Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Fidelity Health Care during CMS and state inspections, most recent first.
A resident with dementia, major depressive disorder, and schizophrenia, assessed as high fall risk with impaired cognition and needing supervision or assistance for transfers and walking, was care planned for close monitoring of location and a safe environment. Despite this, the resident was observed by a family member walking alone in a hallway without staff present, and a CNA did not immediately intervene when notified. Staff interviews revealed that monitoring was based on intermittent checks rather than continuous observation, that one CNA was covering another’s break and could not see all residents, and that staff were not yet fully familiar with the new resident’s needs, contrary to the facility’s fall prevention policy requiring close monitoring of at-risk residents.
A resident with chronic pain syndrome, intact cognition, and independence in daily activities was transferred to a general acute care hospital for pain based on a physician order and documented in progress notes. However, the nurse responsible for the transfer did not complete a Notice of Proposed Transfer/Discharge (NPTD), and the LTC Ombudsman was not notified. During interviews, an LVN, RN, and the DON all acknowledged that facility practice and written policy required completion of an NPTD to inform the resident of the transfer destination and reason, and that this notice should be placed in the medical record and provided to the resident and, if known, a family member or representative.
Two residents with intact cognition and complex medical histories were involved in ongoing verbal and emotional abuse, with one resident repeatedly using derogatory language toward the other. Despite staff awareness and social services intervention, the situation escalated to a physical altercation, resulting in one resident being choked and punched, and sustaining a neck injury. The facility failed to prevent or adequately address the abusive behaviors, leading to a deficiency in protecting residents from abuse.
Two residents with severe cognitive and physical impairments were assisted with eating by CNAs who stood over them rather than sitting at eye level, contrary to facility policy and staff training. This practice failed to honor the residents' right to dignity and proper engagement during mealtime.
Surveyors found that kitchen staff failed to label opened food items with the date opened, did not use pasteurized eggs as required for certain dishes, stored clean dishware and kitchenware uncovered and face up, and did not consistently wear hair restraints in food preparation and dishwashing areas. These actions were not in accordance with the facility's policies and professional standards for food safety.
Staff did not change a resident's nasal cannula for oxygen therapy weekly as required, and personal toiletry items for multiple residents sharing a restroom were found unlabeled and improperly stored, contrary to infection control policies. These lapses were confirmed by staff interviews and policy review.
A resident with severe cognitive impairment and a high risk for falls was found with their call light inaccessible, as it was stuck behind personal belongings. Staff confirmed the resident could not reach the call light, despite care plan and facility policy requiring it to be within reach to ensure timely assistance.
A resident with COPD and diabetes was admitted without a properly completed Advance Directive Acknowledgement (ADA) form. The ADA form lacked documentation of whether the resident had executed an advance directive, was missing a date, and did not have the facility's signature, contrary to facility policy requiring completion within seven days of admission.
A resident with significant care needs was admitted under hospice services, but the facility did not assign a staff member to coordinate with hospice representatives. As a result, scheduled visits by a CHHA could not be verified, and the DON confirmed there was no policy or procedure for assigning responsibility for hospice coordination, leading to uncertainty about whether the resident received necessary hospice care.
A resident with moderately impaired cognition and multiple diagnoses was found to have a bedside electric fan with dust and lint accumulation. An LVN confirmed the fan's unclean condition, and the DON stated that housekeeping is responsible for keeping equipment clean to prevent respiratory issues. Facility policy requires regular housekeeping and maintenance of resident equipment.
The facility failed to follow its policies for screening potential employees for abuse history. The Director of Staff Development did not obtain adequate reference checks for four CNAs, often relying on personal knowledge instead of contacting previous employers. This practice did not comply with the facility's policy, which required at least two reference checks to uncover any past criminal prosecutions or allegations of abuse.
A resident with cognitive impairment was verbally and physically abused by another resident with a history of aggressive behavior. The incident occurred when the assigned CNA left the aggressive resident unattended, contrary to the facility's one-to-one monitoring policy. This lapse in supervision allowed the aggressive resident to scratch and yell at the other resident, resulting in an open cut on the hand.
A facility failed to report an allegation of abuse within the required two-hour timeframe. A resident reported being hit by another resident, but the Social Services Assistant did not inform anyone about the allegation, violating the facility's policy. The reporting failure involved a cognitively intact resident and another resident with schizophrenia. Staff interviews confirmed the importance of timely reporting to prevent further abuse.
The facility failed to submit the Payroll Based Journal (PBJ) staffing data report for the first quarter of 2023, resulting in a one-star staffing rating. Interviews revealed no records of proof indicating the previous Business Office Manager submitted the PBJ data, and the Administrator confirmed the absence of official records. Handwritten notes were found but were not considered official.
The facility failed to ensure call lights were within reach for two residents, leading to potential delays in care and increased fall risk. One resident's bathroom lacked a call light cord, while another's call light was stuck behind a roommate's walker. Both residents had high fall risk and required call lights within reach as per their care plans and facility policy.
The facility failed to supervise two residents adequately, leading to potential safety hazards. One resident with a history of wandering was not provided specific interventions, while another high-risk resident was left unattended multiple times despite requiring continuous one-to-one monitoring.
The facility failed to administer Depakote ER as ordered by splitting the tablet, and did not follow its policy for medication destruction by having an Activity Assistant, supervised by only one licensed nurse, dispose of medications.
The facility failed to monitor and provide a Gradual Dose Reduction (GDR) for two residents, leading to the potential use of unnecessary psychotropic medications. For one resident, a GDR was not completed for Trazodone, and no clinical rationale was documented. For another resident, behaviors related to the use of Zyprexa were not monitored during specific night shifts, contrary to the care plan and facility policy.
The facility failed to discard six glasses of expired milk found in the kitchen refrigerator. The Dietary Supervisor acknowledged that the milk was outdated and should have been removed to prevent food-borne illnesses. The facility's policy indicated that poured beverages should be labeled, dated, and discarded at the end of the day.
The facility failed to follow infection control policies by not ensuring a CNA wore PPE before entering a contact isolation room for a resident with MRSA and by allowing food to be stored in the medication storage room. The CNA entered the resident's room without PPE, and a box of doughnuts was found in the medication room, both actions contrary to the facility's policies.
A resident with COPD, epilepsy, and dementia did not have the privacy curtain closed while a Licensed Vocational Nurse checked the gastrostomy tube site, exposing the resident's abdominal area. This action violated the facility's policy on providing privacy during ADLs and the resident's care plan. The Director of Nursing confirmed the need for the privacy curtain to be closed to maintain the resident's dignity and privacy.
The facility failed to develop a care plan for a resident with dementia, schizophrenia, and anxiety who exhibited wandering behavior by entering other residents' rooms. Despite multiple reports and observations, no care plan addressed the resident's wandering, contrary to facility policy.
The facility failed to conduct an IDT care planning conference for a resident with type 2 diabetes mellitus and anemia within the required timeframe. The DON confirmed that the conference was missed, and an empty form was found in the resident's medical record. This failure had the potential to delay appropriate care and treatment for the resident.
The facility failed to monitor a resident with Parkinson's disease and osteoarthritis during mealtime as required by the care plan, leading to food spillage and potential nutritional deficiencies. Despite observed increased hand tremors, there were no records of assessments or notifications to the medical doctor or occupational therapist.
The facility failed to implement the intervention on a resident's care plan for turning and repositioning every 2 hours, despite the resident's risk for skin breakdown due to impaired mobility and incontinence. Observations showed the resident remained in the same position for extended periods, contrary to the care plan and Resident Positioning Log.
A resident's nasal cannula tubing was observed touching a trash bin, contrary to the facility's Infection Control Policy: Oxygen Use. The resident had COPD and heart failure, and the observation was confirmed by an LVN and the DON, who both acknowledged the risk of infection and cross-contamination.
Failure to Adequately Supervise High Fall-Risk Resident During Ambulation
Penalty
Summary
The facility failed to provide adequate supervision to prevent falls for a newly admitted resident who was identified as high risk for falls and injuries. The resident was admitted with dementia, major depressive disorder, and schizophrenia, and was care planned on admission as being at high risk for injury, accidents, and falls, with interventions including maintaining a safe, hazard-free environment, keeping the bed in low position with bilateral floor mats, and monitoring the resident’s location as often as possible. The resident’s MDS showed moderately impaired cognitive skills for daily decision-making and a need for partial/moderate assistance with ADLs, as well as supervision or touching assistance for transfers and walking. A Fall Risk Evaluation documented intermittent confusion, balance and gait problems, decreased muscular coordination, use of assistive devices, and three or more predisposing diseases, with a total score of 20, indicating high fall risk. Despite these identified risks and care plan interventions, the resident was observed by a family member walking alone in the hallway without staff supervision, and no staff were present in the immediate area monitoring the resident. The family member reported having to search for staff and, upon informing a CNA that the resident was walking alone, the CNA did not immediately intervene. CNA2 later stated that on the date in question, she was covering another CNA’s break in the dining area and was unable to visually observe all residents, and did not see the resident ambulating in the hallway. RN1 explained that resident monitoring was done through frequent checks and staff awareness rather than continuous observation, and noted that the resident was new and staff might not have been fully familiar with the resident’s needs. The DON stated that staff were expected to follow care plans and provide monitoring, and confirmed that the resident was alert but confused, ambulatory, and required assistance with walking. The facility’s fall prevention policy required close monitoring and observation of at-risk residents for ambulation and transfer attempts with supervision and assistance as needed, which was not implemented for this resident at the time of the incident.
Failure to Complete Transfer/Discharge Notice and Notify Ombudsman for Hospital Transfer
Penalty
Summary
The facility failed to complete a Notice of Proposed Transfer/Discharge (NPTD) and failed to notify the long-term care Ombudsman when a resident was transferred to a general acute care hospital. The resident had been initially admitted with chronic pain syndrome and, per a history and physical dated several months prior, had the capacity to understand and make decisions. A subsequent MDS indicated the resident had intact cognition and was independent with daily activities and mobility. On the date of transfer, a physician order directed that the resident be transferred to another general acute care hospital via paramedics, and progress notes documented that the resident was transferred for pain. Interviews and record review showed that no NPTD was completed or filed in the resident’s medical record for this transfer. An LVN stated that the nurse who discharged the resident should have completed an NPTD during the transfer process. The DON confirmed that an NPTD could not be found in the resident’s record and stated that the NPTD should have been completed and maintained in the record. An RN explained that the NPTD’s purpose was to inform the resident of the transfer destination and the reason for the transfer, and that it was the facility’s practice to place the NPTD in the medical record as proof of completion. The facility’s policy on Proposed Transfer and Discharge Notice required that written notice be provided to the resident and, if known, a family member or representative, stating the reasons for the transfer or discharge as soon as practicable before it occurred.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from verbal, mental (emotional), and physical abuse, as evidenced by incidents involving two residents. One resident, with a history of chronic obstructive pulmonary disease, atrial fibrillation, and diabetes, was described as having intact cognition and independence in daily activities. This resident was subjected to physical abuse when another resident, who also had intact cognition and a history of intervertebral disc degeneration, osteoarthritis, COPD, and diabetes, became physically aggressive. The aggressive resident stood up from a wheelchair, grabbed the first resident by the neck, choked, and punched them in the stomach. This altercation was witnessed by staff, who observed the physical contact and subsequent injury, including a scratch on the neck that required treatment. The report also documents ongoing verbal and emotional abuse between the two residents. The aggressive resident reported being repeatedly called derogatory names, such as "crack head," by the other resident over the course of a year, despite having asked for the behavior to stop and social services having intervened multiple times. Staff interviews confirmed that the resident who was physically assaulted had a pattern of teasing and using inappropriate language toward other residents, which was recognized as verbal abuse by both nursing and administrative staff. The facility's policy defined such behavior as abuse, including the use of disparaging or derogatory language. Despite documented behavioral issues and ongoing conflict between the two residents, the facility did not prevent the escalation to physical violence or adequately protect the residents from continued verbal and emotional abuse. Staff were aware of the problematic interactions, and interventions by social services had occurred, but the abusive behaviors persisted, culminating in a physical altercation that resulted in injury. The facility's failure to prevent these incidents constituted a deficiency in protecting residents' rights to be free from all forms of abuse.
Failure to Maintain Resident Dignity During Mealtime Assistance
Penalty
Summary
Certified Nursing Assistants (CNAs) failed to treat two residents with dignity during mealtime assistance. For one resident with Parkinson's disease, dementia, and severely impaired cognitive skills, a CNA was observed feeding the resident while standing over the bed, with the resident's head at the CNA's waist level. The resident was in a high Fowler's position and required assistance with meals as documented in the care plan. Facility staff, including another CNA and the Director of Nursing (DON), confirmed that proper feeding technique requires staff to be seated at eye level with the resident to ensure comfort and engagement. Facility policy also specifies that feeding should be conducted in a patient, respectful, and dignified manner. A second resident, diagnosed with dementia, hemiplegia, and hemiparesis, was also observed being fed by a CNA who was standing at the bedside. This resident had severely impaired cognition and required partial to full assistance with eating and other activities of daily living. Interviews with staff and review of facility policy confirmed that staff should sit at eye level with residents during feeding to promote engagement and maintain a calm, pleasant dining environment. The observed actions were inconsistent with both facility policy and staff training, resulting in a failure to honor the residents' right to dignity during mealtime.
Failure to Follow Safe Food Handling, Storage, and Hygiene Practices in Kitchen
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen to adhere to safe food handling and storage practices as outlined in the facility's own policies and professional standards. Specifically, opened boxes of frozen pineapple sherbet and strawberry ice cream in Freezer 2 were marked only with a received date and not labeled with an opened date, contrary to posted signage and policy requirements. In the walk-in refrigerator, a 36-count of white eggs was stored on top of a box of 150 eggs with no indication that the eggs were pasteurized, despite the facility's policy requiring the use of pasteurized eggs for dishes requiring raw or undercooked eggs. The Dietary Supervisor confirmed that pasteurized eggs should be used to prevent foodborne illness, especially given the vulnerability of the elderly population served. Additionally, clean dishware and kitchenware were stored face up and uncovered on shelves and utility carts, rather than being stored upside down or covered as required to prevent contamination. Staff were also observed in the kitchen and dishwashing areas without wearing required hair restraints, with one staff member handling her hair while in the dishwashing station. The Dietary Supervisor acknowledged that hair restraints are mandatory upon entering the kitchen and that the facility provides hairnets at the kitchen door. Review of facility policies confirmed the requirements for labeling opened food, using pasteurized eggs, storing kitchenware in a sanitary manner, and mandatory use of hair restraints in food service areas.
Failure to Follow Infection Control Protocols for Oxygen Equipment and Personal Toiletries
Penalty
Summary
The facility failed to implement infection control guidelines in two key areas. First, a resident with chronic obstructive pulmonary disease (COPD) and diabetes mellitus was observed using a nasal cannula (NC) for oxygen therapy that had not been changed weekly as required. The NC bag was dated nearly a month prior to the observation, and both the Licensed Vocational Nurse and the Infection Preventionist Nurse confirmed that the NC should be changed weekly to prevent bacterial accumulation, in accordance with facility policy. The resident's medical records indicated an active order for oxygen via NC as needed for respiratory symptoms and comfort. Second, the facility did not ensure that personal toiletry items were properly labeled and stored for several residents sharing a restroom. During an observation, an unlabeled, opened bottle of moisturizing shampoo and body wash was found on the window sill of a shared restroom accessible by six residents with varying degrees of cognitive impairment and assistance needs. The Certified Nursing Assistant and Infection Preventionist Nurse both stated that personal toiletries should be labeled and stored at the resident's bedside or in their drawer to prevent cross-contamination, as outlined in the facility's policies on personal hygiene items and infection control. These failures were identified through observation, interviews with staff, and review of facility policies and resident records. The deficiencies had the potential to contribute to the spread of infection within the facility, as personal care items were not managed according to established infection prevention protocols.
Call Light Not Within Reach for High-Risk Resident
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, as required by the resident's care plan and facility policy. During an observation, the call light was found stuck behind the resident's personal belongings, making it inaccessible. Certified Nurse Assistant 3 confirmed that the resident would not be able to find or reach the call light in its current position. The resident was assessed as high risk for falls and had severely impaired cognition, requiring significant assistance with daily activities. The resident's care plan specifically directed staff to keep the call light within reach and to answer it promptly, given the resident's history of attempting to get out of bed unassisted. The Director of Nursing also stated that the call light should be placed next to the resident's strong arm and hand to allow the resident to call for assistance. Facility policy further required that call lights be within reach when residents are in their rooms. These requirements were not met at the time of the surveyor's observation.
Failure to Complete Advance Directive Acknowledgement on Admission
Penalty
Summary
The facility failed to implement its policy and procedure regarding advance directives for one resident. Upon admission, the required Advance Directive Acknowledgement (ADA) form for this resident was not properly completed. Specifically, the ADA form did not indicate whether the resident had executed an advance directive, was missing a date for the resident's signature, and lacked the facility's signature. The facility's policy requires that ADA forms be completed within seven days of admission by the Social Services Director or designee. The resident involved had diagnoses including chronic obstructive pulmonary disease (COPD) and diabetes mellitus, and was assessed as having intact cognition and requiring some assistance with activities of daily living. During an interview, the Social Service Director confirmed that the ADA form was incomplete and stated that the resident had not executed an advance directive. The incomplete documentation meant that staff would not have clear information about the resident's care and treatment preferences in the event of an emergency.
Failure to Designate Staff for Hospice Coordination
Penalty
Summary
The facility failed to designate a member of its Interdisciplinary Team (IDT) to coordinate care with hospice representatives for a resident who was receiving hospice services. The resident, who had diagnoses including adult failure to thrive and rhabdomyolysis, required substantial to maximal assistance for personal hygiene and dressing, and had unclear speech with limited ability to communicate. The resident was readmitted to the facility under hospice care, and hospice visitation schedules indicated that a Certified Home Health Aide (CHHA) was supposed to visit on specific dates. However, a review of the hospice staff sign-in logs showed no evidence that the CHHA signed in or provided care on the scheduled dates. The Director of Nursing (DON) confirmed that there was no designated staff member responsible for coordinating with hospice staff or monitoring their scheduled visits. Additionally, the facility lacked a policy or procedure for assigning a staff member to coordinate hospice services, resulting in an inability to verify whether the resident received the necessary hospice care as scheduled.
Unsanitary Electric Fan in Resident Room
Penalty
Summary
A deficiency was identified when an electric fan in a resident's room was found to be in an unsanitary condition. During an observation and interview, a black standing fan at the resident's bedside was noted to have dust on the blades and lint on the cover. The Licensed Vocational Nurse present acknowledged that the fan was not clean and stated that the resident could potentially inhale the dust and lint. The resident in question had moderately impaired cognition and required assistance with showering and personal hygiene, as documented in their Minimum Data Set. The resident's medical history included hypertension, anxiety, and osteoarthritis. Further interviews revealed that the Director of Nursing expected housekeeping staff to keep all equipment in residents' rooms clean and in good working condition to prevent respiratory-related illnesses. A review of the facility's Homelike Environment Policy indicated that regular housekeeping and maintenance should be provided while preserving residents' personal touches. The failure to maintain the fan in a clean and sanitary condition constituted a deficiency in ensuring a safe, clean, and comfortable environment for the resident.
Failure to Implement Employee Screening Policies
Penalty
Summary
The facility failed to implement its written policies and procedures for screening potential employees for a history of abuse, neglect, exploitation, or misappropriation of property. Specifically, the facility did not obtain information from previous employers for four sampled Certified Nursing Assistants (CNAs). The Director of Staff Development (DSD) was responsible for conducting reference checks but only contacted the most recent employer and sometimes used personal knowledge as a second reference. This practice did not align with the facility's policy, which required at least two reference checks from current and previous employers. During interviews and record reviews, it was revealed that the DSD often did not document attempts to contact references, making it difficult to verify the thoroughness of the screening process. The facility's policy, titled Patient Abuse Prevention, required informing previous employers of the intention to uncover any past criminal prosecutions or allegations of abuse. The Administrator confirmed that the DSD was responsible for this screening process and acknowledged the failure to adhere to the policy, which had the potential to expose residents to abuse, neglect, exploitation, or misappropriation of property.
Failure to Prevent Resident-to-Resident Abuse Due to Inadequate Supervision
Penalty
Summary
The facility failed to protect Resident 1 from verbal and physical abuse by Resident 2, as per the facility's Abuse Prevention policy. Resident 1, who was readmitted to the facility with multiple diagnoses including osteoarthritis and anxiety, was involved in an altercation with Resident 2. Resident 1, who had moderate cognitive impairment and required assistance with daily activities, was scratched on the right hand by Resident 2, resulting in an open cut. The incident occurred after a verbal disagreement over the room light, and later, Resident 2 approached Resident 1, yelled, and hit them on the hand. Resident 2, who was diagnosed with schizophrenia and depression, had a history of aggressive behavior and was under orders for one-to-one monitoring due to these tendencies. However, on the day of the incident, the assigned CNA left Resident 2 unattended to use the restroom without informing another staff member, leaving Resident 2 unsupervised. This lapse in supervision allowed Resident 2 to engage in the altercation with Resident 1, which was not immediately addressed by staff. The facility's policies on Abuse Prevention and One-on-One Monitoring were not adhered to, as continuous supervision was not maintained for Resident 2. The Director of Nursing acknowledged that the CNA should have informed another staff member before leaving Resident 2 unattended. The lack of adherence to the monitoring policy and the absence of staff during the incident contributed to the failure to prevent the abuse of Resident 1 by Resident 2.
Failure to Report Alleged Abuse Within Required Timeframe
Penalty
Summary
The facility failed to report an allegation of abuse within the required two-hour timeframe as per their policy and procedure titled 'Abuse Prevention.' On March 6, 2025, a resident reported to the Social Services Assistant (SSA) that another resident had hit them. Despite the report, the SSA did not inform anyone about the allegation, which was a violation of the facility's policy and legal requirements. The SSA acknowledged the importance of reporting such incidents to prevent further abuse and to determine the facts of the situation. The deficiency involved two residents: one who reported being hit and another who was accused of hitting. The resident who reported the incident was cognitively intact and capable of making decisions, while the accused resident had a diagnosis of schizophrenia and was moderately cognitively impaired. Interviews with various staff members, including the Director of Staff Development and the Administrator, confirmed that all staff were mandated reporters and that any allegations of abuse should be reported within two hours to the appropriate authorities, including the Department of Health and the LTC Ombudsman.
Failure to Submit PBJ Staffing Data Report
Penalty
Summary
The facility failed to ensure that the Payroll Based Journal (PBJ) staffing data report was submitted quarterly as required by the Centers for Medicare and Medicaid Services (CMS) for the first quarter of 2023. During a review of the facility's Certification and Survey Provider Enhanced Reports (CASPER) 1705D, it was found that the PBJ Staffing Data Report indicated a failure to submit data, resulting in a one-star staffing rating. Interviews with the Payroll Human Resources (PHR) and the Business Office Manager (BOM) revealed that there were no records of proof indicating the previous BOM submitted the PBJ data for the specified period. Handwritten notes were found, but no official records of data submission to CMS were available. The Administrator (ADM) confirmed that the facility had no records of proof of submission of PBJ data and no records that CMS received them for the first quarter of 2023. The ADM acknowledged that handwritten notes on PBJ were not official and emphasized the importance of submitting accurate PBJ reports to CMS before the deadline to maintain compliance with federal regulations. A review of the facility's Policy and Procedure (P&P) on PBJ Reporting Policy indicated that the human resources department is responsible for overseeing PBJ reporting and ensuring compliance with federal regulations. The failure to submit the PBJ report on time could affect the facility's star rating and indicate a staffing concern for the facility.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that the call lights were within reach for two residents, leading to potential delays in care and increased risk of falls. Resident 31's bathroom did not have a call light cord, which was confirmed through observations and interviews with the resident, an LVN, and the DON. The resident's care plan indicated a high risk for falls and required the call light to be within reach, but this was not adhered to. The facility's policy also mandated that call lights be within reach, but this was not followed in Resident 31's case. Similarly, Resident 7's call light was not within reach as it was stuck behind the roommate's walker. This was observed and confirmed by an LVN and the DON. Resident 7's care plan also indicated a high risk for falls and required the call light to be within reach. The facility's policy on call lights was not followed, putting Resident 7 at risk. Both residents had significant medical histories that made the availability of call lights crucial for their safety and timely care.
Failure to Supervise Residents Adequately
Penalty
Summary
The facility failed to supervise two residents adequately, leading to potential safety hazards. Resident 67, who had a history of wandering due to dementia and schizophrenia, was observed wandering into other residents' rooms in search of cigarettes. Despite having a Wanderguard and a care plan indicating frequent monitoring, the facility did not implement specific interventions to address this behavior. Multiple residents reported feeling uneasy and witnessing Resident 67's wandering behavior, which was not adequately addressed by the staff or reflected in the care plan. Resident 70, assessed as high risk for falls, was not provided continuous one-to-one monitoring as required by their care plan. Observations revealed that Resident 70 was left unattended multiple times, despite the assigned CNAs acknowledging the need for continuous supervision. The facility's monitoring logs confirmed that the assigned staff failed to maintain continuous visual supervision, leaving Resident 70 at risk of falling again. Interviews with staff, including the Director of Nursing and Social Services Director, confirmed the lapses in supervision and the inadequacy of the existing care plans. The facility's policies on supervision and one-on-one monitoring were not followed, leading to potential safety risks for both residents. The staff acknowledged the need for more effective interventions and continuous monitoring to ensure resident safety.
Medication Administration and Disposal Deficiencies
Penalty
Summary
The facility failed to ensure medications were administered and disposed of according to its policy and procedure. Specifically, a Licensed Vocational Nurse (LVN) split a Depakote Extended Release (ER) 500 mg tablet in half and administered it to a resident with a seizure disorder, contrary to the physician's order and the medication's intended use. The resident's care plan indicated that medications should be administered as ordered, and the facility's policy stated that extended-release medications should not be altered. The LVN acknowledged that there was no physician order to break the Depakote ER in half and that doing so could affect the medication's efficacy. The Director of Nursing (DON) and the facility's Pharmacy Consultant confirmed that Depakote ER should not be split, as it would modify the medication's release and effectiveness. Additionally, the facility did not follow its policy for the destruction of discontinued medications. The policy required that two licensed nurses witness the destruction of medications, but an Activity Assistant (AA) was tasked with this responsibility, supervised by only one licensed nurse. The DON admitted to instructing the AA to help with medication disposal, which was against the facility's policy. The AA confirmed that only one licensed nurse was present during the medication destruction process, contrary to the policy that required two licensed witnesses.
Failure to Monitor and Provide Gradual Dose Reduction for Psychotropic Medications
Penalty
Summary
The facility failed to monitor and provide a Gradual Dose Reduction (GDR) for two residents, leading to the potential use of unnecessary psychotropic medications. For Resident 67, a GDR was not completed for the use of Trazodone 100 mg, and no clinical rationale was documented. Despite consistent sleep patterns, the Nurse Practitioner (NP) did not attempt a GDR, and the Director of Nursing (DON) acknowledged that the GDR request was missed. The Psychiatric Progress Note and the Note to the Attending Physician/Prescriber did not provide specific benefits for the continued use of the medication, and the Pharmacist Consultant emphasized the importance of documenting failed GDR attempts and following up accordingly. For Resident 7, the facility did not monitor behaviors related to the use of Zyprexa for schizophrenia during specific night shifts. The care plan required staff to evaluate the effectiveness of Zyprexa and monitor paranoid delusions, but there was no documented monitoring for the specified dates. Both the Registered Nurse (RN) and the DON confirmed the lack of monitoring, which was necessary to determine the medication's effectiveness. The facility's policy indicated that all residents receiving psychotropic medications should be monitored for effectiveness and adverse reactions, but this was not followed in Resident 7's case. These deficiencies highlight the facility's failure to adhere to its own policies and procedures regarding the use of psychotropic medications. The lack of proper documentation and monitoring for GDR and behavior assessments could lead to the continued use of unnecessary medications, posing potential risks to the residents involved.
Expired Milk Not Discarded
Penalty
Summary
The facility failed to follow required food sanitation and handling practices by not discarding six glasses of expired milk found in the kitchen refrigerator. During an initial kitchen tour with the Dietary Supervisor (DS), it was observed that the milk was outdated and should not have been left inside the refrigerator past the expiration date. The DS acknowledged that consuming expired milk could cause food-borne illnesses such as diarrhea and vomiting and stated that expired food should be removed and discarded by the end of the expiry date. A review of the facility's Policy and Procedure (P&P) on Food Receiving and Storage of Cold Foods indicated that poured beverages like milk should be labeled, dated, and discarded at the end of the day.
Infection Control Policy Violations
Penalty
Summary
The facility failed to follow infection control policy and procedures by not ensuring that a Certified Nursing Assistant (CNA) wore the required personal protective equipment (PPE) before entering a contact isolation room for a resident diagnosed with MRSA. The CNA entered the resident's room, picked up the resident's call light from the floor, and placed it back on the bed linen without wearing gloves or other PPE. The resident's care plan indicated the need for isolation precautions, and the facility's policy required staff to wear appropriate PPE when entering the room of a resident with a contagious infection. The Infection Preventionist Nurse confirmed that staff needed to wear PPE to prevent the transmission of infection and protect other residents. Additionally, the facility failed to ensure that food was not stored in the medication storage room. During an observation, a box of doughnuts was found on top of the medication cabinet. The Registered Nurse and Director of Nursing both stated that food should not be stored in the medication room and should be kept in the employee break room. The facility's policy on food storage indicated that food should be stored properly to maintain safety and prevent contamination. The Infection Prevention Nurse also confirmed that food should be stored in the employee lounge to prevent the spread of infection.
Failure to Ensure Privacy During G-Tube Check
Penalty
Summary
The facility failed to ensure privacy for Resident 42 while checking the gastrostomy tube (G-tube) site. During an observation, Licensed Vocational Nurse 1 (LVN 1) opened the resident's gown and checked the G-tube site without closing the privacy curtain, thereby exposing the resident's abdominal area. This action was contrary to the facility's policy on providing privacy during activities of daily living (ADL) and the resident's care plan, which required nursing staff to provide privacy at all times. LVN 1 acknowledged that the privacy curtain should have been closed to maintain the resident's dignity and privacy. Resident 42, who was admitted to the facility on 8/28/2017 and readmitted with diagnoses including chronic obstructive pulmonary disease (COPD), epilepsy, and a need for attention to the gastrostomy, did not have the capacity to understand and make decisions. The resident's care plan indicated muscular weakness and dementia, requiring maximum assistance with various ADLs. The Director of Nursing (DON) confirmed that the privacy curtain should have been closed to maintain the resident's privacy and dignity. The facility's policy emphasized treating residents with dignity, respect, and sensitivity, and required the use of closed doors, curtains, or partitions to provide privacy during ADLs.
Failure to Develop Care Plan for Wandering Resident
Penalty
Summary
The facility failed to develop a care plan for Resident 67, who exhibited wandering behavior by entering other residents' rooms. Resident 67, diagnosed with dementia, schizophrenia, and anxiety, was observed wandering alone in the hallways and entering other residents' rooms. Multiple residents reported that Resident 67 frequently entered their rooms, sometimes attempting to take items such as cigarettes. Despite these reports and observations, there was no care plan addressing Resident 67's wandering behavior, which was confirmed by the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON). The facility's policy required care plans to be updated based on specific behaviors, but this was not done for Resident 67's wandering behavior. Interviews with staff, including the Social Services Director (SSD) and the DON, revealed that the facility's usual response to wandering behavior was to redirect the resident to activities and notify the family. However, this approach was not documented in a care plan for Resident 67. The SSD and DON acknowledged that the care plan should have been updated to include specific interventions for Resident 67's wandering behavior. The facility's policy on care plan revision emphasized the need for measurable objectives and timetables to meet the resident's needs, which was not adhered to in this case.
Failure to Conduct Timely IDT Care Planning Conference
Penalty
Summary
The facility failed to conduct an Interdisciplinary Team (IDT) care planning conference for Resident 184 in accordance with its Policy and Procedure (P&P) titled Care Planning Interdisciplinary Team. Resident 184 was admitted to the facility with diagnoses including type 2 diabetes mellitus and anemia. The Minimum Data Set (MDS) indicated that Resident 184 had clear speech and the ability to understand others and make self-understood. However, during an interview and record review, the Director of Nursing (DON) confirmed that Resident 184 did not have an IDT care planning conference within the required timeframe. An empty form titled Admission / 72 hours IDT Conference was found in Resident 184's medical record, indicating that the conference was not conducted as required. The DON stated that the IDT conference should have been completed within 72 hours after admission, but it was missed and delayed for Resident 184. The facility's P&P indicated that a comprehensive care plan should be developed within seven days of the resident assessment, involving multiple departments and the resident or responsible party to create a person-centered plan of care. The failure to conduct the IDT care planning conference in a timely manner had the potential to prevent Resident 184 from receiving appropriate care and treatment promptly.
Failure to Monitor Resident During Mealtime
Penalty
Summary
The facility failed to ensure that Resident 5 was assessed and monitored during mealtime as indicated in the resident's care plan. Resident 5, who has diagnoses including Parkinson's disease and osteoarthritis, was observed eating alone in her room with her right hand shaking, causing food to spill on the tray. This lack of supervision during mealtime was contrary to the care plan interventions, which specified that the resident should be monitored during meals due to the potential for injury from tremors and involuntary movements. Additionally, the care plan indicated the need to observe the resident for a decline in mobility and function and to notify the medical doctor promptly, which was not done in this case. Interviews with the Dietary Supervisor and the Registered Nurse Supervisor revealed that Resident 5's increased hand tremors had been noticed, but there were no records indicating that the resident was assessed and monitored during mealtime or that the medical doctor or occupational therapist were notified of the increased tremors. The Director of Nursing confirmed that mobility assessments are typically done annually, quarterly, and as needed, but there was no documentation to support that these assessments were conducted for Resident 5. The facility's policy on Assistance with Meals, which requires residents to receive meal assistance in a manner that meets their individual needs, was not followed in this instance.
Failure to Implement Repositioning Interventions
Penalty
Summary
The facility failed to implement the intervention on the resident's care plan for turning and repositioning every 2 hours for Resident 23, who was at risk for skin breakdown due to impaired mobility and incontinence. Despite the care plan and the Resident Positioning Log indicating that Resident 23 should be turned and repositioned every 2 hours, multiple observations on 4/24/2024 showed that Resident 23 remained in the same position for extended periods, specifically on her left side facing the door from 9:07 am to 2:08 pm, before being repositioned on her back at 2:52 pm. Interviews with CNA 3 and the DON confirmed the importance of turning and repositioning every 2 hours to prevent skin breakdown for residents with poor mobility. The DON acknowledged that Resident 23 needed to be turned and repositioned at least every 2 hours. However, the observations and the review of the Resident Positioning Log indicated that this intervention was not consistently implemented, placing Resident 23 at risk for developing skin breakdown.
Failure to Maintain Clean Oxygen Tubing
Penalty
Summary
The facility failed to ensure that a resident's nasal cannula tubing was not touching the trash bin, which is against professional standards of practice and the facility's own Infection Control Policy: Oxygen Use. The resident, who had diagnoses including chronic obstructive pulmonary disease (COPD) and heart failure, was observed with their oxygen tubing in contact with the trash bin while eating breakfast. This observation was confirmed by a Licensed Vocational Nurse (LVN), who acknowledged that the tubing should not be touching the trash bin due to the risk of infection and contamination. The Director of Nurses (DON) also confirmed that oxygen tubing should not be in contact with the trash bin to prevent infection and cross-contamination. The facility's policy, dated April 2018, states that oxygen equipment should be inspected regularly for signs of damage, wear, or contamination, and that any damaged or contaminated equipment should be replaced or repaired promptly. The failure to adhere to this policy had the potential to increase the risk of infection for the resident.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near El Monte
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Gardens Of El Monte | 0.6 mi | ★★★★★ | 23 | 0 |
| Temple City Healthcare | 0.7 mi | ★★★★★ | 36 | 0 |
| Santa Fe Lodge | 1.1 mi | ★★★★★ | 21 | 0 |
| Mayflower Care Center | 1.1 mi | ★★★★★ | 3 | 0 |
| Madera Post Acute Center | 1.2 mi | ★★★★★ | 26 | 0 |
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