the meat and that the recipe was not followed.
Food Safety Lapses in Kitchen and Storage Areas
Penalty
Summary
Food safety and sanitation guidelines were not followed for 87 of 93 residents who received meals prepared in the facility's kitchen. During the initial kitchen tour, a Diet Aide was observed working in the food preparation area with uncovered facial hair, even though the facility's Dress Code policy stated that beards and mustaches must wear beard restraint. The DSS was interviewed and stated that facial hair should be covered, and verified that all facial hair should be covered with a hair restraint. The ice machine was also observed to be dirty. During inspection of Ice Machine 1, the Maintenance Supervisor stated he cleaned the ice machine monthly, but when the front panel was opened, the vertical evaporator grid was visibly coated with reddish-brown material in the cells where the ice cubes are formed. In addition, two opened and sealed packages of dry pasta were observed in the dry storage area without an open date or use-by date, and the DSS verified the food items were not dated. The facility's policy stated newly opened food items must be closed and labeled with an open date and used by the date that follows the storage guidelines.
Infection Control Failures in Environmental Cleaning, Laundry Practices, Legionella Prevention, and Hand Hygiene
Penalty
Summary
The facility failed to ensure infection control practices were followed in multiple areas of the building and during resident care. During an initial tour, Room A’s restroom door frame was observed with yellow discoloration and peeling, and the toilet seat had multiple scratches. The facility also had cracked floor tiles in hallways outside the laundry room, outside Room B, and outside Room C, creating uncleanable surfaces. The Maintenance Supervisor verified these findings during observation and interview. In the laundry room, clean towels were stored uncovered in open cabinets while the room door was open, exposing them to dust from the doorway. Dust was observed on the laundry room vent, cobwebs were present on the laundry room door, and unsealed clean PPE gowns were stored next to a lint-producing pump outside the laundry room. Cracked floor tiles were also observed behind one washing machine, and another heavy-duty washing machine had yellow discoloration and a hole on its side. Laundry staff stated there was no eye protection available for staff to use while sorting soiled laundry, and the cracked floor tiles and damaged machine were verified during observation and interview. The facility also failed to ensure staff were educated about Legionnaire’s disease and that its Legionella policy included the temperature range required for prevention. The IP stated staff had not been provided education on the signs and symptoms of Legionnaire’s disease. The Maintenance Supervisor stated water temperatures were being tested to keep them below 120 degrees F, and boiler temperatures were observed at 115 degrees F and 110 degrees F. In addition, during medication administration for a resident with a GT, an LVN performed hand hygiene and donned new gloves, but after touching the resident’s tube feeding pump, gown, and blanket, she continued with checking GT residual and administering care without performing hand hygiene and changing gloves. The LVN acknowledged this during interview, and the IP and DON were informed and acknowledged the findings.
Incomplete Psychotropic Medication Informed Consents
Penalty
Summary
The facility failed to ensure that residents or their representatives were fully informed in advance of proposed psychotropic medication treatments for two sampled residents. Review of the facility’s informed consent policy and the CDPH psychotherapeutic drug informed consent requirements showed that the consent form was expected to include the reason for use, benefits, and other required treatment information. The facility’s own policy also stated that the licensed health care practitioner responsible for the treatment must disclose material information, including the reason for treatment, the nature and seriousness of the illness, expected improvement, side effects, risks, and alternative treatments. For one resident, the medical record showed no capacity to understand and make decisions, and physician orders included Seroquel for anxiety and difficulty sleeping and Geodon for depressed mood related to schizoaffective disorder. The psychotherapeutic drug informed consent for Geodon listed depressed mood and eliminating symptoms related to mood, but did not include the diagnosis supporting the medication. The informed consent for Seroquel listed anxiety and difficulty falling asleep with expected benefits of promoting sleep and relieving anxiety, but also did not include a diagnosis supporting the medication. For another resident, the medical record showed no capacity to understand and make decisions, and physician orders included Zoloft for depressed mood related to paranoid schizophrenia and Zyprexa for paranoid schizophrenia as manifested by paranoia. The informed consent for Zyprexa listed paranoid schizophrenia, but did not include the resident’s manifested behaviors or expected benefits associated with the medication. The informed consent for Zoloft also listed paranoid schizophrenia, but did not include the resident’s manifested behaviors or expected benefits. During interview and record review, the ADON verified these omissions, and the DON was informed and acknowledged the findings.
Homelike Environment Not Maintained
Penalty
Summary
The facility failed to maintain a homelike environment for residents. During observation, yellow stains were seen on ceiling tiles in multiple areas of the facility, including outside the residents' dining room and activities room. The lobby ceiling, an area used by residents requiring supervision, was also observed to have cracks and peeling paint. During a concurrent interview on 5/19/26 at 1203 hours, the Maintenance/Housekeeping Supervisor verified these findings.
Care plans not updated for pain interventions and wheelchair alarm use
Penalty
Summary
The facility failed to keep the comprehensive person-centered care plan current for three sampled residents by not revising it to reflect their assessed needs and ordered interventions. The report states that the care plan was not revised within 7 days of the comprehensive assessment and was not prepared, reviewed, and revised by an interdisciplinary team as required. Facility policy required care plans to reflect current standards of practice and to be revised when a resident’s condition changed, when the desired outcome was not met, after hospital readmission, and at least quarterly. For one resident, the physician ordered a wheelchair alarm to alert staff when the resident attempted to get up unassisted because of poor safety awareness. The resident was observed seated in a wheelchair with a wheelchair alarm attached, and staff confirmed the resident had previously used a lap buddy but was now using the alarm. The care plan, however, still addressed the discontinued lap buddy as a restraint and did not include the current wheelchair alarm intervention. Staff acknowledged that the care plan had not been updated to reflect the change. For two other residents, the care plans for pain were not revised to include ordered nonpharmacological interventions. One resident had an order for Tylenol as needed with specified nonpharmacological interventions to be provided prior to administration, but the care plan only included medication administration as ordered. The other resident had an order for a detailed list of non-pharmacological pain management interventions, but the care plan again only included medication administration as ordered and did not include those interventions. Staff reviewed the records and acknowledged that the pain care plans should have included the ordered nonpharmacological interventions.
Failure to Monitor and Report Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to ensure side effects of psychotropic medications were monitored, documented, and reported to the physician for one resident. The resident had diagnoses including paranoid schizophrenia and no capacity to understand and make decisions, and had physician orders for Zoloft 50 mg every morning and Zyprexa 20 mg every morning and at bedtime. The physician also ordered psychotropic medication monitoring for side effects, including tremor and extrapyramidal symptoms, with staff instructed to tally side effects each shift on the MAR. On observation, the resident was seen ambulating in her room with a tremor in her left hand, and a CNA stated the shaking had been present for a long time and might be related to the resident's medication for mental illness. The CNA said she had reported it once a long time ago but had not reported it again. Review of the MAR and medical record showed no documentation that the left-hand tremor was monitored, assessed, or reported to the physician. The ADON later observed the resident with a visible left-hand tremor, verified it, and stated she would notify the physician; the DON was informed and acknowledged the findings.
LAL Mattress Left in Static Mode While Resident Was in Bed
Penalty
Summary
The facility failed to ensure that Resident 1’s low air loss (LAL) mattress was not set in static mode while the resident was in bed. Resident 1 was admitted and later readmitted to the facility, and the H&P examination dated 3/20/26 stated the resident had no capacity to understand and make decisions. The physician’s order dated 5/19/26 directed that the LAL mattress be used for skin management due to immobility, set to alternating pressure and the resident’s weight, with special instructions to check each shift that the mattress was functioning in alternating pressure mode and not static. On 5/19/26 at 0958 hours, Resident 1 was observed lying in bed on the LAL mattress, which was set at normal pressure and static mode. During a concurrent interview at 1000 hours, LVN 1 verified the mattress was in static mode and stated it should not be in static mode while the resident was in bed. LVN 1 also stated the resident was at high risk for pressure injuries due to immobility and that the LAL mattress helped prevent and promote healing of existing pressure injuries by providing alternate normal pressure. On 5/20/26 at 1127 hours, the DON stated static mode should not be used when the resident was lying in bed except during meals or care such as bathing or repositioning, and acknowledged the mattress setting observed for Resident 1 was not accurate per the resident’s needs or physician’s order.
Failure to Notify Physician and Responsible Party of Significant Weight Loss
Penalty
Summary
The facility failed to ensure that a resident with significant weight loss received required notification to the physician and the resident’s responsible party. Facility policy titled Nutrition (Impaired) unplanned weight Loss- Clinical Protocol stated staff will report significant weight gains or losses, or abrupt or persistent changes from baseline appetite or food intake, to the physician so medical causes can be reviewed before interventions are ordered. Resident 7 had no capacity to understand and make decisions, was admitted and later readmitted to the facility, and had documented weights of 124 lbs., 120 lbs., 119 lbs., and then 110 lbs., reflecting a 14-lb. loss from the earlier weight and a 7.5% loss within 10 days after readmission. The Nutritional Status Update dated 5/18/26 documented that Resident 7 was receiving nutritional shake supplements three times daily and juice three times daily, and noted the resident was readmitted from the acute care hospital with a 9-lb. weight loss in 10 days and that further weight loss was not clinically indicated. However, the record did not show evidence that the physician or the resident’s representative was notified of the significant weight loss. During interview and record review, LVN 1 confirmed the weight loss met the facility’s criteria for significant weight change and stated the physician and responsible party must be notified, but could not locate documentation that this occurred. The DON also verified that the physician and responsible party should have been notified when the significant weight loss was identified on readmission.
Improper GT Medication Administration and Enteral Feeding Set Changes
Penalty
Summary
Appropriate care and services were not provided for residents with gastrostomy tubes for two of three sampled residents reviewed for tube feeding management. For one resident with a GT and multiple physician orders for medications and supplements to be given via GT, an LVN was observed administering diluted medications through the GT by using the syringe plunger to push the medication and water into the tube rather than allowing gravity flow. The LVN administered fludrocortisone acetate, Dilantin, Pepcid, multivitamins, aspirin, Tylenol, and Pro-Stat using the same technique, and later stated she believed this method was acceptable based on prior facility training. The DON stated medications via GT should be administered by gravity flow and acknowledged the finding. For another resident who had no capacity to understand and make decisions, the enteral feeding formula bottle and the water bag were observed hanging on the feeding pump pole with labels showing they had been started two days earlier. The resident had orders for Jevity 1.5 or equivalent at 40 ml/hr for 12 hours and concurrent water flushes at 80 ml/hr for 12 hours. The RN verified that the formula and water bag should have been changed every 24 hours when the feeding started, and the DON acknowledged the finding.
Unlabeled suction equipment in resident room
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not met for Resident 7. During an observation in the resident’s room, the suction canister connected to the suction tubing was seen on top of the drawer beside the bed. The suction tubing contained yellowish fluid, and the tubing was connected to a Yankauer stored inside the top shelf of the drawer in an opened original package. The suction canister, suction tubing, and Yankauer were not labeled to show the date they were last changed. An IP observed and confirmed that Resident 7’s suction canister, suction tubing, and Yankauer were not labeled. The IP stated these items should be labeled with the date they were last changed and changed weekly to minimize the risk of infection. Resident 7 was not present in the room during the observation. The medical record showed Resident 7 had an order for suctioning as needed for excessive saliva/drooling and had no capacity to understand and make decisions.
Inadequate Competency for GT Medication Administration
Penalty
Summary
The facility failed to ensure one licensed nurse reviewed for competency had the specific competencies and standard of practice skill sets needed to provide safe and efficient nursing care. During an observation of medication administration for Resident 3, LVN 3 was observed administering diluted fludrocortisone acetate and other medications via GT, including Dilantin, Pepcid, multivitamins, aspirin, Tylenol, and pro-stat. Instead of allowing the medications to flow by gravity as described in the facility procedure, LVN 3 poured 10 ml of water into the enteral syringe and used the syringe plunger to flush the medications into the GT. During interview, LVN 3 confirmed she pushed the medications into the GT with the syringe plunger rather than letting them flow by gravity and stated she should have stopped and checked GT patency because the medications were flowing very slowly. She also stated she had been told during facility training that she could push medications into the GT slowly with the syringe plunger. Review of LVN 3's skills checklists showed entries for gastric/NG medication administration with comments noting difficulty with administration and questions about flushing, and the forms were signed by a previous facility trainer. The DON stated licensed nurse competency was reviewed upon hire, on the 90th day, annually, and as needed, and acknowledged the findings for LVN 3.
Unsecured Over-the-Counter Medications in Accessible Storage Area
Penalty
Summary
The facility failed to provide necessary pharmacy services to ensure proper storage of medications in one of one medication storage room inspected. During an observation and concurrent interview, an unlocked and easily accessible storage room located within the facility’s administrative office building was found to contain multiple bottles of over-the-counter medications, including aspirin, loratadine, artificial tears, and arthritis pain medications, stored openly on a counter and inside an open box. The Central Supply Staff stated that the Business Office Manager, Chief Financial Officer, Administrator, and housekeeping staff all had keys that provided access to the office building. The DON later verified and acknowledged that the over-the-counter medications were not secured and were accessible to unauthorized personnel.
Food Safety and Sanitation Lapses in Kitchen
Penalty
Summary
Food safety and sanitation guidelines were not followed for 87 of 93 residents who received meals prepared in the facility's kitchen. During the initial kitchen tour, a Diet Aide was observed working in the food preparation area with uncovered facial hair, despite the facility's Dress Code policy stating that beards and mustaches must wear beard restraint. When interviewed, the DSS stated facial hair should be covered and verified that all facial hair should be covered with a hair restraint. The ice machine was observed during an inspection with the Maintenance Supervisor, who stated he cleaned it monthly. When the front panel was opened, the vertical evaporator grid was visibly coated with reddish-brown material in the cells where the ice cubes were formed, and the Maintenance Supervisor acknowledged the material. In the dry storage area, two opened and sealed packages of dry pasta were observed without an open date or use-by date, and the DSS verified the food items were not dated.
Failure to Offer Alternate Meal Choices After Meal Refusal
Penalty
Summary
The facility failed to ensure residents in the TRC were offered suitable alternate meal choices when they refused a planned meal. Review of the facility census showed 45 residents lived in the TRC, and the facility policy stated that residents who refused the planned meal were to be provided a suitable nourishing alternate meal and that nursing personnel were to ask why the resident was not eating and offer a food substitution in accordance with the resident's diet order. During interview, LPT 1 stated that if a resident refused a meal or remained hungry after a meal, the resident was offered only a nutritional supplement drink. The DSS also stated that in the TRC dining room, residents who did not eat their meals were offered only a nutritional supplement drink and were not provided an alternate meal of choice in accordance with the facility's policy.
Incomplete Advance Directive Documentation
Penalty
Summary
The facility failed to ensure the medical record was complete and accurate for one of 19 sampled residents, Resident 8. Review of the facility policy on charting and documentation showed that documentation in the medical record was to be objective, complete, and accurate. Resident 8 was admitted and later readmitted to the facility, and the H&P dated 12/18/25 documented that the resident had no capacity to understand and make decisions. Review of Resident 8’s POLST dated 3/15/22 showed that in Section D, the box for No Advance Directive was checked. Review of the Advance Directive Acknowledgement form dated 3/15/22 showed that Durable Power of Attorney for Healthcare was not checked off. However, the medical record also contained a copy of Resident 8’s DPOA for Healthcare dated 2/18/19. During interview and concurrent record review, the SSD stated Social Services was responsible for reviewing the POLST and that the Advance Directive Acknowledgement form was not updated to reflect the active DPOA for healthcare. The SSD stated Section D of the POLST should have identified the resident’s legal decision maker and that the Advance Directive Acknowledgement form should have shown the active DPOA for healthcare.
Facility Assessment Missing Staffing Recruitment, Retention, and Contingency Planning
Penalty
Summary
The facility failed to ensure its Facility Assessment addressed a plan to maximize recruitment and retention of direct care staff and a contingency plan for staffing needs. Based on interview and facility document review, the Facility Assessment was reviewed and did not show either of these required elements. The report states that CMS QSO-24-13-NH dated 6/18/24, with an implementation date of 8/8/24, provided revised guidance for the Facility Assessment, including active involvement of direct care staff in developing the assessment, staffing resources necessary to care for residents including weekends, a plan to maximize recruitment and retention of direct care staff, and a contingency plan for staffing needs for events not activating the emergency plan. On 5/20/26 at 0902 hours, the Administrator was interviewed and the Facility Assessment was reviewed concurrently; the Administrator verified the findings and stated he was not aware of the current guidance. He acknowledged the Facility Assessment was not updated based on the latest CMS guidance.
Failure to Obtain Informed Consent for Bed Exit Alarms
Penalty
Summary
The facility failed to obtain informed consent for the use of bed exit alarms for three residents. Medical record reviews showed that two residents lacked capacity to make decisions due to dementia, while one resident was determined to have decision-making capacity. Despite physician orders for bed exit alarms to prevent falls and injuries, there was no documentation of informed consent from either the residents or their responsible parties for the use of these devices. The facility's policy requires that residents or their responsible parties be informed and provide consent for treatments or procedures, but this was not followed in these cases. Interviews with nursing staff and the Director of Nursing confirmed that bed exit alarms were in use for all three residents and that the facility had never obtained informed consent for their use. The absence of consent was verified through both medical record review and staff statements, indicating a consistent failure to adhere to the facility's own policy regarding informed consent for the use of bed exit alarms.
Failure to Promote Dignity During Meal Assistance
Penalty
Summary
Staff failed to provide care that promoted dignity and respect for multiple residents who were dependent on assistance with eating. Certified Nursing Assistants (CNAs) were observed feeding two residents at the same time by alternating spoonfuls and beverages between them, rather than focusing on one resident at a time. This practice was observed with several residents who had severe cognitive impairment and were fully dependent on staff for eating, as documented in their Minimum Data Set (MDS) assessments. Specifically, CNA 1 was seen feeding two residents simultaneously, then later feeding another pair of residents at the same time. CNA 2 and CNA 3 were also observed feeding two residents at once. Interviews with the CNAs confirmed that this was a common practice in the facility. The facility's policy on Assistance with Meals required that residents who cannot feed themselves be fed with attention to safety, comfort, and dignity, and that staff should minimize interactions with others while assisting residents with meals. Further interviews with the Director of Staff Development (DSD) and a Licensed Vocational Nurse (LVN) revealed that CNAs were trained to feed only one fully dependent resident at a time, and that feeding two fully dependent residents simultaneously was not in accordance with facility policy. The DSD acknowledged the need to monitor seating arrangements and staff availability to ensure proper assistance during meals.
Failure to Prevent Unnecessary Psychotropic Medication Use and Inadequate Monitoring
Penalty
Summary
The facility failed to prevent the use of unnecessary psychotropic medications and did not ensure proper monitoring and documentation for residents prescribed antipsychotic drugs. In several cases, standing orders for injectable antipsychotics, such as Haldol, were implemented without documentation of nonpharmacological interventions being attempted prior to administration. For example, a resident with bipolar disorder, anxiety disorder, and substance use disorder had a standing order for Haldol IM if oral psychotropic medications were refused, but the medical record and facility policy did not specify or document any nonpharmacological interventions prior to use. Staff interviews confirmed the absence of such documentation and the lack of evidence that alternatives were considered before administering the medication. Additionally, the facility did not consistently monitor for orthostatic hypotension in residents receiving antipsychotic medications, as required by physician orders and facility policy. Multiple residents on medications such as Seroquel, Clozaril, and risperidone had orders for regular orthostatic blood pressure monitoring, but records showed either identical blood pressure readings for different positions (lying, sitting, standing), or readings taken hours apart, which is not consistent with proper orthostatic assessment. In some cases, significant drops in blood pressure were not reassessed or reported to the physician, and there was no documentation of resident assessment following abnormal readings. Staff interviews revealed a lack of understanding regarding the parameters for orthostatic hypotension and the appropriate steps to take when abnormal readings were identified. The facility's policies required monitoring for side effects and adverse consequences of antipsychotic medications, including orthostatic hypotension, but these were not followed in practice. Documentation failures included not recording nonpharmacological interventions, not obtaining or documenting informed consent with specific medication details, and not accurately or consistently monitoring and documenting orthostatic blood pressure as ordered. These deficiencies were verified by staff and the DON during interviews and record reviews.
Failure to Provide Individualized Cultural Activities for Non-English Speaking Resident
Penalty
Summary
The facility failed to provide an individualized and ongoing activity program to meet the needs and interests of a resident with severe cognitive impairment who only spoke a foreign language. Despite documented assessments and care plans specifying the need for cultural music and TV programs in the resident's primary language to promote therapeutic stimulation, observations on multiple occasions revealed that the resident's TV was set to English-language programming and no radio was present in the room. Communication cards in the resident's primary language were observed, but no other individualized activities reflecting the resident's cultural preferences were provided in the room. Interviews with staff, including the Activities Director and a CNA, confirmed that while group cultural music and events were offered in the activities room, the resident did not receive cultural music or TV programming in their room as required by their care plan. The Activities Director acknowledged the lack of appropriate TV channels and was unsure why a radio was not available in the resident's room. Documentation of activity participation indicated general activities such as socialization and entertainment, but did not reflect the provision of individualized cultural activities as outlined in the resident's assessments and care plan.
Failure to Provide Supervision and Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure the safety and supervision of residents in two key areas: smoking supervision and fall prevention. Four residents were observed smoking unsupervised in the designated outdoor smoking area, which lacked essential safety equipment such as a fire extinguisher, smoking apron, or smoking blanket. The facility's policy did not require staff-supervised smoke breaks, and residents were not assessed for their ability to smoke safely without supervision. Both the Assistant Administrator and TRC Program Director confirmed that residents were allowed to smoke unsupervised and that no safety equipment was present in the area. In the case of one resident, the facility did not implement or monitor fall prevention interventions as outlined in the care plan. After an unwitnessed fall, the care plan required monitoring of vital signs and blood pressure in lying, sitting, and standing positions, but the medical record showed this was not done. Additionally, following a witnessed fall, the resident was to have bilateral floor pads in place and undergo 24-hour neurochecks. Observations revealed that only one floor pad was in place, and the care plan interventions were not fully individualized or implemented as required. The facility also failed to notify the physician when the resident's neurological status changed, specifically when the resident's speech changed from clear to rambling during neurochecks after a fall. This change was documented in the medical record, but there was no evidence of physician notification or further monitoring of the resident's speech. Interviews with nursing staff and the DON confirmed these lapses in care plan implementation and communication.
Failure to Accurately Label and Store GT Feeding Formulas
Penalty
Summary
The facility failed to provide necessary gastrostomy tube (GT) care and services for two residents receiving enteral feeding. Observations revealed that the GT feeding formulas for both residents were not labeled accurately according to the physician's orders, with discrepancies in the feeding rates written on the labels compared to the orders in the medical records. Additionally, the date and time when the formula was hung were missing from the labels. Both residents had unopened bags of their respective feeding formulas stored at their bedsides, contrary to facility policy, which requires unopened formulas to be stored in temperature and light-controlled conditions within a locked utility room. Interviews with nursing staff and the Director of Nursing (DON) confirmed that the labels on the GT feeding formulas did not match the physician's orders and that the storage of unopened formula at the bedside was not in accordance with facility policy. The DON stated that proper labeling is necessary to ensure the correct resident, rate, and formula are administered, and that unopened formulas should be stored in the utility room. The observed practices did not align with the facility's written policies and procedures for enteral feeding safety precautions and error prevention.
Failure to Provide Safe and Appropriate Pain Management
Penalty
Summary
The facility failed to provide adequate and appropriate pain management for two of three residents reviewed for pain management. For one resident, the facility did not administer pain medication according to the physician's orders. The resident, who lacked capacity to make decisions, was given Tylenol for a pain level that was considered moderate, despite the physician's order specifying Tylenol only for mild pain. Both the LVN and the DON confirmed that the medication administered did not match the resident's pain level and that the physician should have been contacted to obtain an appropriate order for moderate pain. For another resident, the facility did not implement or document non-pharmacological pain interventions prior to administering PRN Tylenol for reported pain. The resident, who also lacked decision-making capacity, received Tylenol multiple times for pain levels ranging from moderate to severe. However, there was no documentation in the medical record that non-pharmacological interventions were attempted or their effectiveness assessed before giving the medication, as required by facility policy. Staff interviews confirmed that such interventions should have been tried and documented before administering PRN pain medication. The facility's policy on pain assessment and management requires that pain be managed according to the resident's clinical condition and treatment goals, with non-pharmacological interventions attempted and documented prior to pharmacological measures. In both cases, the facility did not follow its own policy, resulting in residents not receiving pain management services as ordered or documented.
Failure to Ensure Staff Competency in Orthostatic Hypotension Monitoring
Penalty
Summary
The facility failed to ensure that licensed nurses and nurse aides possessed the necessary competencies to properly obtain and evaluate orthostatic hypotension in residents. The Director of Nursing (DON) and Assistant Administrator confirmed that annual competency evaluations specific to orthostatic hypotension monitoring were not conducted or documented for the staff, including LVNs and LPTs. The facility's policy defined orthostatic hypotension and required reporting significant changes to a physician, but there was no evidence that staff were trained or assessed on this procedure. Interviews with staff revealed a lack of knowledge regarding the correct parameters for orthostatic hypotension and inconsistent practices in monitoring and documentation. Medical record and facility document reviews showed multiple instances where residents had significant drops in blood pressure readings between sitting and standing positions, consistent with orthostatic hypotension, but these were not properly identified, documented, or reported. For example, one resident had a diastolic blood pressure drop of 19 mmHg, and another had a drop of 12 mmHg, yet there was no evidence of appropriate follow-up or physician notification. Additionally, medication administration records and change of condition logs indicated that blood pressure readings were sometimes recorded incorrectly or not compared as required by policy. Interviews with nursing staff further demonstrated gaps in knowledge and competency. Some staff were unable to state the correct criteria for orthostatic hypotension or the appropriate actions to take when significant changes were observed. Others relied on CNAs to obtain vital signs but did not verify or interpret the results according to policy. The DON acknowledged that staff had not been specifically trained or evaluated on orthostatic hypotension monitoring, and this lack of competency assessment was confirmed by the DSD and other administrative staff.
Medication Administration and Controlled Substance Documentation Deficiencies
Penalty
Summary
The facility failed to ensure accurate administration of medications and proper reconciliation and documentation of controlled substances. During a medication administration observation, a registered nurse did not administer the complete dose of a resident's docusate sodium, as significant residue was left in the medication cup after administration. The nurse acknowledged that if residue is observed, more applesauce should be added to ensure the full dose is given, which was not done in this instance. The Director of Nursing confirmed that all medications should be administered as ordered and that the complete dose should be given if residue remains. Additionally, the facility did not accurately reconcile and document controlled medications for a resident. Review of records showed discrepancies between the removal of controlled substances, such as alprazolam and morphine sulfate, and their documentation on the Medication Administration Record (MAR). For example, doses of morphine sulfate were removed at two different times, but only one administration was documented on the MAR. The Director of Nursing verified these discrepancies and acknowledged that the documentation did not match the removal records, indicating a failure in the facility's process for tracking and documenting controlled substances.
Medication Storage, Labeling, and Temperature Monitoring Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and separation of medications, as observed during an inspection of the medication room. Orally administered medications were stored together with externally used medications, such as suppositories and eye drops, without any physical separation. This was confirmed by staff present during the observation, who acknowledged that these medications should be stored separately to prevent errors in medication administration. Additionally, the facility did not consistently monitor and document the temperature of the refrigerator used to store medications requiring refrigeration, such as insulin pens and PPD test bottles. Although a daily monitoring sheet was present and the temperature was within the required range at the time of observation, there were missing temperature records for two consecutive days. Staff verified these omissions and acknowledged the requirement for daily temperature monitoring and documentation. The facility also failed to monitor the storage conditions of enteral formulas and oral nutritional supplements. Multiple bags and bottles of enteral formula and supplements were stored in a utility room without any temperature monitoring in place. The product provider's guidelines specify that these products should be stored at room temperature and not exposed to excessive heat or freezing. Staff confirmed the lack of temperature monitoring and verified the storage conditions at the time of inspection.
Multiple Sanitation and Food Safety Deficiencies Identified in Kitchen
Penalty
Summary
Surveyors identified multiple failures in the facility's kitchen related to food safety and sanitation. During an initial tour and interviews, it was observed that an opened bag of chicken nuggets in the walk-in refrigerator was not labeled or dated, and there was no box to identify when the bag was received or opened. The facility's policy required all food items in storage to be labeled and dated, and this was verified as a deficiency by staff. Additionally, the heated plate lowerator was found to be unclean, containing dirt, a fork, a foil, and later a spoon, with these findings confirmed by the Dietary Services Supervisor (DSS). The DSS stated that maintenance was responsible for cleaning and disassembling the lowerator monthly, but the equipment was not clean at the time of inspection. Further observations revealed a thick ice build-up on the interior plastic lining near the door of the walk-in freezer, which was verified by staff. The surveyors also found that the metal drainpipe under the dishwasher extended below the flood level rim and into the drainage inlet, lacking the required air gap for backflow prevention as outlined in both the FDA Food Code and the facility's own policy. These deficiencies were confirmed by both the DSS and the Maintenance/Housekeeping Director. The report notes that 91 of 98 residents received food prepared in the kitchen where these issues were identified.
Failure to Follow Policy for Storage and Handling of Food Brought by Visitors
Penalty
Summary
The facility failed to follow its own policies and procedures regarding the use and storage of food brought in by family members and visitors for residents. Observations and staff interviews revealed inconsistent practices and a lack of staff awareness about the facility's protocols for safe food handling of outside food. Specifically, staff provided conflicting information about where and how such food should be stored, with some indicating that food was kept in an unmonitored employee refrigerator, while others stated it was stored in a designated area in the kitchen. The employee refrigerator, which was not monitored for temperature or sanitation, was observed to have a temperature of 40 degrees F and visible rust on the freezer door. No resident food items were present in the refrigerator at the time of observation. Further interviews with nursing and dietary staff indicated a lack of training and documentation regarding the safe handling and storage of food from outside sources. Staff members were either unaware of the facility's policies or had not received specific training on the subject. The Director of Nursing and Dietary Services Supervisor were unable to provide evidence of any inservices or education provided to staff on this topic. These failures were identified through review of facility policies, staff interviews, and direct observation.
Failure to Implement Hand Hygiene Practices During Resident Care
Penalty
Summary
The facility failed to implement its infection prevention and control program as outlined in its policies and procedures, specifically regarding hand hygiene practices among staff during resident care. Certified Nursing Assistants (CNAs) were observed assisting multiple residents with meals without performing hand hygiene between residents. For example, one CNA assisted two residents with feeding at the same time, touching their bibs, and did not perform hand hygiene between assisting each resident. Similar observations were made with other CNAs who also failed to perform hand hygiene between assisting different residents during mealtime. Additionally, a Licensed Vocational Nurse (LVN) was observed administering oral medications to a resident, then preparing and administering a nebulizer treatment without performing hand hygiene between the two different routes of medication administration. The LVN handled the resident's bed controls and nebulizer equipment after administering oral medications, contrary to the facility's policy which requires hand hygiene before preparing and handling medications and after contact with objects in the resident's immediate vicinity. Interviews with the involved staff confirmed that hand hygiene was not performed as required by facility policy. The Director of Staff Development (DSD) and Director of Nursing (DON) both acknowledged that staff are expected to perform hand hygiene before and after assisting residents with meals and between different medication administration routes, but these practices were not followed during the observed incidents.
Failure to Obtain and Renew Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents and their responsible parties were fully informed and provided with appropriate, timely, and specific informed consent regarding the use of psychotropic medications. Multiple residents, including those with significant mental health diagnoses and those lacking capacity to make their own medical decisions, did not have their informed consents renewed every six months as required. In several cases, the consent forms did not specify the exact dose, frequency, or reasons for prescribing the medications, and the process for obtaining consent did not consistently involve direct communication between the prescribing physician and the resident's conservator or responsible party. For one resident with bipolar disorder, anxiety disorder, and substance use disorder, who had conservators for medical decisions, the medication consent form only listed medication names and dosage ranges, omitting the specific dose, frequency, and indications as required. The conservator confirmed that the physician did not directly contact them to obtain informed consent, and the process relied on faxed forms or verbal consent via nursing staff, without adequate explanation of the medications. The physician acknowledged that their signature on the consent form only verified the medication list and dosage range, not that informed consent had been properly obtained. Other residents, including those with no capacity to make decisions, were also affected. Informed consents for psychotropic medications such as risperidone, Lexapro, Belsomra, Seroquel, and Remeron were not renewed after six months, and facility policy and procedure documents had not been updated to reflect the new regulatory requirements for six-month renewals. Nursing staff and the DON confirmed that the required renewals had not occurred, and that the facility's tracking and policy review processes were insufficient to ensure compliance. These failures were identified through interviews, medical record reviews, and policy reviews, and were acknowledged by facility staff.
Failure to Develop Comprehensive Care Plans for Smokers and Roommate Disputes
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for all residents with identified needs. Specifically, care plans were not created for 23 residents in the TRC unit who were identified as smokers, despite documentation confirming their smoking status. Medical record reviews for these residents, including two specific examples, showed no care plan problems were initiated to address their smoking habits or the associated risks. The TRC Program Director confirmed that these care plans were missing during an interview and record review. Additionally, the facility did not develop care plans to address ongoing disputes between two residents regarding whether their shared room door should be open or closed. Documentation showed repeated arguments and incidents between the two residents, including loud altercations and complaints, but no care plan was initiated to address or manage these recurring issues. Interviews with staff and the TRC Program Director confirmed that the disputes were known and discussed among staff, but appropriate care planning was not completed.
Failure to Follow Posted Menu and Communicate Food Substitution
Penalty
Summary
The facility failed to follow its posted menu and recipes by serving mashed potatoes instead of roasted red potatoes to residents on regular-textured diets. This substitution was not communicated in advance to the residents, as required by facility policy. Review of facility documents showed that seven out of 52 residents on the SNF side were to receive regular-textured food, and the weekly menu specified roasted red potatoes for those on regular, NCS, and low fat/low cholesterol diets. During a trayline observation, it was confirmed that mashed potatoes were served instead, and the Dietary Services Supervisor (DSS) acknowledged that the menu should have been followed and the correct item served. The facility's policy requires that any deviations from the posted menu be documented with reasons for the change, but this was not done in this instance.
Failure to Provide Psychiatric Services as Ordered
Penalty
Summary
The facility failed to provide necessary psychiatric services as ordered by the physician for a resident diagnosed with senile dementia with psychosis. The resident was admitted to the facility with a physician's order for a psychiatric evaluation and treatment, which was not fulfilled. The medical record review revealed no documentation of the resident being scheduled or seen for the required psychiatric evaluation and treatment. Interviews conducted with the resident, an LVN, and the DON confirmed the deficiency. The resident stated they had not seen the psychiatrist, and the LVN verified that the psychiatric follow-up had not occurred. The DON acknowledged the oversight, confirming that the psychiatric evaluation and treatment were not conducted as ordered by the physician.
Failure to Complete Post-Fall Assessments for Residents
Penalty
Summary
The facility failed to complete post-fall assessments for two residents, leading to potential delays in identifying and responding to neurological changes after falls. Resident 4 experienced an unwitnessed fall on 6/10/24, where they were found with their knees and legs on the floor. Despite the facility's policy requiring neuro checks after such incidents, there was no documented evidence of these assessments being completed for Resident 4. Interviews with LVN 2 and LVN 1 confirmed that neuro checks should have been conducted every 15 minutes for one hour, then every 30 minutes for two hours, and every two hours for 24 hours, but this was not done. Similarly, Resident 5, who was at high risk for falls, had an unwitnessed fall on 7/5/24. The neuro check sheet for Resident 5 was incomplete, with missing assessments at 0930, 1130, and 1330 hours on 7/6/24. The DON confirmed that the neurological assessments, including vital signs, should have been completed and filed in the resident's medical record. The failure to complete these assessments for both residents was acknowledged by the DON, indicating a lapse in following the facility's post-fall assessment policy.
Sanitary Failures in Kitchen
Penalty
Summary
The facility failed to meet sanitary requirements in the kitchen, as evidenced by multiple observations and interviews. The heavy-duty blender used for puree preparation was not air-dried prior to use, contrary to the facility's policy and USDA Food Code 2022. Instead, it was dried using a paper towel, which the Dietary Supervisor acknowledged was incorrect and could lead to contamination. Additionally, the kitchen hood was found to have blackish dirt residue, indicating it had not been cleaned as frequently as required by the facility's policy and USDA guidelines. The Dietary Supervisor confirmed that the hood should be cleaned every three weeks by staff and every three months by an outside company, but the last service was in December 2023, well beyond the recommended interval. The ice machine used for residents and staff was also found to be in an unsanitary condition. The interior of the ice machine bin had yellowish/blackish residue, and the last recorded cleaning by dietary staff was in April 2024, with the maintenance staff last cleaning it in January 2024. The Maintenance Supervisor admitted uncertainty about the residue and confirmed that the ice was not safe for use. Furthermore, the cutting boards in the kitchen were heavily marred with deep grooves, making them difficult to clean and sanitize, as required by the USDA Food Code 2022. The Dietary Supervisor acknowledged that these cutting boards should have been replaced to prevent bacterial contamination. Several kitchen utensils were found to be in poor condition and not clean. Four rubber spatulas were cracked and chipped, and other utensils like stainless spatulas and a basting brush were partially melted and worn off. The Dietary Supervisor confirmed that these utensils were unsafe for use and should have been replaced. Additionally, multiple scoops and a peeler were observed with dry, crusted food residue, indicating they had not been properly washed after use. The Dietary Supervisor verified these findings, acknowledging that the utensils should have been cleaned to prevent contamination.
Infection Control Program Deficiencies
Penalty
Summary
The facility failed to maintain its infection control program, which is designed to prevent the development and transmission of diseases and infections. Specifically, the facility did not implement its infection control surveillance program for January through March 2024. The Infection Preventionist (IP) was responsible for conducting surveillance of residents' infections using the McGeer's Criteria. However, the Monthly Antimicrobial/Infection Control Surveillance forms for several residents were inaccurately documented, failing to classify infections as community-acquired (CAI) or healthcare-associated infections (HAI) and incorrectly stating that antibiotic use met McGeer's criteria. This led to inaccurate monthly and quarterly infection surveillance reports, as verified by the IP during the review process. For example, Resident 72's form did not classify the infection, and the criteria for a urinary tract infection (UTI) were not met, among other similar discrepancies for other residents. The facility also failed to maintain proper infection control practices in the laundry room area. During an inspection, it was observed that soiled and clean linens were not stored separately, and items such as slings, socks, and blankets were improperly placed, posing a risk of cross-contamination. The Laundry Supervisor confirmed these findings. Additionally, crates containing residents' shoes and clothing were stored on the floor, and a bottle of lotion was found with folded pillowcases in the clean laundry area, further indicating lapses in maintaining a sanitary environment. Furthermore, the facility did not ensure that staff performed proper hand hygiene during medication administration. Two Licensed Vocational Nurses (LVNs) were observed failing to perform hand hygiene after touching contaminated surfaces and before administering medications. One LVN touched a trash bin lid and then handled a resident's insulin pen injector without washing hands, while another LVN had long fingernails and did not perform hand hygiene between touching a resident and administering medications. These actions were verified by the LVNs themselves, highlighting a significant breach in infection control practices as per the facility's policies and procedures.
Failure to Offer PCV15/PCV20 Immunizations
Penalty
Summary
The facility failed to offer PCV15/PCV20 immunizations to 11 of 19 sampled residents and 47 nonsampled residents in accordance with CDC recommendations. This failure was identified through interviews, medical record reviews, and facility policy and procedure reviews. The facility's policy stated that all residents should be offered pneumococcal vaccines upon admission, but this was not consistently followed. The Infection Preventionist (IP) admitted that the pneumococcal vaccine was always offered upon admission, but the type of vaccine administered depended on the physician's order. The IP also mentioned that she had started using the California Immunization Registry (CAIR) to track residents' immunizations only four months ago. Despite this, the residents' immunization reports did not show records of the pneumococcal vaccination, and the IP confirmed that she did not offer PCV15 or PCV20 to residents who had never received any pneumococcal vaccine. Further review of the residents' medical records showed that the facility did not offer a dose of PCV15 or PCV20 a year after residents received PPSV23, as per CDC guidelines. The IP verified these findings and stated that she only offered what was ordered by the physician. She was not aware of the current CDC guidelines for pneumococcal vaccines, leading to the deficiency in offering the appropriate vaccines to the residents.
Failure to Ensure Timely Level II Mental Health Evaluation
Penalty
Summary
The facility failed to ensure a timely Level II Mental Health Evaluation for a resident with suspected mental illness. The initial Level 1 PASRR screening conducted on 3/20/23 indicated the need for a Level II evaluation, but the resident was unavailable due to isolation for health and safety reasons. Despite the requirement to submit a new Level 1 screening after the isolation period, the facility did not conduct another Level 1 PASRR screening until 3/29/24, approximately a year later. This delay resulted in the resident not receiving the necessary Level II evaluation and the accompanying specialized services until 4/3/24. The Director of Nursing (DON) confirmed that the initial positive Level 1 screening required a Level II evaluation, which was not performed due to the resident's isolation. The DON also verified that the facility failed to conduct another Level 1 PASRR screening for over a year, leading to a significant delay in the resident receiving the required mental health evaluation and specialized services. This oversight posed a risk of failing to incorporate the recommendations from the PASRR Level II determination into the resident's care plan and transition of care.
Deficiencies in Hospice Coordination, Medication Administration, and Fall Risk Assessment
Penalty
Summary
The facility failed to coordinate the care of a resident with the contracted hospice provider. The hospice calendar and sign-in/out forms did not show complete skilled nursing and CHHA visits as per the physician's orders. Additionally, the nursing clinical notes and hospice aide notes were not updated, which was verified by the LVN, Social Services Director, and DON. These failures had the potential for the resident to not receive appropriate hospice care and services. The facility did not ensure that a resident's medication order for Lantus solution was administered per the physician's order. The MAR for May showed that the Lantus solution dose for a specific date was not administered or documented as held for any reason. The DON verified that the insulin was not administered as ordered, posing a risk for the resident to have a hyperglycemic episode and to receive unnecessary short-acting insulin doses. The facility also failed to complete a fall risk assessment after a resident had an unwitnessed fall and was transferred to the acute care hospital for evaluation. The resident's medical record did not show a completed Fall & Skin Risk Summary after the fall, which was confirmed by the LVN and DON. The facility's P&P required a fall risk assessment to be done within 24 hours of a fall, but this was not completed, posing a risk of not receiving immediate care based on the evaluation.
Failure to Attempt Alternatives Before Using Bed Rails
Penalty
Summary
The facility failed to ensure that alternatives were attempted before using elevated side rails for Resident 20, who was at risk for entrapment and serious injury. The FDA has issued a Safety Alert regarding entrapment hazards with hospital bed side rails, particularly for frail or elderly residents or those with conditions that may cause them to move about the bed. The facility's policy requires that alternatives to bed rails be attempted and documented before their use, but this was not done for Resident 20. Resident 20, who had limited physical mobility, impaired cognition, and a high risk for falls, was observed using an elevated side rail during ADL care and repositioning. However, a review of the medical record showed no documented evidence that alternatives were attempted before the use of the elevated side rail. Interviews with facility staff confirmed that alternatives were not tried prior to the implementation of the side rail for Resident 20.
Failure to Ensure RN Coverage for Required Hours
Penalty
Summary
The facility failed to have a registered nurse (RN) on duty for at least eight consecutive hours a day, as required. This deficiency was identified through interviews and document reviews. The facility's Nursing Sign-in sheets and Employee Time Cards for October and November 2023 showed multiple instances where RNs did not work the required eight hours. For example, on several dates, the sign-in sheets indicated that an RN worked eight hours, but the actual hours worked were less, ranging from 6.17 to 7.75 hours. The Social Worker and the receptionist confirmed that the hours recorded on the sign-in sheets did not match the actual hours worked by the RNs. The receptionist admitted to entering eight hours for RNs based on instructions from the Director of Staff Development (DSD) or Director of Nursing (DON), even when the RNs did not work the full eight hours. The Administrator confirmed that the facility did not have an RN staffing waiver and acknowledged the discrepancy in RN hours. The Administrator also mentioned that the facility did not have a Skilled Nursing Facility (SNF) DON at the time and that the Transitional Care (TRC) DON was on duty since the facility had less than 120 beds. The Social Worker, who was responsible for submitting the staffing report, did not review the actual RN hours worked and relied on the receptionist to enter the hours. This failure to ensure that an RN was on duty for the required hours has the potential to impact the clinical needs of the residents, either directly or indirectly through the oversight of licensed nurses.
Discrepancies in Documentation and Handling of Discontinued Controlled Medications
Penalty
Summary
The facility failed to provide the necessary pharmacy services to meet the needs of the residents, as evidenced by discrepancies in the documentation and handling of discontinued controlled medications. During an observation and interview with the SNF DON, it was found that the quantities documented for discontinued controlled medications did not match the actual quantities in the medication bubble packs or bottles. Specifically, discrepancies were noted in the quantities of lorazepam, alprazolam, and morphine sulfate for three residents. Additionally, one resident's lorazepam was not documented on the Discontinued Controlled Drug Log sheet. The SNF DON acknowledged these findings and attributed the errors to not wearing eyeglasses while documenting the quantities. Similarly, an observation and interview with the TRC DON revealed that two discontinued controlled medications were not documented on the Discontinued Controlled Drug Log sheet. The medications in question were clonazepam and lorazepam for two residents. The TRC DON admitted to forgetting to add these medications to the log sheet. Both the Administrator and the respective DONs were informed of and acknowledged these findings, which had the potential for drug diversion.
Failure to Monitor Medication Parameters
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications. Specifically, Resident 18 was administered Norvasc, a medication used to treat high blood pressure, despite the resident's pulse rate being below the parameter prescribed by the physician. The medical record review showed that the physician's order required Norvasc to be held if the pulse rate was less than 60 beats per minute. However, on 5/10/24, Norvasc was administered when Resident 18's pulse rate was 56 beats per minute. This was verified by the Director of Nursing (DON) during a concurrent interview and medical record review on 5/22/24. Resident 18 had no capacity to understand and make decisions, as noted in the history and physical examination dated 1/18/24.
Failure to Monitor Psychotropic Medication Use and Document Behavioral Summaries
Penalty
Summary
The facility failed to ensure that three residents were free from unnecessary psychotropic medications. Specifically, Residents 3 and 54 were not properly monitored for orthostatic blood pressures as ordered by their physicians while on Seroquel. The medical records showed that the orthostatic blood pressure readings were either incomplete or inaccurately recorded, with only the systolic blood pressure being noted. This was confirmed by an LVN and the SNF DON, who acknowledged the importance of accurate monitoring due to the potential for hypotension caused by the medications. Additionally, the facility did not complete the required monthly behavior summaries for Resident 18, who was on multiple psychotropic medications including Abilify, Seroquel, Zyprexa, Lithium carbonate, Buspar, and Prozac. The monthly summaries, which are essential for assessing the need for gradual dose reductions, were last completed in March 2024. This lapse was confirmed by both an LPT and the DON, who stated that the summaries should be updated monthly to assess the resident's behaviors. These deficiencies indicate a failure to adhere to the facility's policies and procedures regarding the monitoring and documentation of psychotropic medication use. The lack of proper monitoring and documentation had the potential to result in adverse consequences for the residents involved.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure the medications were safely and securely stored, leading to several deficiencies. Resident 32's insulin pen was not properly labeled, with a gray stain making the label hard to read. Additionally, the insulin pen was left unattended near the foot of the resident's bed while the LVN went to the restroom, despite the LVN claiming she could see it from the mirror. This compromised the safe storage of the medication and posed a risk of unauthorized access or misuse. For Resident 53, the facility failed to ensure that the staff reported to the licensed nurse when the resident's medicated patch came off. The CNA admitted to throwing the Exelon patch in the trash without informing her supervisor, citing being busy as the reason. This lack of communication could lead to improper medication administration and affect the resident's treatment for dementia. The facility also failed to maintain the medication storage areas properly. An inspection of the medication room revealed expired containers of Sani-Hands sanitizing wipes, which should not have been stored there. Additionally, a medication cart was found unlocked and unattended in a hallway, accessible to residents and staff passing by. These lapses in securing medication storage areas and ensuring the proper labeling and reporting of medication issues highlight significant deficiencies in the facility's medication management practices.
Failure to Complete Ordered TSH Blood Test
Penalty
Summary
The facility failed to ensure that a TSH blood test was completed for Resident 18 as ordered by the physician. The facility's policy and procedure (P&P) titled Lab and Diagnostic Test Results - Clinical Protocol, revised in September 2012, mandates that the physician will identify and order diagnostic and lab testing based on diagnostic and monitoring needs, and the staff will process test requisitions and arrange for tests. Resident 18, who had no capacity to understand and make decisions, was admitted and readmitted to the facility on unspecified dates. A physician's order dated January 11, 2024, required a TSH laboratory test to be completed every three months. However, a review of Resident 18's medical record on May 22, 2024, revealed that the laboratory blood test result for the TSH level, which was due in April 2024, was missing. The Director of Nursing (DON) confirmed that the TSH test was not completed as ordered.
Incomplete Medical Records for Two Residents
Penalty
Summary
The facility failed to ensure the medical record was accurately maintained for two residents. Resident 40 was transferred to an acute care hospital due to shortness of breath, but the medical record did not document the change of condition that necessitated the transfer. An interview with the LVN assigned to Resident 40 confirmed that the change of condition was not documented at the time of the transfer. Resident 20's medical record was also found to be incomplete. The POLST form for Resident 20 did not include documentation regarding whether the resident had formulated an advance directive. The Director of Nursing verified this omission during a concurrent medical record review and interview.
What surveyors are citing around you — mapped
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What surveyors actually found near you
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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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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Westminster
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mission Palms Healthcare Center | 0.6 mi | ★★★★★ | 23 | 0 |
| Garden Grove Post Acute | 1.4 mi | ★★★★★ | 23 | 0 |
| Rowntree Gardens | 1.7 mi | ★★★★★ | 20 | 0 |
| Stanley Healthcare Center | 1.8 mi | ★★★★★ | 22 | 0 |
| Park Anaheim Healthcare Center | 3.9 mi | ★★★★★ | 28 | 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 August 2026) and official state health department websites.