Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Flower Villa, Inc during CMS and state inspections, most recent first.
Unjustified mittens were applied to both hands of a resident with severe cognitive impairment, total dependence for ADLs, and non-ambulatory status without a documented medical indication or a physician order. An LVN did not know why the mittens were in place, the MDSC stated the resident was not supposed to have restraints because there were no indications or orders, and the DON stated this violated residents’ rights and dignity.
The facility failed to accurately code the MDS for two residents with positive Level II PASRR determinations. One resident had diagnoses including major depressive disorder, schizoaffective disorder, and schizophrenia, and the other had psychosis, anxiety disorder, and bipolar disorder. Records showed both residents had serious SMI findings and required Level II mental health evaluations and specialized add-on services, but the MDSC stated the annual MDS assessments were incorrectly coded and did not reflect the positive PASRR status. The DON stated the MDS should reflect the care the resident is receiving.
Enteral feeding tubing and formula labeling were not managed according to orders and policy. A resident with a G-tube had an enteral feeding order that was not delivering the prescribed amount, and two other residents had feeding tubing left in place beyond the expected change interval. Staff also observed an inaccurate formula label date, and an LPN, IP, and DON acknowledged the labeling and tubing-change issues.
Kitchen food safety practices were not maintained when expired garlic cloves and tuna salad were found in the refrigerator, the dry storage room lacked a labeled dented can area, and an ice scoop had no cleaning date or documentation of cleaning. The DS stated expired food should be discarded, dented cans need a designated separated area, and the ice scoop was washed as needed but there was no record showing when it was cleaned; the DON stated expired food should be thrown away and the ice scoop needed daily cleaning documentation.
Failure to Verify Informed Consent for Ativan: A resident with anxiety disorder, encephalopathy, and moderately impaired cognition received PRN Ativan multiple times, but the chart did not contain a verification of informed consent form for the psychotropic medication. MDSC stated nurses are to verify informed consent before administering psychotropic meds, and the DON stated staff should confirm the resident understood the risks and benefits and agreed to receive the medication.
The facility failed to send the Ombudsman a copy of the notice of proposed transfer for two residents who were sent to a GACH for medical reasons. Both residents had serious psychiatric diagnoses, were cognitively intact, and needed staff help with ADLs. Staff stated the Ombudsman notification should be faxed as soon as practicable, but one resident's notice was delayed and the other was not sent at all.
Failure to Provide Daily Hearing Aid Assistance: A resident with hearing loss and a care plan for daily hearing aid placement was repeatedly observed without his hearing aids and stated he could not hear. A CNA said she had never given him the hearing aids and was unsure where they were, while the SSD and DON stated staff were supposed to offer them daily but no log or documentation was kept, despite the facility policy requiring recording of hearing aid checks and related details.
A resident with anxiety disorder, encephalopathy, bipolar disorder, and non-Alzheimer's dementia had orders for Aricept, Wellbutrin, and Haldol, and was noted to have moderately impaired cognition, an unsteady gait, and refusal of select ADLs such as bathing and hygiene care. The IDT and MDS review showed no individualized dementia care plan or care plan with measurable goals and interventions for the resident's cognitive status, and the MDSC and DON confirmed that nursing staff had not developed one.
Lack of monitoring for targeted behavior with PRN Ativan: A resident with anxiety disorder and encephalopathy had a PRN order for Ativan for inability to relax, but the MAR showed no documented monitoring of the targeted behavior. The care plan called for behavior management techniques, medication administration per order, observation for side effects, and documentation of behavior, while the DON stated staff are to monitor psychotropic-related behaviors and tally them monthly per policy.
Open Kitchen Trash Can Without Lid: Surveyors observed an open trash can without a lid in the kitchen by the handwashing sink. The DS stated kitchen trash cans need lids to prevent infection spread and cross contamination. The facility policy required trash containers to have tight-fitting lids or covers and remain closed when not in use.
Resident Rooms Did Not Meet Required Square Footage: Surveyors found that 18 of 21 resident rooms did not meet the required 80 sq ft per resident for multiple-occupancy rooms. The Client Accommodation Analysis showed the affected rooms had 2 beds each with only 67 to 76.38 sq ft per bed, despite observations that staff and residents had enough space for care, movement, privacy curtains, and room access to the corridor.
The facility failed to provide required infection preventionist (IPN) coverage to oversee its infection prevention and control program. Review of schedules and timecards showed the IPN only worked a few 8‑hour shifts per month, despite leadership acknowledging a 40‑hour‑per‑week IPN coverage requirement. Staff interviews indicated the IPN was present only once or twice a week for a few hours and did not provide consistent infection prevention in‑services or training, even though the IPN was responsible for setting isolation protocols and infection control guidelines. The facility’s own policies and Facility Assessment identified infection prevention and control, including dedicated infection control staff and systems for preventing, identifying, reporting, investigating, and controlling infections, as necessary for the resident population.
A resident with multiple chronic conditions experienced severe weakness, inability to eat, and inability to speak. Staff did not immediately assess or notify the physician of these significant changes, initially attributing symptoms to the need for rest. Only after further decline and abnormal vital signs did staff contact the physician, who ordered emergency transfer to a hospital. This delay was inconsistent with facility policy and resulted in the resident's further decline.
The facility did not ensure an RN was onsite for at least 8 consecutive hours daily, as required, on multiple occasions. Staffing records and interviews with the DSD and DON confirmed the lack of RN coverage, impacting the oversight of nursing services for 31 residents.
The facility did not provide the required Notice of Medicare Non-Coverage (NOMNC) at least two days before the end of Medicare-covered skilled nursing services for three residents. Instead, the NOMNC was issued only one day prior to the last covered day, despite residents having varying medical conditions and cognitive statuses. This was confirmed by record review and staff interview, and was not in accordance with facility policy or federal requirements.
Surveyors found that drawers in three resident rooms did not close properly and had chipped paint, as confirmed by the Maintenance Director and DON. This failure to maintain resident room furniture in good condition did not meet facility policies for providing a safe, clean, and homelike environment.
The facility did not post actual nursing hours worked by licensed and unlicensed staff for three consecutive days, displaying only projected hours and omitting required calculations for unlicensed staff. Staff interviews revealed confusion about posting requirements, and review of facility policy confirmed that daily posting of actual hours and NHPPD values was not being followed.
Surveyors identified failures in food safety and kitchen sanitation, including unclean storage areas, grease accumulation on kitchen equipment, and multiple open food containers in the refrigerator lacking required use-by dates. Staff confirmed the labeling oversight, and the DON reported that hand sanitizer had been removed from the kitchen.
The facility did not ensure that medical records and transfer documentation were accurate and complete for several residents. One resident's POLST and Advance Directive forms contained errors, including incorrect relationship information and missing signatures. For three other residents, Notice of Proposed Transfer/Discharge forms were not signed by the residents or their representatives, and there was no documentation that the Ombudsman was notified of their transfers. These deficiencies resulted in incomplete and inaccurate records.
The facility did not submit complete and accurate PBJ staffing data to CMS for three required quarters, resulting in reported gaps in RN and LVN coverage on multiple days. The DSD confirmed that the data submitted by the corporate office was inaccurate, despite facility policies requiring accurate reporting. This deficiency had the potential to impact all residents by risking delays in necessary care and services.
A Hoyer Lift was found without documentation of annual manufacturer inspection, showing rust and chipped paint. The Maintenance Director stated that the lift had not been professionally inspected as required, and that he performed repairs without manufacturer certification, contrary to facility policy.
A resident with multiple psychiatric diagnoses and prescribed Ativan for anxiety did not have a care plan developed to address the use of this psychotropic medication. Despite receiving numerous doses and being cognitively intact, the facility failed to document a care plan to guide staff in managing the resident's anxiety or monitoring medication effects, as confirmed by staff interviews and record review.
A resident with COPD did not receive required pre- and post-nebulizer lung sound assessments as ordered by the physician and outlined in facility policy. Nursing staff administered and completed nebulizer treatments without consistently auscultating lung sounds before and after therapy, and staff interviews revealed a lack of awareness of this requirement.
A resident's ipratropium-albuterol inhalation solution was found in the medication cart with an opened foil pouch and undated unit-dose vials, despite manufacturer guidelines requiring use within one week of opening. The LVN and DON confirmed that the medication should have been labeled with the date it was first opened, but this was not done.
A medication error rate above 5% was identified when an LVN crushed and combined three oral medications—ProAmatine, Risperdal, and Vitamin D3—before administering them to a resident with severe cognitive impairment and multiple diagnoses. This practice was not in accordance with facility policy, as confirmed by the DON, and resulted in three errors out of 28 medication opportunities.
A nurse crushed and administered three medications together for a resident with severe cognitive impairment and multiple medical conditions, contrary to facility policy and accepted standards. The DON confirmed that these medications should not have been crushed and given together.
A resident with multiple chronic conditions and moderate cognitive impairment was not provided a routine dental visit as ordered, despite the facility's policy and the availability of dental services for other residents. This was confirmed through record review and staff interview.
Eighteen resident rooms did not meet the required minimum of 80 square feet per resident, with room sizes ranging from 67 to 76.38 square feet per bed. Despite this, observations indicated that residents and staff had enough space to move and provide care, and all necessary furnishings and equipment were present.
A resident at high risk of fractures was improperly repositioned by a single CNA, contrary to the care plan requiring two to three-person assistance. The resident's refusal of care was not documented or reported, leading to a humerus fracture. The facility also failed to document a change of condition, delaying appropriate care.
Unjustified mittens applied without a doctor’s order
Penalty
Summary
The facility failed to ensure one sampled resident was free from unnecessary physical restraint when mittens were applied to both hands without documented medical justification and without a doctor’s order. Resident 9 was admitted and re-admitted with diagnoses including weakness, neuropathy, gastrostomy status, displaced fracture of the right clavicle, dysphagia, dementia, and schizophrenia. The resident’s H&P stated the resident did not have the capacity to understand and make decisions, and the MDS indicated severe cognitive impairment, total dependence for oral hygiene, toileting hygiene, showering/bathing, upper and lower body dressing, putting on/taking off footwear, and non-ambulatory status. During observation and interview, an LVN stated she did not know why mittens were placed on both hands. The MDSC stated the resident was not supposed to have restraints because there were no indications justifying use and no doctor’s orders to restrain the resident. The DON stated applying physical restraints without indications and a doctor’s order was a violation of residents’ rights and dignity and could cause physical injuries and harm. The facility policy stated restraints shall only be used to treat the resident’s medical symptom(s), never for discipline or staff convenience, and only when a specific medical symptom cannot be addressed by a less restrictive intervention.
Incorrect PASRR Coding on MDS Assessments
Penalty
Summary
The facility failed to accurately code the MDS to reflect Level II PASRR status for two sampled residents. Resident 2 was originally admitted on 2/3/2023 and later readmitted with diagnoses including major depressive disorder, schizoaffective disorder, and schizophrenia. Records showed a State Health Care Services Department PASRR Level I screening letter dated 1/24/2025 stating the resident had a serious SMI and required a Level II mental health evaluation, followed by an Individual Determination letter dated 1/28/2025 stating the resident had a serious mental illness and required specialized add-on services including mental health rehabilitation activities, ADL training, psychotherapy/counseling, and behavior monitors. Resident 7 was originally admitted on 11/20/2018 and re-admitted on 12/20/2025 with diagnoses including psychosis, anxiety disorder, and bipolar disorder. Records showed a PASRR Level I screening form dated 9/9/2024 stating the resident had a serious SMI and required a Level II mental health evaluation, and an Individual Determination letter dated 9/11/2024 stating the resident had a serious mental illness and required specialized add-on services including medication education and training, ADL training, neuropsychology consultation, and safety monitors. During a concurrent interview and record review, the MDSC stated she incorrectly coded the annual MDS assessments for Resident 2 and Resident 7 and did not accurately reflect that both residents had positive Level II PASRRs. The DON stated the MDS is a comprehensive assessment that should reflect the care the resident is receiving, and that incorrect coding may result in the wrong assessment and reflection of care.
Enteral feeding tubing and formula labeling were not managed according to orders and policy
Penalty
Summary
The facility failed to follow its Enteral Feeding - Safety Precautions policy for three sampled residents with feeding tubes. The report states that Resident 12 had a physician order for Jevity 1.5 to run via enteral pump at 50 cc per hour to provide 1000 cc to 1500 cc in 20 hours or until the dose was completed, with feeding to start between 2 and 3 p.m. During the survey, Resident 12 was identified as having severe cognitive impairment, being totally dependent for multiple ADLs, and being non-ambulatory. For Resident 4, the record showed diagnoses including dysphagia, dementia, and schizophrenia, and the resident was dependent on staff for ADL care. The physician orders directed enteral feeding by pump at 50 cc per hour, with feeding to start between 2 p.m. and 3 p.m., and another order directed that the enteral feed administration set be changed every night shift. During observation, the Glucerna 1.2 formula was connected and running at 50 cc per hour, and the tubing was labeled 4/8/2026. In a concurrent interview, LVN 1 stated the tubing was changed whenever a new bottle was hung, but also stated the tubing should have been changed when the new feeding formula was hung and that not changing it could allow bacteria into the stomach. For Resident 9, the record showed diagnoses including dysphagia, dementia, and bipolar disorder, with cognitive impairment and dependence on staff for ADL care. The physician orders directed enteral feeding by pump at 65 mL per hour, with feeding to start between 2 p.m. and 3 p.m., and another order directed that the enteral feed administration set be changed every night shift. During observation, Jevity 1.5 was connected and running at 70 mL per hour, the bottle was labeled with a start date of 4/10/2026 at 2 p.m., and there was 900 cc of residual formula remaining. LVN 1 was unable to explain why the bottle had 900 cc left. In a separate observation, the formula label on Resident 9’s feeding was dated 4/12/2026 while the feeding was observed on 4/11/2026. The IP stated this was an error and explained that the label should reflect the accurate date so the next nurse knows when the bottle needs to be changed. The DON stated the tubing should be changed every 24 hours and that inaccurate labeling could result in the next nurse not changing it.
Expired Food, Dented Can Storage, and Ice Scoop Cleaning Deficiencies
Penalty
Summary
Safe and sanitary food storage and preparation practices were not maintained in the kitchen when expired ready-to-eat foods were found in the refrigerator and other food safety controls were not in place. During a kitchen observation, surveyors found a container of fresh garlic cloves with a use-by date of 4/3/2026 and a container of tuna salad with a use-by date of 4/8/2026 still stored in the refrigerator after those dates had passed. The Dietary Supervisor stated that food beyond its use-by date should be discarded to prevent foodborne illness and cross contamination. Surveyors also observed that the dry storage room did not have a designated dented can section. The Dietary Supervisor stated the facility did not have a dented can area sectioned off and labeled, and explained that dented cans need to be separated so staff know not to use them. The facility policy on dented cans stated that cans with dents, rust, leaks, or broken containers shall not be retained or used, and that dented cans are to be separated and placed in a specified labeled area for return or removal. In addition, an ice scoop in the kitchen did not have a date showing when it was cleaned, and the facility had no documentation that it had been cleaned. The Dietary Supervisor stated the facility washed the ice scoop as needed but had no documentation showing when it was cleaned, and the DON stated the ice scoop needed to be cleaned daily with documentation to show it was done. The facility policy and the Food Code excerpt reviewed by surveyors both addressed cleaning of food-contact surfaces and self-service utensils such as scoops.
Failure to Verify Informed Consent for Ativan
Penalty
Summary
The facility failed to ensure that informed consent was verified before administering Ativan to one sampled resident. Resident 19 had diagnoses including anxiety disorder and encephalopathy, and the Minimum Data Set indicated moderately impaired cognition along with active diagnoses of anxiety disorder, bipolar disorder, and schizophrenia. The resident's physician ordered Ativan 1 mg by mouth every 6 hours as needed for inability to relax, and the Medication Administration Record showed the resident received Ativan on multiple occasions in October 2025. During a concurrent interview and record review, MDSC stated there was no Verification Form for Ativan in the resident's chart and that nurses are to verify informed consent prior to administering psychotropic medication. The DON stated staff are to verify with the resident that the risks and benefits of the psychotropic medication were explained and that the resident agreed to receive it. The resident stated he had received Ativan in the past but did not know what it was used for. The facility policy required nurses to confirm documentation of informed consent in the medical record and place the completed consent form in the resident's chart before treatment or procedure.
Failure to Notify Ombudsman of Emergency Hospital Transfers
Penalty
Summary
The facility failed to ensure that a copy of the notice of proposed transfer for medical reasons was sent to the State Long-Term Care Ombudsman as soon as practicable for two residents who were transferred to a general acute care hospital. The deficiency was identified during interview and record review and involved Resident 5 and Resident 38, both of whom had emergency medical transfers from the facility to the hospital. Resident 5 was admitted with diagnoses including schizophrenia, bipolar disorder, and COPD. The MDS dated 1/16/2026 indicated the resident was cognitively intact and required supervision or touch assistance with ADLs. The notice of proposed transfer/discharge documented a transfer to a GACH for the resident's welfare because needs could not be met in the facility, and the facility fax cover sheet showed the Ombudsman was not notified until 3/11/2026. The MRD stated the notice should have been faxed the next day, on 3/3/2026, and that the purpose of the notification was to ensure the Ombudsman's office knew where the resident was. Resident 38 was admitted and later readmitted with diagnoses including schizophrenia, bipolar disorder, and dementia. The MDS indicated the resident was cognitively intact and dependent on staff for ADL care. The notice of proposed transfer/discharge documented a transfer to a GACH for the resident's welfare because needs could not be met in the facility, but the MRD stated the Ombudsman notification was not done. The MRD and DON both stated the notice should be faxed as soon as possible, on the day of transfer or the next day after transfer, so the Ombudsman would know the resident was not in the facility, and the DON stated the notification was done per facility policy and federal regulations.
Failure to Provide Daily Hearing Aid Assistance
Penalty
Summary
The facility failed to implement one resident’s communication care plan intervention by not providing or applying the resident’s hearing aid daily as required by the facility’s Care of Hearing Aid policy. The resident had decreased hearing, and the communication care plan, initiated after re-admission, identified hearing loss with a goal of increasing participation in conversations with staff and peers. The care plan specifically directed staff to apply, check placement, and monitor placement of the hearing aid(s) daily. The resident’s MDS indicated moderately difficult hearing and that he possessed a hearing aid, and also showed he could make himself understood and usually understood others. Records and interviews showed the resident had been issued hearing aids and was educated that nursing staff would help place them, and an ENT consultation recommended hearing aids for both ears. During observations and interviews, the resident was repeatedly found not wearing hearing aids, stated he could not hear and needed a hearing aid, and became frustrated when unable to hear during an interview. A CNA stated she had never given the resident his hearing aids and was not sure where they were located, while the SSD stated the hearing aids were to be offered in the morning and removed at night. The DON stated charge nurses had a list of residents with hearing aids and were to offer them daily, but nursing staff were not documenting when the hearing aid was offered. The facility policy required documentation of the date and time the hearing aid was checked or battery replaced, the staff member involved, any refusal and intervention taken, and the signature and title of the person recording the data.
Missing Dementia Care Plan With Measurable Goals
Penalty
Summary
The facility failed to develop an individualized care plan with measurable goals and interventions to address the care and treatment needs of Resident 19, who had diagnoses including anxiety disorder, encephalopathy, bipolar disorder, and non-Alzheimer's dementia. The resident's record showed physician orders for Aricept for dementia, Wellbutrin for depression, and Haldol for schizophrenia manifested by striking out at staff without provocation. The interdisciplinary team meeting and care conference documented that the resident ambulated with an unsteady gait, required assistance with activities of daily living including personal hygiene and proper hand hygiene, and was refusing select ADLs such as bathing, hygiene care, and changing soiled clothing. A review of the resident's annual MDS indicated moderately impaired cognition. During record review, the care plans did not include an individualized person-centered dementia care plan or a care plan addressing the resident's cognitive status. The MDS Coordinator stated the resident did not have any care plan with measurable goals and interventions for dementia or cognitive skills and could not provide documented evidence that licensed nursing staff identified or assessed specific behaviors or episodes. The DON stated nursing staff did not develop a care plan with measurable goals and interventions to address the care and services needed by the resident and that a dementia care plan needed to be in place to address the care the resident receives.
Lack of Monitoring for Targeted Behavior with PRN Ativan
Penalty
Summary
The facility failed to provide appropriate monitoring for the targeted behavior associated with Ativan use for one resident with anxiety disorder and encephalopathy. The resident was admitted and later readmitted with diagnoses including anxiety disorder and encephalopathy, and the MDS dated 2/20/2026 indicated moderately impaired cognition. On 3/29/2026, the physician ordered Ativan 1 mg by mouth every 6 hours as needed for the inability to relax. The resident’s care plan for history of current anxiety problems, initiated 10/16/2025, documented episodes of repetitive physical movement, including wringing of hands and inability to relax, with interventions to implement behavior management techniques, administer medications per physician order, observe for side effects, and document behavior in the medication book. A review of the April 2026 MAR showed no documented evidence that licensed nurses monitored the targeted behavior of inability to relax. During interview and record review, the MDSC stated there was no documentation for monitoring the targeted behavior and that the lack of monitoring could lead to the resident not receiving an effective dosage of medication. The DON stated that for all psychotropic medications, staff are to monitor targeted behaviors and tally behaviors monthly, and that monitoring allows the facility to assess whether the resident’s behavior is managed or whether changes need to be implemented. The facility policy titled Behavior Assessment and Monitoring required staff to document the number and frequency of episodes, preceding or precipitating factors, interventions attempted, and outcomes associated with interventions.
Open Kitchen Trash Can Without Lid
Penalty
Summary
The facility failed to ensure a safe, sanitary, and compliant kitchen environment when one of four trash bins in the kitchen did not have a lid. During an observation on 4/11/2026 at 6:32 A.M., surveyors observed an open trash can without a lid located by the handwashing sink in the kitchen. The deficient practice was identified in relation to the facility's policy and procedures titled, Kitchen Garbage and Trash, dated 1/2026, which required trash containers in the kitchen to have tight-fitting lids or covers and to remain closed when not in use. During an interview on 4/11/2026 at 10:19 A.M., the Dietary Supervisor stated that trash cans in the kitchen need to have a lid on them to prevent the spread of infection and cross contamination. The facility policy also stated that trash containers must be durable, easily cleanable, non-absorbent, leak-proof, and designed to prevent contamination and pest prevention, and the FDA Food Code cited in the report stated that refuse shall be stored in receptacles so that they are inaccessible to insects and rodents.
Resident Rooms Did Not Meet Required Square Footage
Penalty
Summary
The facility failed to ensure that 18 of 21 resident rooms met the required square footage per resident. Based on the Client Accommodation Analysis dated 4/11/2026 and the facility’s request for continuation of a room waiver, rooms 1, 2, 3, 4, 5, 6, 7, 9, 10, 11, 14, 15, 16, 18, 19, 21, 23, and 25 were identified as not having at least 80 square feet per resident. The analysis showed that these rooms were all multiple-occupancy rooms with 2 beds each and square footage per bed ranging from 67 to 76.38 square feet. During the initial tour, surveyors inspected the listed rooms and observed that nursing staff had enough space to provide care to the residents, that curtains were present for privacy, and that the rooms had direct access to the corridors. During multiple observations from 4/11/2026 to 4/12/2026, residents and staff had enough space to move freely inside the rooms, and nursing staff had enough space to safely provide care with room for beds, side tables, dressers, and resident care equipment. The facility’s policy titled Resident Rooms, dated 1/2026, stated that resident bedrooms will measure at least 80 square feet per resident in multiple resident bedrooms and at least 100 square feet in single resident bedrooms.
Insufficient Infection Preventionist Coverage for Infection Control Program
Penalty
Summary
The deficiency involves the facility’s failure to employ and schedule a qualified Infection Preventionist Nurse (IPN) at least part time, as required by state expectations and as outlined in the facility’s own Facility Assessment Tool and infection prevention and control policy. Review of the LVN schedules and IPN timecards for November and December 2025 and January 2026 showed the IPN was only scheduled and actually worked a limited number of days and hours each month, far below the 40 hours per week of IPN coverage that the DON and administrator stated were required. In November 2025, the IPN worked three 8‑hour days; in December 2025, three 8‑hour days; and in January 2026 through 1/27/2026, two 8‑hour days. The facility’s policy stated that the designated infection preventionist is responsible for oversight of the infection prevention and control program, including consultation on infectious diseases, room placement, isolation precautions, exposures, surveillance, and epidemiological investigations. Staff interviews confirmed that the IPN was not present on a full‑time basis and did not provide consistent infection prevention in‑services and trainings. A CNA reported that the IPN did not have a full‑time schedule and did not consistently conduct infection prevention education. The MDS coordinator stated that resident isolation protocols and guidelines were set by the IPN and that the IPN came to the facility only once or twice a week for a few hours. The DON and administrator both acknowledged awareness of the 40‑hour IPN coverage requirement but stated that, because the building was smaller, the IPN only came a few times a week. In a telephone interview, the IPN stated she considered herself full time, working two to three 8‑hour shifts per week, and was aware that skilled nursing facilities are required to have 40 hours of IPN coverage. The Facility Assessment Tool identified infection prevention and control as a needed type of care for the resident population and specified that infection control and prevention staff were required, as well as systems for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for residents, staff, volunteers, visitors, and contracted providers.
Failure to Promptly Notify Physician of Resident Change in Condition
Penalty
Summary
Facility staff failed to immediately assess and notify the physician when a resident experienced a significant change in condition, including severe weakness, inability to eat, and inability to speak during a morning shift. The resident, who had a history of type 2 diabetes, hypertensive heart disease, anxiety disorder, schizophrenia, COPD, and hypertension, was noted to have intact cognitive skills prior to the incident and was partially dependent on staff for mobility and transfers. On the morning in question, the resident was found unresponsive to verbal communication and refused breakfast, with initial vital signs showing a heart rate of 59 and oxygen saturation of 94%. Despite these changes, the initial response by one of the LVNs was to allow the resident to rest, believing more sleep was needed, and did not immediately recognize the situation as a change of condition. It was only after further decline, including a heart rate dropping to 40 and oxygen saturation to 89% on nasal cannula, that the charge nurse was notified and the physician was contacted. The physician then ordered the resident to be transferred to an acute care hospital via 911 for further evaluation and treatment. Interviews with staff and review of facility policies confirmed that the delay in assessment and notification was contrary to facility procedures, which require prompt physician notification for significant changes in a resident's condition. The Director of Nursing acknowledged that such delays pose a resident safety risk. The deficiency was identified based on the failure to promptly assess and notify the physician, resulting in further decline of the resident and the need for emergency transfer.
Plan Of Correction
F0580 Notify of Changes (Injury / Decline / Room, etc.) CFR(s): 483.10(g)(14)(i)-(iv)(15) On 12/11/25, resident 3 was transferred to the General Acute Care Hospital (GACH) via 911. On 12/21/25, resident 3 was readmitted to the facility and is currently safe and comfortable. To identify other residents with the potential to be affected, the DON reviewed any changes of condition for the last 30 days and no other residents were found to be affected by this deficient practice. On 12/29/25, the DON in-serviced licensed nurses regarding the facility's policy and procedure titled "Change in a Resident's Condition or Status," with emphasis on the nurse supervisor/charge nurse notifying the resident's Attending Physician or On-Call Physician when there has been a significant change in the resident's physical, emotional, or mental condition. On 12/29/25, the DON also in-serviced licensed nurses regarding the facility's policy and procedure titled "Vital Signs," with emphasis on vital signs being indicators of health status. Licensed nurses are responsible for knowing the usual range of a resident's vital signs, analyzing and interpreting routine vital signs, and notifying the physician of abnormal findings. To ensure that the systems in place are sustained and maintained, the DON or designee will conduct a random audit of five residents weekly for twelve (12) consecutive weeks. These residents will be reviewed to ensure that if there was any change of condition that has been identified, they were properly evaluated and communicated to the appropriate people. The DON will report any negative findings to the Quarterly Quality Assurance and Assessment (QA&A) Committee for review and recommendations for the next 3 months. Corrective Action Completion Date: 12/31/2025
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was onsite for at least 8 consecutive hours a day, seven days a week, as required. Review of the CMS Payroll Based Journal (PBJ) staffing data and the facility's own nursing staffing records revealed that there was no RN coverage on multiple specific days within the reviewed period. This was confirmed through interviews with both the Director of Staff and Development (DSD) and the Director of Nursing (DON), who acknowledged the absence of RN coverage on the identified dates. The facility's policy and procedures state that adequate staffing, including licensed RNs, must be maintained to meet the care and service needs of residents. Despite this policy, the lack of RN coverage was documented and verified, affecting the facility's ability to manage and oversee nursing services for 31 residents. The deficiency was identified through observation, interview, and record review, and was cross-referenced to F851.
Failure to Provide Timely Notice of Medicare Non-Coverage
Penalty
Summary
The facility failed to provide the Notice of Medicare Non-Coverage (NOMNC) at least two days prior to the last covered day of skilled nursing services for three residents. For each resident, the NOMNC was issued and signed only one day before the end of Medicare-covered services, rather than the required two days. This was confirmed through review of admission records, NOMNC forms, and the SNF Beneficiary Protection Notification Review Forms for all three residents. Resident 7, who had diagnoses including COPD, diabetes mellitus, and schizophrenia, was cognitively intact and required supervision for daily activities. The NOMNC for this resident indicated services would end on a specific date, but the notice was provided only one day prior. Similarly, Resident 11, with bipolar disorder and major depressive disorder and also cognitively intact, received the NOMNC one day before the end of covered services. Resident 18, who had gout, chronic kidney disease, and muscle wasting, and was moderately cognitively impaired, also received the NOMNC only one day before coverage ended. During an interview and record review, the Social Services Director confirmed that the facility notified all three residents only one day prior to the end of their covered services, acknowledging that the required notification period is at least two days. Facility policy and the State Operations Manual both require that the NOMNC be provided at least two days before the end of Medicare coverage, which was not followed in these cases.
Failure to Maintain Safe and Homelike Resident Rooms
Penalty
Summary
Surveyors observed that three of seven residents' rooms (Rooms 1, 16, and 20) were not maintained in a safe, clean, and comfortable condition. Specifically, the drawers in these rooms, where residents stored their clothes and belongings, did not close completely and had chipped paint. These issues were identified during a concurrent interview and observation with the Maintenance Director, who confirmed that the drawer sliders needed replacement to restore proper function for resident use. Further interviews with the Director of Nursing confirmed that equipment not in proper condition should be replaced as needed. A review of the facility's policies indicated that the facility is required to provide a safe, clean, and homelike environment and to maintain all equipment and infrastructure regularly. The failure to address the malfunctioning and damaged drawers in residents' rooms was inconsistent with these policies and procedures.
Failure to Post Actual Nursing Hours Per Patient Day
Penalty
Summary
The facility failed to ensure that the actual nursing hours worked by both licensed and unlicensed nursing staff directly responsible for resident care were posted for three consecutive sampled days. Observations on each of these days revealed that only projected nursing hours were displayed on the Direct Care Services Hours Per Patient Day (DHPPD) postings, with no actual hours or calculations for unlicensed nursing staff included. Additionally, there was no DHPPD posting for the previous day on each observed date. Interviews with facility staff, including the Director of Staff and Development, Minimum Data Set Coordinator, and Director of Nursing, confirmed a lack of clarity and understanding regarding the requirements for posting actual nursing hours and including unlicensed staff in the calculations. Review of facility policies indicated that daily posting of actual nursing hours, patient census, and NHPPD values is required, but these procedures were not being followed as observed and confirmed by staff statements.
Deficient Food Safety, Labeling, and Kitchen Sanitation Practices
Penalty
Summary
Surveyors observed multiple failures in food safety and kitchen sanitation practices. Dirt and debris were found under dry storage racks in the corners of the dry food storage room, and grease drips were noted on the sides of the range oven. During a review of open food containers in the kitchen refrigerator, several items including tuna salad, salsa, shredded cheese, mayonnaise, and soy milk were found without required use-by dates. Kitchen staff confirmed that labeling had been overlooked. The Director of Nursing stated that hand sanitizer had been removed from the kitchen, but it was only used when staff left the kitchen. Facility policies reviewed indicated requirements for cleanliness in food service areas and proper labeling of food items, which were not followed.
Incomplete and Inaccurate Medical Records and Transfer Documentation
Penalty
Summary
The facility failed to ensure that medical records for four of five reviewed residents were accurate and complete. For one resident with severe cognitive impairment and multiple diagnoses, the POLST form was incorrectly filled out, listing the brother in the relationship field instead of 'self,' and the Advance Directive form was missing the physician's signature date and had the surrogate decision maker's name entered in error instead of the resident's. The Director of Nursing confirmed these errors during record review and interview. Additionally, three other residents' Notice of Proposed Transfer/Discharge forms were not signed by the residents or their representatives. These residents had varying levels of cognitive function and assistance needs, with some being independent and others requiring substantial or total assistance with activities of daily living. The forms indicated that these residents were transferred to a general acute care hospital, but there was no documentation that the Ombudsman had been notified of the transfers, as verified by the Medical Records Director. Facility policy requires all documentation to be accurate, complete, and reliable. However, the observed deficiencies included incomplete and inaccurate completion of critical forms related to end-of-life care and resident transfers, as well as missing required notifications. These failures resulted in inaccurate and incomplete forms in the medical records, with the potential to affect the delivery of care.
Failure to Submit Accurate PBJ Staffing Data to CMS
Penalty
Summary
The facility failed to ensure the complete and accurate submission of Payroll Based Journal (PBJ) staffing data to CMS for three out of four required quarters in 2024. Review of the Certification and Survey Provider Enhanced Reporting system (CASPER) and CMS PBJ Staffing Data Report revealed missing Registered Nurse (RN) and Licensed Vocational Nurse (LVN) coverage on multiple dates across the 1st, 2nd, and 4th fiscal quarters. Specifically, there were numerous days with no RN hours reported and several days with no 24-hour LVN coverage, as reflected in the PBJ data submitted to CMS. The Director of Staff and Development (DSD) confirmed that PBJ reporting was managed by the corporate office and acknowledged inaccuracies in the data submitted, despite stating that RN and LVN coverage was present on some of the dates in question. Facility policies required accurate and timely PBJ submissions, including all direct care staff and contract employees, in compliance with federal regulations. The CMS PBJ Policy Manual also mandates that staffing information be complete and accurate, with facilities responsible for verifying the accuracy of their submissions prior to the deadline. The failure to submit accurate staffing data had the potential to affect all 41 residents in the facility, as it could result in delays in care, treatment, and services necessary for their physical and emotional wellbeing.
Failure to Maintain and Inspect Hoyer Lift per Manufacturer Guidelines
Penalty
Summary
A Hoyer Lift in the facility was found to be lacking evidence of proper maintenance and inspection. During an observation and interview with the Maintenance Director, it was noted that the lift did not have stickers indicating the date of the last manufacturer's inspection. The lift also showed visible signs of wear, including rust and chipped paint. The Maintenance Director confirmed that the Hoyer Lift had not been inspected annually by the manufacturer, and that he personally replaced broken parts as needed without holding a manufacturer certification to service the equipment. A review of the facility's policies revealed that all Hoyer lifts are required to be regularly inspected, maintained, and repaired according to manufacturer guidelines, with annual inspections by a certified technician. The policies also require comprehensive safety checks, parts replacement, load capacity testing, and maintenance records. These procedures were not followed, as evidenced by the lack of inspection records and the Maintenance Director's statements.
Failure to Develop Care Plan for Psychotropic Medication Use
Penalty
Summary
The facility failed to develop and implement a care plan for a resident who was prescribed Ativan, a psychotropic medication, for anxiety disorder. Despite the resident having active diagnoses of schizophrenia, major depressive disorder, anxiety disorder, and psychotic disorder, and being cognitively intact with the capacity to make decisions, there was no care plan initiated to address the use of Ativan or the resident's anxiety. The resident received multiple doses of Ativan over the course of two months, as documented in the Medication Administration Records, but the care plan documentation did not reflect this intervention. Interviews with facility staff, including the MDS Coordinator and the DON, confirmed that the absence of a care plan for Ativan meant there was no documented approach to guide staff in managing the resident's anxiety or monitoring for potential side effects of the medication. The facility's policy required a person-centered comprehensive care plan to be developed by an interdisciplinary team within seven days of assessment and to be reviewed and revised as needed, but this process was not followed for the resident in question.
Failure to Perform Required Respiratory Assessments During Nebulizer Therapy
Penalty
Summary
The facility failed to provide appropriate respiratory care services for a resident diagnosed with COPD, TIA, and anemia by not following physician orders to auscultate lung sounds before and after nebulized medication administration. Specifically, staff did not listen to the resident's lung sounds prior to or following the administration of Ipratropium/Albuterol (Duoneb) via nebulizer, as required by the physician's order and the facility's own policy. Observations showed that one nurse administered the medication without auscultating lung sounds beforehand, and another nurse removed the nebulizer mask without performing the required post-treatment assessment. Interviews with staff revealed a lack of awareness regarding the physician's order to auscultate lung sounds pre- and post-treatment, despite this being a common practice to assess medication effectiveness. The resident confirmed that staff sometimes, but not always, listened to lung sounds before and after treatments, and on the day in question, the nurse only listened prior to administration. The facility's policy also required documentation of respiratory assessments before and after nebulizer therapy, which was not consistently followed.
Failure to Label Opened Inhalation Medication with Date
Penalty
Summary
A deficiency was identified when a resident's ipratropium-albuterol inhalation solution, used for the treatment of chronic obstructive pulmonary disease (COPD), was found in the medication cart with an opened foil pouch and visible unit-dose vials that were not labeled with the date of opening. The medication label specified that it expires seven days after opening, and manufacturer guidelines require that individual vials be used within one week of opening the foil pouch. During observation and interview, the LVN confirmed that the medication should have been labeled with the date it was first opened. The resident involved had a history of hypertensive heart disease, chronic kidney disease, and COPD, and was independent in activities of daily living with intact cognitive skills. The DON also confirmed that inhalation medication foil pouches should be dated upon opening, in accordance with manufacturer and pharmacy recommendations. Facility policy on nebulizer therapy requires proper administration by nursing staff, but did not specify labeling requirements. The failure to label the medication with the open date was directly observed and confirmed by staff.
Medication Error Rate Exceeds 5% Due to Improper Crushing and Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a medication error rate of 10.71%. This was identified during observation, interview, and record review, where three medication errors were observed out of 28 medication administration opportunities for one resident. The errors occurred when a Licensed Vocational Nurse (LVN) crushed and combined three medications—ProAmatine, Risperdal, and Vitamin D3—together before administering them to a resident, contrary to facility policy and standards of practice. The resident involved had multiple diagnoses, including dementia, vitamin D deficiency, paranoid schizophrenia, anxiety disorder, encephalopathy, and hypotension, and was assessed as having severe cognitive impairment and being dependent on staff for all activities of daily living. The facility's policy required that medications be crushed and administered in accordance with safety and accuracy standards, considering the resident's needs and medication schedule. The Director of Nursing confirmed that the medications should not have been crushed and administered together, indicating a failure to follow established procedures.
Crushing and Administering Multiple Medications Together
Penalty
Summary
A deficiency occurred when a nurse crushed and administered three medications—ProAmatine, Risperdal, and Vitamin D3—together for a resident with multiple diagnoses, including dementia, vitamin D deficiency, paranoid schizophrenia, anxiety disorder, encephalopathy, and hypotension. The resident was severely cognitively impaired and dependent on staff for all activities of daily living. The nurse removed the medications from their packaging, placed them together in a pouch, crushed them simultaneously, and mixed them with applesauce before administration. The facility's policy stated that medications may be combined and administered orally when appropriate, considering resident safety and standards of practice. However, during an interview, the DON confirmed that the medications should not have been crushed and administered together, and that the nurse should have known this. The incident was identified through observation, interview, and record review, and it was determined that the nurse's actions did not align with facility policy or accepted standards for medication administration.
Failure to Provide Routine Dental Care
Penalty
Summary
The facility failed to provide a routine dental visit for one resident who had an order for dental consult and treatment as indicated. The resident, admitted with multiple diagnoses including COPD, bipolar disorder, schizoaffective disorder, CVA, and paraplegia, had moderately impaired cognition and required varying levels of assistance with daily activities. Record review and interview with the Social Services Director confirmed that the resident had not been seen by a dentist since admission, despite the facility's policy to assist residents in obtaining routine and emergency dental care and the presence of a dentist in the facility for other residents.
Resident Rooms Below Required Square Footage
Penalty
Summary
The facility failed to ensure that 18 out of 21 resident rooms met the required minimum area of 80 square feet per resident for multiple occupancy rooms, as specified by federal regulations. Documentation, including a room waiver request letter and a Client Accommodation Analysis, confirmed that these rooms provided less than the required square footage per resident, with measurements ranging from 67 to 76.38 square feet per bed. Observations conducted over several days showed that both residents and staff had sufficient space to move and provide care, and all necessary furniture and equipment were accommodated within the rooms. The facility's own policy also stipulated the same minimum square footage requirements, which were not met in these rooms.
Failure to Prevent Injury and Document Care Refusal
Penalty
Summary
The facility failed to ensure a safe environment for a resident at high risk of fractures, who required maximum assistance with repositioning and perineal care. On 6/10/2024, the resident, who had a care plan requiring two to three-person assistance, was improperly repositioned by a single CNA during perineal care. The CNA did not follow the facility's protocol for turning and repositioning, which led to the resident being turned to her left side for an extended period, despite her hemiplegia on that side. This improper handling resulted in the resident sustaining a humerus fracture. The resident's care plan also included interventions for her resistance to care, which were not followed. The resident expressed refusal to be changed, but the CNA proceeded without seeking additional assistance or reporting the refusal to a supervisor, as required by the facility's policy. The resident's refusal and the CNA's actions were not documented, and the incident was not reported to the charge nurse, which contributed to the oversight of the resident's condition. Furthermore, the facility failed to document a change of condition after the resident sustained the fracture. The Director of Nursing confirmed that no change of condition was completed, which was necessary for a comprehensive assessment of the resident's status. This lack of documentation and communication resulted in a delay in addressing the resident's injury, as evidenced by the resident's severe pain and subsequent transfer to a hospital for further evaluation and treatment.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 6,385 citations issued within 25 miles in the last 12 months — including the 36 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Los Angeles
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pavilion On Pico Healthcare & Wellness Centre, Lp | 0.6 mi | ★★★★★ | 27 | 0 |
| West Pico Terrace Healthcare & Wellness Centre Lp | 0.6 mi | ★★★★★ | 15 | 0 |
| Beverly Hills Rehabilitation Centre | 1.2 mi | ★★★★★ | 3 | 0 |
| Miracle Mile Healthcare Center, Llc | 1.2 mi | ★★★★★ | 46 | 0 |
| Guardian Rehabilitation Hospital | 1.6 mi | ★★★★★ | 17 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.