Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Fountain View Subacute And Nursing Center during CMS and state inspections, most recent first.
Failure to Provide Timely Incontinence Care: A resident who was dependent on staff for ADLs and always incontinent did not receive timely perineal care when a CNA responded to a call light, asked if the resident was okay, and left without physically checking or changing the resident despite the RP reporting urine odor. Staff interviews confirmed the CNA should have checked and assisted the resident, and the DON stated leaving the resident soiled was unacceptable and could increase the risk for skin breakdown and UTI.
A facility failed to develop specific, person-centered care plans and failed to carry out ordered meds, glucose checks, and wound treatments for three residents. One resident’s seizure-related care plan was vague and not individualized, while two residents had multiple missed doses of anticonvulsants and other ordered meds. Another resident with DM had missed BG monitoring and insulin doses, and a resident with cellulitis and skin breakdown missed ordered topical and wound treatments. Staff interviews confirmed the care plans and treatment orders were not followed as written.
The facility failed to complete ordered monitoring for three residents with complex medical conditions. Ordered checks for pain, seizure activity, vital signs, medication side effects, opioid overdose symptoms, blood glucose, pulse oximetry, and anticoagulant monitoring were missed on multiple shifts, and the DON acknowledged that multiple assessments and related documentation were not completed for the sampled residents.
A facility failed to administer multiple ordered medications for three residents. One resident with seizure disorder, hypotension, and colon cancer missed repeated doses of seizure meds, midodrine, Depakote, and an antibiotic; a second resident with seizure disorder, diabetes, and HTN missed repeated doses of lamotrigine, levetiracetam ER, and pregabalin; and a third resident with diabetes and cellulitis missed ordered sliding-scale insulin doses, with blood glucose not monitored at the missed times. An LVN stated meds should be given as ordered, and the ADON and pharmacy consultant acknowledged the missed administrations.
A resident with colon cancer, seizures, hypotension, muscle weakness, and impaired cognition had a Depakote dose and frequency documented below usual dosing guidance, along with repeated severe and moderate drug-to-drug interaction alerts involving Ativan, Depakote, phenytoin, and lorazepam. An LVN and the ADON confirmed the nurse acknowledged the alerts but did not notify the MD, and the pharmacy consultant stated the facility had not reported the medication irregularities or interactions.
Inaccurate NP Progress Note for Resident in Hospital: A resident with colon cancer, weakness, seizures, and hypotension had a 30-day follow-up note stating the NP saw and evaluated the resident at the facility, even though the resident had been transferred to the hospital and progress notes showed the resident had not returned. The NP later said the note was an error, and the ADON stated the documentation was not acceptable because staff should not chart that they saw a resident if they did not.
Menu Not Followed for Pureed Diet Lunch: Eleven residents on a pureed diet were served pureed carrots instead of the pureed mixed vegetables listed on the lunch menu. Cook1 stated the mixed vegetables were not prepared due to a mistake and that the menu was not followed. The DS stated cooks were expected to serve what was on the menu and report any needed substitutions.
Unsafe food storage, sanitation, and temperature control practices were observed in the kitchen. A box of breaded chicken was thawing in the walk-in cooler with no thaw date, the ice machine had pink residue on the ice bin baffle, an employee wore layered gloves and did not wash hands or change gloves when switching tasks, and potato salad held for lunch service was 55.5 degrees F instead of 41 degrees F or below.
Inaccurate and incomplete documentation was found for three residents. An RN charted skin checks incorrectly for a resident with a mitten restraint and invasive tubes, a change-in-condition form for a resident with generalized weakness was left incomplete, and MAR documentation for another resident included blank entries and false administration of temazepam that had not been delivered. Staff and the DON confirmed the charting errors and omissions.
Failure to obtain informed consent before starting sertraline for a resident with depression and dementia. The resident had fluctuating decision-making capacity, severe problems with thinking or memory, and a designated responsible party, but the MRD and DON both confirmed there was no documentation of informed consent for the psychotropic medication. The care plan also noted that informed consent was to be provided to the resident or healthcare decision maker.
Call Light Not Within Reach: A resident with significant cognitive impairment, Alzheimer’s disease, weakness, and difficulty walking was observed sitting in bed without the call light visible or within reach. An LVN found the call light hanging along the side of the bed, and staff confirmed it should have been accessible to the resident at all times per facility policy.
Incomplete Advance Directive Acknowledgement Form: A resident with intact cognition and decision-making capacity had an Advance Directive Acknowledgement Form that was left incomplete, with no option boxes checked to show whether advance directive information was offered or whether the resident chose to execute or decline one. The SSD, ADM, and DON all confirmed the form did not document the resident’s choices, and the facility policy required residents to be informed of their right to complete or decline an Advance Directive.
A resident with severe cognitive impairment, dementia, aphasia, and multiple chronic conditions was changed from skilled therapy to custodial care, but the facility did not provide the required NOMNC to the resident or representative when Medicare Part A coverage ended. The BOM initially was unsure whether the notice was needed, then acknowledged after speaking with the ARC that the resident had not exhausted Medicare benefits and that the NOMNC should have been issued so an appeal could be made.
A resident with orders for PRN Alprazolam for anxiety was not given adequate monitoring for anxiety symptoms or verbalizations of nervousness/anxiousness. RN and DON both stated there was no physician order to monitor those symptoms, and the resident reported feeling anxious, especially when people bothered him at night.
Inaccurate MDS Failed to Document DVT Diagnosis: A resident with multiple comorbidities, including dementia, ESRD, COPD, and reduced mobility, had records showing DVT findings on ultrasound, a change in condition note for leg pain with a new DVT, and an H&P documenting RLE DVT. However, the MDS did not check the DVT/PE/PTE item in Section I, and the MDSN and DON confirmed the assessment was inaccurate.
The facility failed to ensure individualized care plans were in place for two residents with significant cognitive impairment and multiple medical diagnoses. One resident had orders for mirtazapine with monitoring for side effects and effectiveness, and another resident had orders to monitor episodes of restlessness and document intervention effectiveness every shift, but the DON stated no care plans were in place for either resident. Interviews confirmed care plans are intended to guide nursing interventions, and facility policy required care plans within 7 days of the comprehensive assessment.
Failure to Update Hemodialysis Care Plan: A resident with ESRD and intact cognition had a care plan that listed HD Monday through Friday, but the order summary later added multiple HD-related orders and a revised HD schedule. The LVN and DON stated the care plan was not updated to reflect the changed HD orders and treatment days, despite the resident’s ongoing dialysis needs and the facility policy requiring care plans to be reviewed and revised as resident condition changes.
A resident with severe comorbidities, cognitive impairment, and existing pressure ulcers developed a right heel wound that was repeatedly treated as a skin tear by an LPN/TN. The wound was later identified by NP as a stage 2 pressure ulcer, while the TN stated he did not know the pressure ulcer stages and had not notified the wound specialist. The DON also observed extra linens on the resident’s LALM, which he said defeated the purpose of the mattress.
A resident with ESRD, HTN, and mobility impairment did not have current HD orders maintained in the chart after readmission and after a change in the HD schedule. Staff also found the dialysis emergency kit in a clear bag mixed with the resident’s belongings instead of being clearly labeled and readily accessible. The DON, MRD, and HDN all described breakdowns in communication and documentation between the contracted dialysis provider and facility nursing staff.
An LPN/Treatment Nurse was found not competent in wound care after misidentifying a resident’s right heel wound as a skin tear instead of a Stage 2 pressure injury. The resident had multiple complex conditions, including diabetes, malnutrition, dementia, ventilator dependence, and existing pressure ulcers. The wound was treated under physician orders for weeks before NP assessment reclassified it, and the DON stated the nurse should have recognized the skin change and identified the pressure ulcer.
An open Trelegy Ellipta inhaler for a resident was found in the SNF North med cart with only a partial open date recorded. An LVN stated the full date, including the day, was required to determine expiration, and the facility P&P required opened multi-dose meds to be dated and discarded within the applicable timeframe.
Hand hygiene was not performed between resident care tasks for two residents who needed help with eating. One CNA assisted a resident with feeding and then did not clean her hands before cutting another resident’s food, and another CNA handled a dirty lunch tray and then did not clean her hands before assisting the second resident with eating. The IP, RN, DON, and facility policy all stated hand hygiene was required before and after resident contact and between care tasks to prevent spread of infection.
Insect Presence in Resident Room: A brown insect resembling a cockroach was observed on the floor in a resident's room, adjacent to a wall with cracks and a missing section of baseboard. The MND and IP both observed the insect during the survey, and the IP acknowledged that insects pose infection control risks. Facility pest control reports showed cockroaches and rats were targeted pests, and the ADM stated pest control is important for infection control and resident comfort.
A resident with heart failure, intact cognition, and extensive ADL needs reported that a CNA touched her inappropriately in the vaginal area during perineal care and stated she informed the social worker but no action was taken. The SSW acknowledged receiving the abuse allegation and knowing the abuse reporting policy but did not notify the Administrator, DON, or other leadership, did not complete required SOC 341 documentation, and did not contact law enforcement or the Ombudsman. The DSD reported that the Ombudsman had previously relayed that the same resident said she had been touched inappropriately by staff, but the DSD did not obtain details, assumed it referred to back rubs, and did not initiate an investigation or remove the CNA from resident contact. The DON stated he was not informed at the time of the allegation, and review of facility policy showed abuse allegations must be reported within two hours and accused staff removed from resident contact, which did not occur.
A resident with heart failure and intact cognition, dependent on staff for most ADLs, reported that a CNA touched her inappropriately during perineal care. The resident informed the SSW, who acknowledged knowing the abuse reporting policy but did not notify the Administrator or DON, did not complete required SOC 341 documentation, and did not contact law enforcement or the Ombudsman. The DSD was told by the Ombudsman that the resident had reported being touched inappropriately by staff but did not obtain details, assumed it referred to routine back rubs, and did not initiate an investigation or remove the CNA from resident contact. Review of facility policy showed that abuse allegations must be reported within two hours to leadership and external agencies, and that accused staff must be placed on leave without resident contact, which did not occur.
A resident with heart failure, intact cognition, and extensive ADL needs reported that a CNA touched her inappropriately during perineal care and stated she informed the social worker, but no action was taken. The social services worker acknowledged receiving the abuse allegation and knowing the requirement to immediately report it to administration and outside agencies, yet did not notify the Administrator or DON, did not complete the SOC 341, and did not contact law enforcement or the Ombudsman. The DSD also learned of a similar allegation during an Ombudsman visit but did not obtain details, assumed it referred to routine back rubs, and did not initiate an investigation or remove the alleged perpetrator from resident contact. The DON and Administrator were unaware of the allegation, and review of facility policy showed that abuse allegations must be reported within two hours and that accused staff must be placed on leave, which did not occur.
A resident with heart failure, obesity, and reduced mobility requested a transfer to another facility but did not receive timely updates or follow-up from staff for about a month. The Social Services Worker admitted to not contacting the requested facility or informing the resident of the status, leading to the resident's frustration and dissatisfaction with communication and care.
A resident with severe cognitive impairment and complex medical needs missed multiple scheduled medical appointments due to lack of escort availability, transportation issues, and poor communication among staff. Additionally, nursing staff failed to document the resident's return from appointments and update new orders or follow-up care in the medical record, contrary to facility policy.
A resident with heart failure, obesity, and reduced mobility requested assistance with transferring to another facility but did not receive timely follow-up or communication from the Social Services Worker (SSW) for about a month. The resident experienced frustration and dissatisfaction due to the lack of updates, and records showed no documentation of contact with the requested facility or communication about the transfer status. The DON confirmed it was the SSW's responsibility to assist with such requests and keep residents informed.
A resident with left eye blindness and low vision in the right eye had an order for atropine eye drops, but the record contained no comprehensive care plan interventions for the condition, including goals, monitoring, comfort measures, or physician notification requirements. The resident reported missed eye medication doses caused dryness and pain, and an LPN acknowledged a scheduled dose was not given and pain was not assessed during the shift; the DON stated the omission should have been documented and endorsed by licensed nurses.
A resident with left eye blindness and low vision in the other eye missed scheduled atropine eye drops, including a morning dose that was not administered, documented, or endorsed to the oncoming nurse. The MAR also showed prior omitted doses without explanation. The resident reported dry, painful eyes, and the LVN acknowledged the medication was in the cart, had not been given as scheduled, and that pain was not assessed.
The emergency tracheostomy ventilator unit box (e-kit) was found locked without documentation of its last check, and staff were unable to confirm when or by whom it was last maintained. The required monthly checks and documentation, as outlined in facility policy, were not completed, leaving the e-kit’s readiness for emergencies unverified.
The facility did not follow prescribed menu and portion sizes for residents on pureed, controlled carbohydrate, and soft and bite size diets. Residents on pureed diets received less food than required, those on CCHO diets received excessive rice, and soft and bite size diet meals were not prepared to the correct texture and size, as specified by facility policy and diet guidelines.
The facility failed to follow safe food storage and preparation practices by serving unpasteurized shell eggs to residents and storing pureed desserts without proper labeling or identification. Staff were unaware that the eggs used were not pasteurized, and prepared foods were not labeled according to policy, increasing the risk of foodborne illness for residents.
A resident with severe cognitive impairment and total dependence on staff had medication administered through a g-tube by an LVN without the privacy curtain being pulled, leaving the resident's abdomen exposed while a roommate was present. Both the LVN and DON confirmed that privacy should have been maintained during the procedure, in accordance with facility policy.
A resident with chronic respiratory failure, obesity, and encephalopathy who required ventilator and tracheostomy care did not have a care plan addressing these needs. Despite receiving oxygen therapy, suctioning, and mechanical ventilation, the facility did not create a care plan for ventilator/tracheostomy care, as confirmed by both the MDS Nurse and DON during interviews and record review.
A resident with severe cognitive impairment and a history of acute respiratory failure and epilepsy, who required a hand mitten restraint to prevent removal of invasive tubing, did not have their care plan updated quarterly as required. Despite facility policy and physician orders, the care plan had not been revised for several months, which could have led to missed nursing interventions.
A resident with a Stage 4 sacral pressure ulcer was found to have a Low Air Loss Mattress (LALM) set above the physician-ordered range, despite orders and manufacturer instructions to set the mattress based on the resident's weight. The resident reported discomfort, and staff confirmed the settings were incorrect, potentially impacting wound management.
A CNA failed to change PPE and perform hand hygiene between providing care to two residents on enhanced barrier precautions, both of whom had significant medical conditions and required full assistance. This lapse was observed and confirmed by facility staff, and was not in accordance with the facility's infection control policies.
Twelve resident rooms were found to provide less than the required 80 square feet per resident, based on facility records and direct measurement. Although staff were observed to have enough space to provide care and residents did not express concerns about room size, the documented square footage in these rooms did not meet regulatory standards.
A facility failed to follow care plan interventions for a resident with multiple medical conditions, including ESRD and diabetes. The care plan required vital signs to be recorded and Amoxicillin to be administered twice daily. However, a dose was missed, and vital signs were not consistently documented. The DON acknowledged documentation gaps, attributing them to new nursing staff.
The facility failed to maintain accurate medical records for two residents, leading to deficiencies in documentation. One resident's ventilator administration record contained inaccuracies, with procedures marked as completed despite the resident being discharged to a hospital. Another resident's vital sign summaries and nurse progress notes were incomplete and inaccurate, with errors in the recorded date of death. The DON acknowledged these issues, attributing them to staff errors and the need for improved documentation practices.
The facility failed to adhere to its staff meal-break policy, as confirmed by interviews with LVNs and the ADON. LVNs were scheduled for 12-hour shifts, but when the census was low, their hours were flexed, requiring them to take unpaid lunch breaks or leave early, resulting in less than 12-hour shifts. This practice violated the signed meal waiver agreement, which allowed waiving a second meal break only if working more than 10 but less than 12 hours.
The facility did not post the actual hours worked by nursing staff for two days, displaying only projected hours on the DHPPD board. Interviews with the DON and ADM confirmed that actual hours should have been posted, as required by the facility's policy.
A facility failed to implement effective infection control measures for scabies, leading to a potential risk of transmission among residents and staff. A resident with a skin rash was not placed on contact precautions when treatment began, and the diagnosis of scabies was confirmed later. The facility did not maintain contact precautions as per the physician's order, and the infection preventionist acknowledged that precautions were initiated late. This deficiency resulted in a potential risk of scabies transmission to 86 in-house residents, staff, and the community.
A facility failed to ensure its Infection Preventionist Nurse completed required annual training, leading to inadequate contact precautions for a resident diagnosed with scabies. The resident, with multiple health issues, was not properly isolated, risking the spread of infection. The Director of Nursing acknowledged the oversight in infection control measures.
The facility failed to ensure that a CNA's certification was up to date, allowing the CNA to work for over a month with an expired certificate. This lapse in following the facility's policy on licensure and certification could lead to inadequate resident care.
The facility failed to develop comprehensive care plans for four residents, leading to deficiencies in monitoring CVA and aspirin use, adverse effects of Lexapro, transmission-based precautions, and a skin disorder. This was confirmed by the DON and LVNs, who acknowledged the oversight and the importance of individualized care plans.
The facility failed to provide complete RNA treatments and proper documentation for three residents, leading to increased risk for contractures and decline in physical function. The residents did not receive the ordered PROM and AROM exercises, and the records were incomplete, with no documentation of treatment provided or refused on specific dates.
The facility failed to account for controlled substances for several residents, leading to discrepancies in medication counts and documentation. LVNs admitted to either not documenting administered medications or documenting medications that were not administered. Additionally, the DON failed to include verifying signatures on accountability logs, leading to potential inaccuracies and diversion risks.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for a resident who was dependent on staff for toileting hygiene, personal hygiene, bathing, dressing, and oral hygiene, and who was always incontinent. The resident’s record also showed diagnoses including lymphedema, muscle weakness, dementia, and obesity. The care plan directed staff to assist with perineal care as needed, and the resident’s admission record and MDS reflected mild cognitive impairment and total dependence for several activities of daily living. On 7/11/2026, the resident’s representative pressed the call light around 3:00 p.m. after smelling urine in the room and asked CNA 1 to check and change the resident. CNA 1 responded about 30 minutes later, asked the resident if she was okay, did not physically check whether she was wet, and walked out after the resident said she was okay. The representative followed CNA 1 into the hallway and again asked if she was going to change the resident, but CNA 1 repeated that the resident said she was okay and left. CNA 1 later confirmed she did not physically check the resident. Interviews with CNA 2, LVN 1, and the DON indicated CNA staff should respond to call lights, physically check residents when requested, and provide care when indicated; the DON stated leaving the resident soiled was unacceptable and could increase the risk for skin breakdown and UTI. The resident’s record also included a UA showing bacteria present and a CBC with an elevated WBC count, and nursing notes documented the physician was notified of the UTI findings.
Incomplete Care Plans and Missed Ordered Medications and Treatments
Penalty
Summary
The facility failed to develop and implement person-centered care plans for three residents. For one resident with colon cancer, muscle weakness, seizures, and hypotension, the care plan entries were not specific or individualized. The care plan documented interventions such as administering medication as ordered, checking range of motion, continuing interventions on the at-risk plan, taking vital signs, and monitoring for weight loss, but the interventions did not specify the medication, frequency, or exact parameters to follow. The resident’s MDS indicated impaired cognition and inability to make decisions. The facility also failed to implement ordered medication interventions for two residents with seizure disorders and other diagnoses. For one resident, physician orders included Keppra, Lacosamide, and Depakote, and the care plan directed administration of these medications as ordered, but the MAR showed multiple missed doses of Depakote, Lacosamide, and Keppra in May 2026. For another resident with muscle weakness, seizure disorder, hypertension, diabetes, and a history of falls, physician orders included Lamotrigine, Levetiracetam ER, and Pregabalin, and the care plan directed medication administration in accordance with physician orders, but the MAR showed missed doses of Lamotrigine, Levetiracetam ER, and Pregabalin across May and June 2026. The facility further failed to implement ordered diabetes monitoring and treatment for a resident with diabetes and cellulitis. The physician ordered insulin aspart by sliding scale before meals and at bedtime, and the care plan directed blood glucose monitoring and administration of antidiabetic medication as ordered. The MAR showed that blood glucose was not monitored and insulin was not administered on multiple occasions. In addition, for the resident with bilateral lower extremity cellulitis and skin breakdown, physician orders required Polysporin to both lower extremities and wound care to the left lower leg venous ulcer and right lower leg blister, but the TAR showed multiple missed treatment administrations. Interviews with LVN 1 and the ADON confirmed that the care plans and treatment orders were not followed and implemented as ordered.
Missed Monitoring and Documentation for Multiple Residents
Penalty
Summary
The facility failed to ensure that three sampled residents were adequately monitored for changes in condition and adverse effects of medications. Resident 1 had diagnoses including colon cancer, muscle weakness, seizure, and hypotension, and the MDS indicated the resident’s cognition was not intact and the resident was unable to make decisions. Physician orders included pain monitoring, seizure activity monitoring, monitoring for signs and symptoms, hours of sleep monitoring, and anti-convulsant and anti-depressant monitoring, but the MAR showed multiple missed entries for pain monitoring, seizure monitoring, vital signs, anti-depressant monitoring, hours of sleep, and anti-convulsant monitoring on several dates and shifts. Resident 2 had diagnoses including muscle weakness, seizure, hypertension, diabetes, and history of fall, and the MDS indicated cognition was intact. Physician orders included monitoring for anti-anxiety, anti-convulsant, and anti-depressant medication side effects, monitoring for opioid overdose symptoms, observing for seizure episodes, pain monitoring, and abnormal signs and symptoms every shift including blood pressure, temperature, pulse, and respiratory rate. The MAR showed missed documentation for anti-anxiety, anti-convulsant, anti-depressant, opioid overdose symptom monitoring, seizure observation, pain monitoring, and vital signs on multiple dates and shifts. Resident 3 had diagnoses including cellulitis of both lower limbs, diabetes, and hypertension, and the MDS indicated cognition was intact. Physician orders included insulin administration with finger stick blood glucose checks before meals and at bedtime, pulse oximetry every shift, pain monitoring every shift, monitoring for opioid overdose symptoms, anticoagulant monitoring, and abnormal signs and symptoms every shift including blood pressure, temperature, pulse, and respiratory rate. The MAR showed missed finger stick blood glucose checks, pulse oxygen monitoring, pain monitoring, opioid overdose symptom monitoring, anticoagulant monitoring, and vital signs on multiple dates and shifts. The DON acknowledged that multiple assessments for the sampled residents were not completed and that no documentation or progress notes were done for the missing dates and times.
Repeated Missed Medication Administrations
Penalty
Summary
The facility failed to ensure that medications were administered as ordered for three sampled residents. Resident 1 had diagnoses including colon cancer, muscle weakness, seizure disorder, and hypotension, and the MDS indicated the resident’s cognition was not intact and the resident was unable to make decisions. The physician orders included Keppra, lacosamide, Depakote, midodrine, and metronidazole, but the MAR showed multiple missed doses of each medication across May 2026, including repeated missed evening doses of seizure medications, missed midodrine doses, missed Depakote doses, and missed metronidazole doses. Resident 2 had diagnoses including muscle weakness, seizure disorder, hypertension, diabetes, and a history of falls, and the MDS indicated cognition was intact. The physician orders included lamotrigine, levetiracetam ER, and pregabalin, but the MAR showed multiple missed doses of all three medications in May and June 2026. The missed doses included repeated omissions of the seizure medications and pregabalin at scheduled administration times. Resident 3 had diagnoses including cellulitis of both lower limbs, diabetes, and hypertension, and the MDS indicated cognition was intact. The physician order included insulin aspart by sliding scale before meals and at bedtime, but the MAR showed that blood glucose was not monitored and the insulin order was not administered on multiple occasions in June 2026. During interviews, an LVN stated medications should be administered as ordered, and the ADON acknowledged that the residents had multiple medications not administered as ordered. The pharmacy consultant stated antibiotics should be given as scheduled and completed, missing seizure medications increase the chance of seizure episodes, and the facility should follow physician orders for medication administration.
Failure to Report Medication Irregularities and Drug Interactions
Penalty
Summary
The facility failed to ensure safe medication management for one resident with colon cancer, muscle weakness, seizures, hypotension, and impaired cognition who was unable to make decisions. During review of the resident’s record, a nursing progress note documented Depakote 250 mg by mouth in the afternoon for anticonvulsant use, and the dose and frequency were below the usual dosing regimen noted in the record. The facility also documented multiple drug-to-drug interaction alerts involving Ativan, Depakote, phenytoin sodium extended capsule, and lorazepam, including severe and moderate interactions. Interviews with an LVN and the ADON confirmed that when these interaction alerts and the out-of-recommendation dose occurred, the nurse acknowledged the alerts but did not notify the physician, and no progress notes were found showing physician notification for the events. The pharmacy consultant stated the facility had not reported any drug-to-drug interactions or medication orders outside of recommendation guidelines, and the facility policy required the physician to be immediately informed when treatment needed to be altered significantly.
Inaccurate NP Progress Note for Resident in Hospital
Penalty
Summary
The facility failed to ensure accurate medical record documentation for one resident when the Nurse Practitioner documented in a 30-day follow-up note that the resident was seen and evaluated at the facility on 6/18/2026, even though the resident had been transferred to the hospital on 6/16/2026 and was not physically present at the facility on that date. The resident’s record showed an admission history that included colon cancer, muscle weakness, seizures, and hypotension, and the Minimum Data Set dated 4/21/2026 indicated the resident’s cognition was not intact and the resident was unable to make decisions. The resident’s Change of Condition report documented the hospital transfer, and progress notes from 6/17/2026 through 6/20/2026 indicated the resident remained in the hospital and had not returned to the facility. During interview, the NP first stated she saw the resident on 6/18/2026, then stated she did not see the resident that day and that the 30-day follow-up note was an error. The ADON stated the documentation was not acceptable and that if the physician or NP did not see the resident, they should not document that they did. The facility policy stated documentation in the medical record must be objective, complete, and accurate.
Menu Not Followed for Pureed Diet Lunch
Penalty
Summary
The facility failed to ensure the standardized lunch menu was followed for residents on a pureed diet. On 6/8/2026, during tray line service at 12:30 PM, eleven residents on pureed diets were served pureed carrots instead of the pureed mixed vegetables listed on the menu. The lunch menu reviewed for that day listed pureed fried chicken, pureed potato salad, pureed mixed vegetables, pureed bread, pureed mandarin oranges, and a beverage of choice for the pureed diet. During interview, Cook1 stated that pureed mixed vegetables were not prepared because of a mistake and that pureed carrots were served to all residents on the pureed diet instead of the mixed vegetables. Cook1 stated the menu was not followed. The Dietary Supervisor stated cooks needed to follow the menu and serve what was on the menu, and to inform the Dietary Supervisor when any ingredient needed to be replaced. The facility’s cooks spreadsheet for that day also listed pureed mixed vegetables for the pureed/Level 4 diet, and the facility policy stated menus would be planned in advance and served as written unless a substitution was provided for preference, unavailability, or a special meal.
Unsafe Food Storage, Ice Machine Sanitation, Glove Use, and Cold Holding
Penalty
Summary
Safe and sanitary food storage and preparation practices were not maintained in the kitchen. During observation in the walk-in refrigerator, one large box of breaded chicken was found thawing on the bottom shelf with no thaw date. The Dietary Supervisor stated the chicken had been delivered frozen on 6/4/2026, had been stored in the freezer, and that thawed food was kept in the refrigerator for three days before cooking. Facility policy required foods to be stored wrapped or in covered containers, labeled and dated, and arranged to prevent cross contamination. The ice machine was not maintained in a sanitary manner. During observation of the ice machine, a clean paper towel swipe of the ice storage bin ceiling produced small amounts of pink residue under the plastic baffle. The Dietary Supervisor stated an outside vendor cleaned the ice machine once a month and acknowledged the residue should be cleaned better. The District Manager stated the vendor should come twice a month to make sure the ice machine was clean. Facility policy required ice to be prepared and distributed in a safe and sanitary manner, and the FDA Food Code required enclosed components of ice makers to be cleaned at a frequency necessary to preclude accumulation of soil or mold. During kitchen observation, Cook1 was wearing layered gloves and moved between tasks without washing hands or changing gloves appropriately. Cook1 transferred cooked food to the steam table, left the area to get serving utensils, returned to prepare minced chicken in a blender, removed only the top layer of gloves when they became dirty, and continued working with the gloves underneath. Cook1 stated the extra layer of gloves was used to move quickly from one task to another and that the correct practice was to wear one layer of gloves, wash hands, and replace gloves when dirty. In addition, during lunch service, potato salad held for cold service registered 55.5 degrees F. The Dietary Supervisor stated it should be 41 degrees F or lower and directed that it be returned to the refrigerator. Staff stated the potato salad had been portioned around 11:30 AM and had not had enough time to become cold before lunch service. Facility policy and the FDA Food Code required cold TCS foods to be held at 41 degrees F or below.
Inaccurate and Incomplete MAR and Change-in-Condition Documentation
Penalty
Summary
Documentation in the medical record was inaccurate and incomplete for three sampled residents. For one resident with chronic respiratory failure, cerebral infarction, tracheostomy, gastrostomy, ventilator dependence, hemiplegia, and hemiparesis, the physician order required a left-hand mitten to be released every two hours, with circulation and skin integrity checks every two hours and documentation of "+" for new skin alterations and "-" when none were present. The MARs for April, May, and June 2026 showed multiple entries by RN 2 documenting "+" on several occasions. During interview, RN 2 stated the resident did not have any skin alterations and that the "+" entries were mistakes; the DON also stated the entries were erroneous and should have reflected the resident’s actual status. For another resident with type 2 diabetes, sepsis, ESRD on dialysis, hemiplegia, and hemiparesis, the Change in Condition Evaluation for generalized weakness was started but not completed. The form stated there was no documentation that the physician or representative was notified and no signature or date was present on the evaluation. RN 3 stated the resident was weak, the physician was notified, and the resident was sent to the hospital, but the change-in-condition documentation was not completed. The DON stated the form should have contained the details of what occurred, the resident’s assessment, physician notification, and recommendations, and confirmed that the evaluation was not completed. For a third resident with Parkinson’s disease, Alzheimer’s disease, schizophrenia, anxiety disorder, and dementia, the MAR did not document administration for some ordered medications on certain dates, and it documented temazepam as administered on dates when the medication had not been delivered to the facility. RN 1 stated blank MAR entries meant the LVN did not document administration. The PharmD stated temazepam had not been received from the facility order process, the DON could not find temazepam in the medication carts, and two LVNs stated they had marked temazepam as given by mistake even though they had never administered it. The DON stated the blank entries showed the documentation policy was not followed and that staff did not follow up with the pharmacy or escalate the issue.
Failure to Obtain Informed Consent for Sertraline
Penalty
Summary
The facility failed to obtain informed consent from Resident 62 or the resident’s responsible party before starting sertraline 25 mg by mouth daily for depression manifested by difficulty falling asleep. Resident 62’s admission record showed diagnoses including depression and dementia, and the face sheet identified a designated responsible party. The H&P dated 4/3/2026 stated the resident had fluctuating capacity to understand and make decisions, and the MDS dated 4/21/2026 indicated severe problems with thinking or memory. The order summary report dated 4/6/2026 showed the sertraline order, and the care plan dated 4/7/2026 stated the resident was currently using sertraline for depression and that informed consent was to be provided to the resident or healthcare decision maker. During interviews on 6/10/2026, the MRD and DON both stated there was no documentation of informed consent for the resident’s sertraline. The DON stated informed consent for psychotropic medications was important and acknowledged there was no documentation of informed consent for Resident 62’s sertraline.
Call Light Not Within Resident’s Reach
Penalty
Summary
The facility failed to provide reasonable accommodation of a resident’s needs by not keeping the call light within reach for Resident 12. Resident 12 was admitted and readmitted with diagnoses including metabolic encephalopathy, Alzheimer’s disease, history of falling, generalized muscle weakness, and difficulty walking. The MDS dated 5/28/2026 indicated significant cognitive impairment, use of a walker for ambulation, and need for varying levels of assistance with oral hygiene, toileting, dressing, and showering. During an observation on 6/8/2026 at 12:14 p.m., Resident 12 was sitting in bed and stated she was unable to find her call light. LVN 1 located the call light hanging along the left side of the bed, out of Resident 12’s reach. During interview, LVN 1 stated the call light was not in reach but should have been, and that it is important for residents to have their call bell in reach. RN 1 stated that rounding includes checking that the call light is in reach and that the call light should always be within easy reach of the resident. The DON stated the facility’s call light policy requires the call light to be within the resident’s reach, and the facility policy titled Answering the Call Light stated the call light should be accessible to the resident at all times.
Incomplete Advance Directive Acknowledgement Form
Penalty
Summary
The facility failed to complete the Advance Directive Acknowledgement Form for one sampled resident who was admitted originally on 3/2/2024 and readmitted on 4/24/2026 with diagnoses including muscle weakness, gait abnormalities, end stage renal disease, and essential hypertension. An untitled history and physical dated 8/3/2025 indicated the resident had the capacity to understand and make decisions. The Advance Directive Acknowledgement Form dated 4/24/2026 showed the resident had not executed an Advance Directive and was not offered options to execute or decline an Advance Directive, and the Minimum Data Set dated 4/28/2026 indicated the resident made herself understood, understood others, and had intact cognitive functioning. During interview and record review, the Social Service Director, Administrator, and Director of Nursing each stated the form was incomplete because none of the option boxes were checked. They stated the unchecked boxes did not show whether the resident was provided advance directive information or whether any choices were selected. The facility policy titled Advance Directive, dated 11/20/2025, stated admission staff or designee will inform the resident of the right to execute an Advance Directive, that each resident is informed it is their choice to complete the form, and that the choice not to complete the form is recorded in the medical record.
Failure to Provide Required Medicare Non-Coverage Notice
Penalty
Summary
The facility failed to ensure that Resident 32 and/or the resident’s representative received the required Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) / Notice of Medicare Non-Coverage (NOMNC) when Medicare coverage was ending and the resident was being treated as custodial care. The record showed Resident 32 was originally admitted on 11/10/2021 and readmitted on 3/23/2026 with diagnoses including heart failure, type 2 DM, COPD, muscle weakness, hemiplegia and hemiparesis following cerebral infarction, dementia, aphasia, contractures of multiple sites, and schizophrenia. The MDS dated 11/5/2025 indicated severe cognitive impairment and dependence for eating, oral hygiene, toileting, showering/bathing, and upper/lower body dressing. The facility’s SNF Beneficiary Protection Notification Review stated the facility did not give Resident 32 or the resident’s representative a NOMNC because the resident was on custodial care. During interview, the BOM stated Resident 32 did not receive a NOMNC and that the last Medicare Part A coverage was 11/5/2025, with therapy discontinued and the resident becoming custodial on 11/6/2025. During interviews, the BOM stated she was not sure whether Resident 32 or the representative should have received a NOMNC, then after speaking with the ARC, acknowledged that Resident 32 had not exhausted Medicare Part A benefits and that a NOMNC should have been given. The BOM and DON further stated the NOMNC should have been provided so the resident or representative could appeal and to protect against surprise or hidden charges. The facility policy titled Medicare Advance Beneficiary and Medicare Non-Coverage Notices stated written notices are to be provided in advance when Medicare payment denial or change in coverage is likely, and the facility’s NOMNC form included appeal rights and QIO contact information.
Failure to Monitor Anxiety Symptoms for Resident Receiving PRN Alprazolam
Penalty
Summary
The facility failed to ensure adequate monitoring for symptoms of anxiety for one resident who had an order for Alprazolam 0.25 mg by mouth every 6 hours as needed for anxiety manifested by verbalization of feeling nervous/anxious for 14 days. The resident was admitted with diagnoses including intervertebral disc degeneration, type 2 DM, need for assistance with personal care, difficulty walking, and hypertension. The record review showed there was no physician order to monitor the resident for symptoms of anxiety, and RN 1 stated that without such an order, nurses would not be prompted to monitor the resident for anxiety symptoms. During interview, the DON also stated there was no physician order to monitor the resident for verbalization of nervous/anxious feelings and that the resident needed to be monitored for those symptoms. The DON stated there was potential for the resident to experience symptoms of anxiety that were not addressed and that the physician might not know whether Alprazolam was effective if the symptoms were not monitored. The resident stated he had feelings of anxiousness, especially when people bothered him at night. The facility policy on psychotropic medication use stated that anti-anxiety medications are psychotropic medications and that residents receiving psychotropic medication are monitored and the response to treatment is documented.
Inaccurate MDS Failed to Document DVT Diagnosis
Penalty
Summary
The facility failed to provide an accurate MDS for one sampled resident by not documenting a diagnosis of DVT in Section I, Active Diagnoses in the last seven days. Resident 6 was admitted with multiple diagnoses including encephalopathy, COPD, reduced mobility, functional quadriplegia, dementia, type 2 DM, ESRD, and acute embolism and thrombosis of unspecified deep veins of the left lower extremity. Records reviewed showed a left lower extremity ultrasound identified a DVT of the left posterior tibial vein, and a Change of Condition Evaluation noted left lower extremity pain with a new DVT and PAD. An acute hospital record also documented a partially occlusive DVT of the right leg, and the resident was prescribed Xarelto for DVT. During interview and record review, the MDS Nurse confirmed the H&P showed a right lower extremity DVT, but the MDS did not have the DVT, PE, or PTE item checked. The DON also reviewed the MDS and stated it was not accurate because the MDS nurse did not indicate the resident had a DVT. The resident’s H&P stated the resident did not have the capacity to understand and make decisions, while the MDS indicated the resident usually could make himself understood and usually had the ability to understand others. The facility policy on certifying accuracy of the resident assessment stated that any person who completes any portion of the MDS assessment is required to sign certifying the accuracy of that portion.
Failure to Develop Individualized Care Plans for Medication Monitoring and Restlessness
Penalty
Summary
The facility failed to ensure individualized care plans were in place for two residents with identified needs. One resident had a history of metabolic encephalopathy, Alzheimer's disease, generalized muscle weakness, and depression, and the MDS showed significant cognitive impairment with assistance needs for ambulation and activities of daily living. Physician orders dated 6/11/2026 directed staff to administer mirtazapine 7.5 mg for depression and to monitor every shift for side effects and for effectiveness based on verbalizations of feeling sad and crying, but the DON stated there was no care plan in place for this resident. A second resident had diagnoses of type 2 diabetes mellitus, vascular dementia, and altered mental status, and the MDS showed significant cognitive impairment with assistance needs for showering, toileting, and dressing. Physician orders dated 1/27/2026 directed staff to monitor for episodes of restlessness and document the effectiveness of interventions every shift, but the DON stated there was no care plan in place for this resident. Interviews with an LVN, RN supervisor, and DON confirmed that care plans are used to guide nursing interventions and that licensed nurses, the DON, and the MDS nurse are responsible for creating and implementing them; the facility policy stated care plans should be developed within 7 days of completion of the comprehensive assessment.
Failure to Update Hemodialysis Care Plan
Penalty
Summary
The facility failed to update and revise Resident 73’s care plan for hemodialysis after the resident’s dialysis-related orders changed. Resident 73 was admitted with diagnoses including muscle weakness, gait abnormalities, end stage renal disease, and essential hypertension. The resident’s record also indicated the resident had the capacity to understand and make decisions, and the MDS showed the resident made herself understood, understood others, and had intact cognitive functioning. Resident 73’s care plan dated 7/31/2025 listed hemodialysis treatment as two to four hours bedside dialysis on Monday through Friday. The order summary from the same date also reflected dialysis treatment days Monday through Friday. On 4/25/2026, the order summary included additional dialysis-related orders: emergency care instructions after dialysis treatment day, hemodialysis access monitoring every shift, no blood pressure in the right arm, dialysis emergency kits at bedside as needed, and monitoring the AV fistula for signs and symptoms of infection, edema, and bleeding. During interviews and record review, LVN 1 stated the care plan should have been updated to reflect the changed dialysis orders and the revised treatment schedule. A home hemodialysis order dated 5/12/2026 showed a new schedule of four treatments per week, Monday, Tuesday, Wednesday, and Friday, with Thursday off. The DON also stated the care plan had not been updated with the dialysis care ordered on 4/25/2026, and the facility policy stated care plans are reviewed and revised as resident information and condition change.
Failure to Recognize and Report a Heel Pressure Ulcer
Penalty
Summary
The facility failed to ensure Resident 2 received appropriate pressure ulcer care when the resident’s right heel wound was treated as a skin tear for an extended period before it was identified as a stage 2 pressure ulcer. Resident 2 was admitted with multiple serious diagnoses, including chronic respiratory failure, COPD, ventilator dependence, type 2 diabetes, severe protein-calorie malnutrition, dysphagia, dementia, tracheostomy, gastrostomy, contractures, and existing stage 4 pressure ulcers. The resident’s MDS indicated severe cognitive impairment, dependence for many activities of daily living, risk for pressure ulcers, and use of a pressure-reducing device for bed. After a skin injury occurred to the right heel during wound care, the wound was documented and treated as a skin tear with cleansing, xeroform, and dry dressing orders that were repeatedly renewed and carried out by TN 1. During observation, the right heel was seen with thickened dark brown skin, an open wound with a red base, and a moist lifting skin flap. TN 1 stated he believed the wound was a skin tear, did not know or remember when it opened, and did not know when it became a stage 2 pressure ulcer. TN 1 also stated he did not really know how to describe the different stages of pressure ulcers. NP 1 later assessed the right heel and identified it as a stage 2 pressure ulcer, stating this was the first time she had been made aware of the wound. TN 1 stated he notified the attending physician but not the wound specialist, and the DON stated the wound specialist’s documentation did not show awareness of the right heel pressure ulcer because it had been documented as a skin tear. The DON also observed Resident 2 on a Med Aire LALM with a cloth pad and bed sheet on top of it and stated that having more than one bedsheet on the LALM defeated the purpose of the mattress. Facility records also showed TN 1 had been deemed competent in skin evaluation, while the DON stated TN 1 did not identify the change in the resident’s skin and should have notified the DON and wound specialist.
Hemodialysis orders not maintained and emergency kit not clearly identified
Penalty
Summary
The facility failed to ensure effective coordination and communication of hemodialysis care for one resident with end stage renal disease, muscle weakness, gait abnormalities, and essential hypertension. The resident was admitted originally on 3/2/2024 and readmitted on 4/24/2026. The record showed an order for dialysis emergency kits at bedside as needed, and the resident was documented as having the capacity to understand and make decisions and as being cognitively intact. During observation on 6/10/2026, a clear plastic bag was found on the resident’s bedside table mixed with personal belongings. The LVN identified the bag as the dialysis emergency kit but stated it was not labeled, should have been clearly identified as a dialysis emergency kit, and should have been located with easy access rather than mixed in with the resident’s belongings. The DON also stated the dialysis emergency kit should have been labeled and located at the bedside for dialysis access emergencies. Record review and staff interviews showed the facility did not have the resident’s current hemodialysis orders in the medical record after readmission and after the dialysis schedule changed on 5/12/2026. The Medical Records Director stated there was no hemodialysis treatment order dated 4/25/2026 for the readmission and no order dated 5/12/2026. The DON stated nurses should have placed the hemodialysis orders on readmission and when the schedule changed to four treatment days per week, and that there was a failure to communicate the orders from the contracted dialysis provider nurse and the facility nurse. The HDN stated the provider dialysis nurse did not document verbal communication of the admission hemodialysis orders to the admitting nurse, and that documenting this communication was important to ensure the orders were in the resident’s medical record.
Treatment Nurse Misidentified Heel Pressure Ulcer as Skin Tear
Penalty
Summary
The facility failed to ensure that one of three Treatment Nurses was competent in wound care services when TN 1 did not correctly identify a wound on a resident’s right heel as a Stage 2 pressure ulcer. The resident was admitted with multiple serious diagnoses, including chronic respiratory failure, COPD, ventilator dependence, type 2 diabetes, severe protein-calorie malnutrition, dysphagia, dementia, a Stage 4 sacral pressure ulcer, tracheostomy, gastrostomy, and contractures of both hands. The resident’s MDS showed severely impaired cognitive skills, dependence for many activities of daily living, and risk for pressure ulcers. The resident’s records showed that the right heel wound was initially treated as a skin tear after a change in condition evaluation documented that skin on the right heel had peeled during wound care. Physician orders were entered for cleansing with NS, applying xeroform, and covering with a dry dressing, and TN 1 confirmed those orders. The TAR showed TN 1 provided the ordered treatment on multiple dates across April, May, and June 2026. During a concurrent observation and interview, TN 1 was observed treating the right foot and stated the wound was a skin tear, that he had noticed part of the skin had fallen off, and that he did not know or remember when the wound opened. On the same day, TN 1 asked NP 1 to assess the wound, and NP 1 determined the wound was not a skin tear but a Stage 2 pressure ulcer. The change in condition evaluation then reclassified the wound as a 6 x 5.5 cm Stage 2 pressure ulcer with partial-thickness tissue loss. TN 1 stated he did not know when the wound became a Stage 2 pressure ulcer and did not really know how to describe the different stages of pressure ulcers. The DON stated TN 1 should have been able to identify the change in the resident’s skin, notify the DON and wound specialist, and that TN 1 needed to be competent in all aspects of wound care. The facility’s job descriptions for the LPN/LVN and wound care/treatment nurse included monitoring skin health, identifying and treating wounds, completing skin assessments, and providing wound treatments as ordered.
Incomplete Open Date on Resident’s Inhaler
Penalty
Summary
The facility failed to label an open Trelegy Ellipta inhaler for Resident 19 with a complete open date in one of the inspected medication carts, the SNF North Cart. During a concurrent observation and interview with LVN 1 in the hallway, the cart contained Resident 19’s opened inhaler with only an incomplete open date of 5/2026. LVN 1 stated that the inhaler should have the day listed as well as the month and year, and that without the full open date the expiration of the inhaler could not be determined. The product labeling indicated Trelegy Ellipta should be used or discarded within six weeks of opening, and the facility policy on Medication Labeling and Storage stated opened multi-dose medication containers are dated and discarded within 28 days unless the manufacturer specifies a different timeframe.
Hand Hygiene Not Performed Between Resident Care Tasks
Penalty
Summary
The facility failed to maintain infection control practices by not ensuring hand hygiene was performed between resident care tasks for two residents who required assistance with eating. One resident was admitted with diagnoses including cerebral infarction, dementia, gastroenteritis, colitis, lack of coordination, and dysphagia, and the MDS indicated severe cognitive impairment and partial to moderate assistance needed for eating. A second resident was admitted with diagnoses including muscle weakness, dysphagia, atrial fibrillation, and dementia, and the MDS indicated severe cognitive impairment and supervision or touching assistance needed when eating. During a concurrent observation and interview in the dining room, CNA 1 assisted the first resident with feeding and then did not perform hand hygiene before cutting the second resident's food; CNA 1 stated she forgot to perform hand hygiene between resident care tasks. During a separate observation and interview, CNA 2 handled a dirty lunch tray and then did not perform hand hygiene before assisting the second resident with eating; CNA 2 stated she forgot to perform hand hygiene after touching the dirty food tray. The IP, RN 1, and DON each stated staff were expected to perform hand hygiene between resident care tasks or before and after resident care to prevent the spread of infection, and the facility policy required handwashing/hand hygiene before and after contact with the resident.
Insect Presence in Resident Room
Penalty
Summary
The facility failed to ensure that one of two residents' rooms, Resident 31's room, was free of insects. During an observation on 6/9/2026 at 10:57 AM, a brown insect resembling a cockroach was seen on the floor next to a wall with cracks and a missing section of baseboard. During a concurrent observation and interview at 11:19 AM, the Maintenance Director observed a brown insect on the floor in the same room and stated that routine monthly pest control services had been completed within the past three months and that he was not aware of any current insect issue. During a concurrent observation and interview at 11:22 AM, the Infection Preventionist also observed the insect on the floor in Resident 31's room and stated they had never seen any insects in the facility before, while acknowledging that such insects pose infection control risks. A review of the facility's Pest Control Customer Service Reports dated 3/11/2026, 4/14/2026, and 5/13/2026 showed that cockroaches and rats were among the targeted pests for pest control services. The Administrator stated on 6/11/26 at 2:04 PM that controlling pests is important for infection control and resident comfort, and that the facility's pest control program includes deep cleaning residents' rooms as needed to ensure a clean environment.
Failure to Immediately Report and Investigate Allegation of Sexual Abuse
Penalty
Summary
Facility staff failed to ensure a resident was free from abuse by not immediately reporting, investigating, and addressing an allegation of sexual abuse. The resident, who had heart failure, intact cognition, and required extensive assistance with ADLs including personal care and toileting, reported that about five days prior a CNA cleaned her perineal area and touched her inappropriately in her vagina. The resident stated she reported this to the social worker, but nothing was done. The resident’s MDS showed she was dependent on staff for lower body dressing, toileting, and footwear, and required maximal or partial assistance for other ADLs, indicating reliance on staff for intimate care. The Social Services Worker acknowledged that the resident reported the allegation of abuse to her on the evening of 1/26/2026 and that she was aware of the facility’s abuse reporting policy, but she did not report the allegation to the Administrator, DON, or other leadership, did not complete an SOC 341, and did not notify police or the Ombudsman. The Administrator confirmed she had not been informed of the allegation and stated it should have been reported the day it occurred. The DSD reported that several days earlier the Ombudsman had informed her that the resident said she had been touched inappropriately by a staff member, but the DSD did not seek further details and assumed the resident was referring to back rubs, and no investigation was initiated and the CNA was not suspended. The DON stated he was not made aware of the allegation when it was reported and that the failure to report prevented implementation of immediate protective interventions. Review of the facility’s abuse policy showed that all abuse allegations must be reported immediately (within two hours) to the administrator and appropriate agencies, and that any employee accused of abuse is to be placed on leave with no resident contact until the investigation is complete, which did not occur in this case.
Failure to Report and Investigate Alleged Sexual Abuse and Remove Accused Staff
Penalty
Summary
The facility failed to implement its abuse prevention and reporting policies when a cognitively intact resident, admitted with heart failure and requiring extensive assistance with ADLs, reported being inappropriately touched in the perineal/vaginal area by a CNA during personal care. The resident stated the incident occurred several days prior and that she informed the social services worker (SSW), but nothing was done. The resident’s MDS showed she needed maximal to total assistance for most personal care tasks, including toileting and hygiene, and setup assistance for eating, indicating reliance on staff for intimate care. On the date the allegation was reported, the SSW acknowledged that the resident directly reported the alleged abuse to her but admitted she did not notify the Administrator, DON, or other leadership, did not complete the SOC 341, and did not contact law enforcement or the Ombudsman as required by facility policy. The Administrator and DON both stated they were unaware of the allegation at the time and confirmed that such an allegation should have been immediately reported and investigated. The Director of Staff Development (DSD) reported that the Ombudsman had previously informed her that the resident said she had been touched inappropriately by a staff member, but the DSD did not seek further details, assumed the resident was referring to back rubs, and did not initiate an investigation or remove the alleged perpetrator from resident contact. Review of the facility’s abuse reporting and investigation policy showed that all abuse allegations must be reported within two hours to the Administrator and appropriate agencies, and that any employee accused of abuse must be placed on leave with no resident contact until the investigation is complete, which did not occur in this case.
Failure to Immediately Report and Investigate Resident Abuse Allegation
Penalty
Summary
The facility failed to ensure an allegation of abuse involving one resident was immediately reported to facility administration and appropriate external authorities as required by policy and federal regulations. The resident, who had heart failure, required extensive assistance with ADLs, and had intact cognition, reported that about five days prior a CNA had cleaned her perineal area and touched her inappropriately in her vagina. The resident stated she reported this to the social worker, but nothing was done. The social services worker confirmed that the resident reported an allegation of abuse to her on the evening of 1/26/2026, acknowledged knowing the abuse reporting policy and the requirement to immediately report such allegations to administration, but did not notify the Administrator, DON, or other leadership, did not complete the SOC 341, and did not contact law enforcement or the Ombudsman as required by facility protocol. The Administrator stated she had not been informed of the allegation and confirmed that such conduct would be considered abuse and should have been reported the day it was reported to staff. The DSD reported that several days earlier, during an Ombudsman visit, the resident had also reported being touched inappropriately by a staff member, but the DSD did not seek further details and assumed the resident was referring to back rubs the resident usually requested; no investigation was initiated and the alleged perpetrator was not suspended. The DON stated he was not made aware of the allegation when it was reported and that the failure to report prevented the facility from implementing immediate protective interventions. Review of the facility’s abuse reporting and investigation policy showed that all reports of resident abuse were to be immediately reported to the administrator and appropriate agencies within two hours, and that any employee accused of abuse was to be placed on leave with no resident contact until the investigation was complete, which did not occur in this case.
Failure to Communicate and Follow Up on Resident Transfer Request
Penalty
Summary
The facility failed to ensure timely follow-up and communication regarding a resident's request to transfer to another facility. The resident, who had diagnoses including heart failure, obesity, and reduced mobility, was cognitively intact and required significant assistance with daily activities. Despite the resident's clear request for assistance with transferring, there was no documented evidence that the facility contacted the requested receiving facility or provided the resident with updates about the status of the transfer for approximately one month. The resident expressed frustration and dissatisfaction due to the lack of communication and support for his care preferences, and even stopped participating in physical therapy sessions in anticipation of the transfer. Interviews revealed that the Social Services Worker acknowledged failing to follow up on the transfer request and not providing updates to the resident. The Director of Nursing confirmed that it was the responsibility of the Social Services Worker to assist residents with grievances and requests, including communicating updates. Review of facility policy indicated that residents have the right to be informed of and participate in care planning, and to have the facility respond to grievances. The lack of timely follow-up and communication impeded the resident's request and negatively affected his experience.
Failure to Ensure Resident Attendance at Medical Appointments and Documentation of Follow-Up Care
Penalty
Summary
The facility failed to ensure that a resident with diagnoses including colon cancer, cognitive communication deficit, and epilepsy attended multiple scheduled physician appointments outside the facility. The resident, who had severely impaired cognition and required maximal to partial assistance with daily activities, missed several important medical appointments for colorectal surgery surveillance and neurology follow-up. The missed appointments were due to issues such as lack of available escorts, transportation staff declining responsibility, and facility staff being unaware of scheduled appointments. There was also a failure to document nursing progress notes following outside medical visits. Specifically, after the resident attended an appointment, the charge nurse did not document the resident's return, update new orders, or follow up in the resident's chart. The charge nurse acknowledged not ensuring a proper handoff to the next shift, which would have facilitated documentation and follow-up on new orders and appointments. The facility's process, as described by staff, included communication of appointments, documentation of departures and returns, and handling of new orders, but these steps were not consistently followed. Interviews with facility staff revealed gaps in communication and documentation practices. The social services worker, registered nurse supervisor, charge nurse, care coordinator, and director of nursing all described processes that were not effectively implemented, resulting in missed appointments and lack of documentation. The facility's policy required assistance with scheduling, transportation, and documentation of appointments and new orders, but these procedures were not adhered to in this case.
Failure to Communicate and Follow Up on Resident Transfer Request
Penalty
Summary
The facility failed to ensure timely follow-up and communication regarding a resident's request to transfer to another facility. The resident, who had diagnoses including heart failure, obesity, and reduced mobility, was cognitively intact and required maximal to total assistance with most activities of daily living. Despite the resident's request for assistance with transferring, there was no documented follow-up or communication from the Social Services Worker (SSW) for approximately one month. The resident expressed frustration and dissatisfaction due to the lack of updates and support for his care preferences, and even stopped participating in physical therapy sessions in anticipation of the transfer. Interviews revealed that the SSW acknowledged not contacting the requested receiving facility or providing the resident with updates about the status of the transfer request. Record review confirmed the absence of documentation regarding any actions taken to facilitate the transfer or communicate progress to the resident. The Director of Nursing (DON) confirmed that it was the SSW's responsibility to assist residents with grievances and requests, including providing updates. The facility's policy also indicated that social services staff are responsible for assisting with transitions of care and advocating for residents' rights.
No Comprehensive Care Plan for Resident with Left Eye Blindness
Penalty
Summary
Failure to develop a Comprehensive Care Plan for one sampled resident with left eye blindness was identified. The resident was admitted with diagnoses including left eye blindness and low vision in the right eye. The MDS dated 11/14/2025 indicated the resident had cognitive skills for daily decision making and required varying levels of assistance with eating, oral hygiene, bed mobility, dressing, toileting, footwear, and sit-to-stand transfers. The resident also had an order dated 11/8/2025 for Atropine Sulfate Ophthalmic Solution 0.01% to be instilled in the left eye every 12 hours for left eye blindness. Review of the resident's record found no care plan interventions addressing the left eye blindness, including no problem statement, goals, monitoring parameters, comfort measures, or physician notification requirements. During interview, the resident stated the eye medication had not been given in the morning, causing the left eye to feel dry and painful and making it difficult to keep the eyes open. The resident also stated there had been other days when the medication was not administered and expressed concern because of blindness in the left eye and low vision in the right eye. The LVN acknowledged the scheduled 6 AM dose had not been administered and was not endorsed during shift report, and also stated she did not assess the resident's pain level during her shift. The DON stated the omission should have been documented, explained, and endorsed by licensed nurses, and that a Comprehensive Care Plan should have been initiated to ensure continuity of care between shifts.
Missed Eye Medication Dose Without Documentation or Shift Endorsement
Penalty
Summary
The facility failed to administer Resident 3’s ordered 6 AM atropine sulfate ophthalmic solution to the left eye on 11/24/2025, and the missed dose was not documented with a reason or endorsed to the oncoming licensed nurse. Resident 3 was admitted with left eye blindness and low vision in the right eye, and the MDS dated 11/14/2025 indicated cognitive skills for daily decision making along with varying levels of assistance for activities of daily living. The order summary dated 11/8/2025 directed 1 drop of atropine sulfate ophthalmic solution 0.01% in the left eye every 12 hours for left eye blindness. Review of the MAR showed the eye medication was also not given on 11/17/2025 at 6 AM and 11/22/2025 at 6 PM, and there was no documentation explaining the omissions on 11/22/2025 and 11/24/2025. During interview, Resident 3 stated the missed morning dose caused her left eye to feel dry and painful and that she had experienced other days without the medication. The LVN who was the charge nurse and medication nurse stated the medication was present in the cart but had not been administered as scheduled, that the missed 6 AM dose was not endorsed during shift report, and that she did not assess Resident 3’s pain level. The DON reviewed the care plan, order summary, and MAR and stated the omission should have been documented, explained, and endorsed by licensed nurses, and that a comprehensive care plan should have been initiated for the resident’s left eye blindness.
Failure to Maintain and Document Emergency Tracheostomy Kit Checks
Penalty
Summary
The facility failed to ensure that the emergency tracheostomy ventilator unit box (e-kit) was properly checked and maintained monthly according to its own policy and procedure. During an observation, the e-kit was found locked without any indication of when it was last checked, and the Respiratory Therapist Supervisor (RTS) was unable to state when the last check occurred or who was responsible for maintaining the equipment inside the e-kit. A review of the e-kit order form revealed it was blank, with no documentation of when it was last opened or checked. The e-kit contained essential emergency supplies such as a tracheostomy cuffed tube, syringes, and normal saline. Interviews with the RTS and the Director of Nursing (DON) confirmed that the e-kit should be checked and maintained regularly to prevent shortages of supplies in emergencies. The facility's policy, reviewed on 3/20/2025, specified that the equipment should be checked monthly by Respiratory Therapy, be operational, locked with an appropriate tag, and have a signed equipment checklist. These requirements were not met, as evidenced by the lack of documentation and uncertainty regarding responsibility for the e-kit’s maintenance.
Failure to Follow Menu and Diet Specifications for Specialized Diets
Penalty
Summary
The facility failed to follow standardized recipes and menu instructions for residents on specialized diets during a lunch service. Six residents on a pureed diet received only half a cup of enchilada instead of the required one cup, as specified in the facility's portion and serving guide. The cook responsible for preparing the meal was unaware of the correct portion size and did not consult the spreadsheet, resulting in residents receiving less food than prescribed. Dietary staff responsible for reading and calling out diet orders also did not notice the discrepancy in portion size, and the registered dietitian confirmed that the meal tickets indicated the correct amount, which was not followed. For residents on a Controlled Carbohydrate (CCHO) diet, 23 individuals received four ounces of Spanish rice instead of the two ounces specified for their diet. Both the cook and dietary aide were unaware that the CCHO diet required a reduced portion of rice compared to the regular diet. The registered dietitian and dietary supervisor confirmed that the menu and spreadsheet clearly indicated the correct portion sizes, and the facility's policy emphasized the importance of adhering to these portions for blood sugar control. Additionally, six residents on a soft and bite size diet received cheese enchiladas that were not cut into the required ½ x ½ inch pieces, as per the facility's policy and IDDSI guidelines. The cook cut the enchiladas into inconsistent sizes using a spatula during service, rather than preparing them in advance to the correct specifications. The issue was identified during a tray check, and the trays were returned to the kitchen for correction. The registered dietitian and dietary supervisor confirmed that the food was not prepared to the required texture and size prior to service, as mandated by facility policy and international guidelines.
Improper Use of Unpasteurized Eggs and Inadequate Food Labeling
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and preparation practices by storing and serving unpasteurized shell eggs and by improperly labeling and storing previously prepared pureed desserts. Observations revealed that unpasteurized shell eggs were kept in the reach-in refrigerator and used to prepare fried eggs for residents, despite facility policy and FDA Food Code requirements that only pasteurized eggs be used for soft-cooked egg items. The dietary staff, including the cook and Dietary Supervisor, were unaware that the eggs in use were unpasteurized, and the purchase order confirmed that regular shell eggs had been received and used. The Registered Dietitian also verified that the eggs were not pasteurized and emphasized the need for checking deliveries to ensure compliance. Additionally, seven single-serving containers of brown pureed food were found in the walk-in refrigerator without proper labeling, and the Dietary Supervisor could not identify the contents or confirm the correct storage period. The facility's policy required that all refrigerated, ready-to-eat TCS foods be labeled with a prepared date and a use-by date not exceeding seven days, but the pureed desserts were labeled with a 14-day range and lacked clear identification. These failures in food storage and preparation practices had the potential to result in harmful bacteria growth and cross-contamination, affecting the majority of residents who received food from the facility.
Failure to Provide Privacy During G-Tube Medication Administration
Penalty
Summary
A deficiency occurred when a Licensed Vocational Nurse (LVN) failed to provide privacy to a resident during the administration of medication through a gastrostomy tube (g-tube). The LVN did not pull the privacy curtain while administering the medication, resulting in the resident's gown being pulled up and the abdomen and g-tube site exposed. During this time, the resident's roommate was present and walking around the room, further compromising the resident's privacy. The LVN later acknowledged not pulling the curtain and stated that it was necessary to do so to provide privacy and uphold the resident's dignity. The resident involved had severe cognitive impairment and was dependent on staff for all activities of daily living, including feeding via a g-tube. The facility's policy required staff to promote and protect resident privacy, including bodily privacy during care and treatment procedures. Both the LVN and the Director of Nursing confirmed that the privacy curtain should have been pulled during the procedure to maintain the resident's dignity, as outlined in the facility's dignity policy.
Failure to Develop Care Plan for Ventilator/Tracheostomy Care
Penalty
Summary
The facility failed to develop a care plan addressing ventilator and tracheostomy care for one resident who was admitted with chronic respiratory failure, obesity, and encephalopathy. The resident required ongoing interventions including oxygen therapy, suctioning, tracheostomy care, and invasive mechanical ventilation. Despite these needs, a review of the resident's care plans revealed that there was no care plan in place specifically for ventilator or tracheostomy care at the time of review. Interviews with the MDS Nurse and the Director of Nursing confirmed that the absence of a ventilator/tracheostomy care plan meant that essential aspects of care, such as monitoring suctioning, stoma management, and ventilator settings, were not formally addressed. The facility's policy required the interdisciplinary team to develop and implement a comprehensive, person-centered care plan for each resident, including measurable objectives and timeframes, but this was not done for the resident in question.
Failure to Update Care Plan Quarterly for Resident Using Hand Mitten Restraint
Penalty
Summary
The facility failed to review and revise the care plan quarterly for a resident who used a hand mitten as a restraint to prevent the removal of invasive tubing. The resident, admitted with diagnoses including acute respiratory failure with hypoxia and epilepsy, was noted to have significant cognitive impairment and required daily use of a limb restraint. The Minimum Data Set confirmed the use of restraints, and a physician order specified the application of a hand mitten to the resident's left hand. However, the care plan, initially created at admission, had not been updated since October of the previous year, despite facility policy requiring quarterly updates. Interviews with the Registered Nurse Supervisor and the Director of Nursing confirmed that the care plan was overdue for revision and that any licensed nurse could perform updates. The facility's policies on comprehensive care planning and restraint use both required quarterly review and updates by the interdisciplinary team. The lack of timely care plan revision had the potential to result in the resident not receiving appropriate nursing interventions related to restraint use.
Failure to Maintain Correct Low Air Loss Mattress Settings for Pressure Ulcer Management
Penalty
Summary
The facility failed to maintain the appropriate settings on a Low Air Loss Mattress (LALM) for a resident who was re-admitted with a Stage 4 pressure ulcer of the sacral region. The physician's order specified that the LALM should be set between 250-280 lbs and checked every shift, based on the resident's weight of 250 lbs. However, during observation, the LALM was found set at 320 lbs, which was above the recommended range. The resident reported discomfort and stated that the mattress was too hard and was starting to hurt her bottom. Staff interviews confirmed that the LALM settings should match the resident's weight and that incorrect settings could impact wound healing. Further review of the operator's manual for the LALM confirmed that the pressure-adjust knob should be set according to the patient's weight. Multiple staff, including the Infection Preventionist, Treatment Nurse, and Director of Nursing, acknowledged that the settings were incorrect and that the mattress was firmer than intended, which could compromise its pressure-relieving function. The deficiency was identified through observation, interview, and record review, with direct evidence that the LALM was not set as ordered for wound management.
Failure to Adhere to Infection Control Protocols During Resident Care
Penalty
Summary
Certified Nursing Assistant 1 (CNA1) failed to follow proper infection prevention and control practices while providing care to two residents who were on enhanced barrier precautions. During an observation, CNA1 was seen emptying a urinal for one resident and then immediately assisting another resident without changing their gown or mask and without performing hand hygiene. This was confirmed by both the Infection Preventionist nurse and CNA1, who acknowledged that gloves are changed between resident care, but the gown, mask, and hand hygiene were neglected in this instance. Both residents involved had significant medical conditions requiring enhanced barrier precautions. One resident had chronic respiratory failure, a tracheostomy, and a gastrostomy tube, and was severely cognitively impaired and fully dependent on staff for care. The other resident had muscle wasting, a gastrostomy tube, dementia, and was colonized with a multidrug-resistant organism (ESBL). Both residents were always incontinent and required dependent assistance for personal hygiene, increasing their vulnerability to infection. Facility policies and care plans for both residents specified that staff must perform hand hygiene and change PPE, including gowns and gloves, before and after providing care, especially when moving between residents. The facility's own infection control policy and staff interviews confirmed these requirements. However, CNA1 did not adhere to these protocols during the observed care, which was recognized as an infection control issue by the Infection Preventionist nurse and the Director of Nursing.
Resident Rooms Below Minimum Square Footage Requirement
Penalty
Summary
The facility failed to provide the required minimum of 80 square feet per resident in multiple occupancy rooms for 12 out of 36 resident rooms, as determined through observation, interviews, and record review. During an initial tour, nursing staff were observed to have enough space to provide care in each room, and residents attending a council meeting reported no concerns regarding room size. However, a review of the facility's Client Accommodation Analysis confirmed that rooms 2, 4, 6, 8, 14, 18, 20, 22, 24, 28, 30, and 37 did not meet the minimum square footage requirement, with each resident in these rooms having less than 80 square feet of space.
Failure to Follow Care Plan Interventions
Penalty
Summary
The facility failed to ensure that care plan interventions were followed for a resident with multiple medical conditions, including end-stage renal disease, hemiplegia, and diabetes mellitus type two. The resident's care plan for a mouth lesion with a possible infection required vital signs to be taken and recorded, and an antibiotic, Amoxicillin, to be administered twice daily for five days. However, the Medication Administration Record indicated that a dose was missed on one day, and the Director of Nursing confirmed that vital signs were not consistently documented during the specified period. The facility's policies and procedures for nursing documentation and medication administration were not adhered to, as evidenced by the lack of timely and accurate documentation of vital signs and the missed administration of medication. The Director of Nursing acknowledged the documentation gaps and attributed them to the presence of many new nurses, indicating a need for reinforcement of proper documentation practices. This deficiency had the potential to negatively impact the delivery of care and services to the resident.
Inaccurate Medical Records for Two Residents
Penalty
Summary
The facility failed to ensure accurate and complete medical records for two residents, leading to deficiencies in documentation. For Resident 1, inaccuracies were found in the ventilator administration record, where various procedures and checks were marked as completed with checkmarks, despite the resident being discharged to a General Acute Care Hospital. The Director of Nursing (DON) confirmed that the documentation should have indicated the resident was away or in the hospital, and acknowledged that the respiratory therapist responsible for the documentation had not been working at the facility for over eight months. Resident 1 had a complex medical history, including ventilator-dependent respiratory failure, tracheostomy, gastrostomy, chronic atrial fibrillation, and functional quadriplegia. The resident was dependent on staff for various activities of daily living and had severe memory problems. The inaccuracies in the ventilator administration record included daily and weekly procedures such as changing the inner cannula, checking the heat moisture exchanger, and monitoring ventilator settings, which were incorrectly documented as completed. For Resident 3, the facility failed to maintain accurate vital sign summaries and nurse progress notes. The DON verified that the temperature summary was incomplete, with missing entries for several days. Additionally, there was an error in the nursing progress note, which inaccurately recorded the resident's date of death. Resident 3 had a medical history of end-stage renal disease, dependence on renal dialysis, hemiplegia, and diabetes mellitus type two. The resident required varying levels of assistance for daily activities and was cognitively intact. The inaccuracies in documentation were attributed to new nursing staff and the need for reinforcement of proper documentation practices.
Non-compliance with Staff Meal-Break Policy
Penalty
Summary
The facility failed to comply with professional standards of care by not implementing and following its policy and procedure regarding staff meal-breaks. Interviews with three Licensed Vocational Nurses (LVNs) revealed that they were scheduled to work 12-hour shifts as full-time employees. However, when the census in the sub-acute area was low, their hours were flexed, resulting in them either taking an unpaid one-hour lunch break or going home early, which led to them working less than their scheduled 12-hour shifts. This practice was inconsistent with the facility's Employee Acknowledgement agreement, which allowed employees to waive a second 30-minute meal break only if they worked more than 10 hours but less than 12 hours in a day. The Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed that the licensed nurses' hours were adjusted based on census levels, requiring them to take unpaid lunch breaks or leave early, thus not completing their 12-hour shifts. This was contrary to the signed meal waiver agreement, which was not being adhered to. A review of the facility's policy titled 'California Meal and Rest Periods' indicated that employees working over 10 hours but less than 12 hours must start their second 30-minute meal break by the end of the 10th hour unless they choose to waive it. The facility's failure to follow this policy infringed upon the employees' agreement and acknowledgment.
Failure to Post Actual Nursing Staff Hours
Penalty
Summary
The facility failed to ensure that the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift were posted for two sampled days. On both 10/15/2024 and 10/16/2024, observations revealed that only the projected hours were posted on the Direct Care Services Hours Per Patient Day (DHPPD) board, with no actual hours displayed. Interviews with the Director of Nursing (DON) and Administration (ADM) confirmed that the actual hours for the previous day should have been posted alongside the current day's projected hours, but this was not done. The facility's policy and procedure, reviewed on 3/21/2024, mandates the daily posting of nurse staffing data, including actual hours worked for each shift, which was not adhered to in this instance.
Failure to Implement Scabies Infection Control Measures
Penalty
Summary
The facility failed to implement effective infection prevention and control measures for scabies, a highly contagious skin condition, as per their policy and procedure titled 'Scabies Identification, Treatment and Environmental Cleaning.' This deficiency was identified during a recertification survey and involved four residents who were sampled. The facility did not identify and detect symptoms of scabies in a timely manner for a resident who had a skin rash upon readmission. The resident was not placed on contact precautions when treatment with Elimite and Ivermectin began, and the diagnosis of scabies was confirmed days later. The facility also failed to maintain contact precautions as per the physician's order, which was issued after the scabies diagnosis. The resident was not isolated from roommates, and contact precautions were not implemented promptly, increasing the risk of transmission to other residents, staff, and visitors. The infection preventionist acknowledged that contact isolation precautions were initiated late and should have been in place when scabies was suspected. The deficiency resulted in a potential risk of scabies transmission to 86 in-house residents, staff, and the community. The facility's failure to adhere to its scabies policy and procedure led to an Immediate Jeopardy situation, as identified by surveyors, due to the threat posed to the health and safety of residents, staff, and family members.
Removal Plan
- Licensed Nurses completed skin assessments for Residents 1, 2, 3, and 4.
- Resident 1: Noted to have a generalized body rash secondary to diagnosis of eczematous dermatitis and will be re-assessed by a dermatologist after final treatment.
- Resident 2: Noted to have body rash on chest, abdomen, arms, back and thighs secondary to dermatitis.
- Resident 3: Noted to have a body rash on bilateral arm secondary to dermatitis.
- Resident 4: Noted to have body rash extending from back to abdomen secondary to dermatitis.
- Treatment Plan for Residents 1, 2, 3 and 4 included:
- Resident 1: Clobetasol Propionate External Cream 0.05% to generalize body topically daily, Permethrin External Cream 5% to neck and toes topically at bedtime every Thursday and Ivermectin 9 mg via GT every Wednesday.
- Resident 2: Refused treatment and was educated regarding risks of refusing treatment and the importance of receiving treatment. Resident 2 was subsequently placed in contact isolation pending test results.
- Resident 3: Clobetasol Propionate External Cream 0.05% to arms twice daily.
- Resident 4: Hydrocortisone Cream 0.1% and Clindamycin Phosphate External Gel I% to abdomen and back.
- Residents 2, 3, and 4 had skin scraping completed, pending results.
- Environmental Service completed a deep cleaning of the room for Residents 1, 2, 3, and housekeeping department will continue with deep clean schedule for all resident care areas. Work areas were also deep cleaned.
- The Infection Control committee, including the Medical Director held an ad hoc QAA meeting to review the IJ Removal Plan for further review and recommendations.
- The Infection Control Nurse and/or designee connected with the Public Health Nurse for further recommendations and validation to confirm that the facility took all necessary steps for Residents 1, 2, 3, and 4.
Inadequate Infection Control Training Leads to Scabies Outbreak
Penalty
Summary
The facility failed to ensure that the Infection Preventionist Nurse (IP) completed the required specialized training related to infection control on an annual basis. This deficiency was identified during an interview and record review, where it was revealed that the IP had not completed the necessary continuing education units (CEUs) for 2023. The IP acknowledged the importance of continuous training to stay updated on changes and guidelines in infection control, which is crucial for preventing the spread of infections within the facility. The deficiency led to a failure in maintaining contact precautions for a resident diagnosed with scabies, a highly contagious skin condition. The resident was readmitted to the facility with multiple diagnoses, including chronic respiratory failure, pneumonia, and heart failure. Upon readmission, the resident was found to have a generalized body rash, which was later confirmed as scabies through a positive skin scraping. Despite the diagnosis, the facility did not implement the necessary contact precautions in a timely manner, as indicated by the lack of appropriate signage and protective measures for staff and visitors. The Director of Nursing (DON) admitted uncertainty about the CEU requirements for the IP but emphasized the importance of the IP being up-to-date with infection control issues. The DON also acknowledged that contact precautions should have been initiated earlier for the resident and their roommates to prevent the spread of scabies. The facility's policy on infection prevention and control, which aims to maintain a safe and sanitary environment, was not adequately followed, contributing to the deficiency.
Expired CNA Certification
Penalty
Summary
The facility failed to ensure that the certification requirements for one of its certified nurse assistants (CNA 2) were up to date. CNA 2's certificate had expired, yet the CNA continued to work for over a month with an expired certificate. The Director of Staff Development (DSD) acknowledged that it was her responsibility to ensure that all CNAs were certified and that their credentials were current. Despite this, CNA 2 was hired with an expired certificate and continued to provide patient care without an active certificate. The Assistant Director of Nursing (ADON) confirmed that CNAs should not work with expired credentials as it could lead to inadequate nursing care. A review of the facility's policy and procedure on licensure, certification, and registration of personnel indicated that recertifications must be presented to the human resources director or designee before the expiration of current certifications. This policy was not followed in the case of CNA 2, leading to a potential knowledge, training, and certification deficit among the CNA, which could result in inadequate resident care. The facility's failure to adhere to its own policy and ensure that CNA 2's certification was up to date represents a significant deficiency in maintaining proper staff qualifications.
Failure to Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to develop a comprehensive care plan for four residents, leading to several deficiencies. For Resident 31, the care plan did not include measurable goals for monitoring cerebrovascular accidents (CVA) and the use of aspirin for CVA prophylaxis. This oversight was confirmed by both the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON), who acknowledged the absence of monitoring for aspirin side effects such as bleeding and bruising. The Minimum Data Set Coordinator (MDSC) also admitted that the verification of the care plan was overlooked, resulting in a lack of patient-centered care for Resident 31. Resident 70's care plan was deficient in monitoring the adverse effects of the psychotropic medication Lexapro. Despite the resident's diagnosis of depression and the prescription of Lexapro, there was no individualized plan to monitor for potential adverse effects. This was confirmed by LVN 6 and the DON, who both acknowledged the importance of monitoring for adverse effects to ensure the resident's health was not negatively impacted. Resident 188's care plan did not include transmission-based precautions (TBP) despite the resident's history of carbapenem-resistant Enterobacterales (CRE) and immunocompromisation. The DON confirmed that the absence of a care plan for TBP increased the risk of spreading infections to other residents. Similarly, Resident 25's care plan failed to address a skin disorder, which was confirmed by the DON. The facility's policies and procedures were not followed, resulting in the lack of comprehensive care plans for these residents, which should have included measurable objectives and timetables to meet their medical, physical, mental, and psychosocial needs.
Failure to Provide RNA Treatments and Proper Documentation
Penalty
Summary
The facility failed to provide complete Restorative Nursing Assistant (RNA) treatments as per physician's orders for three residents, leading to increased risk for contractures and decline in physical function. Resident 2, who had severe cognitive impairment and was dependent on staff for various activities, did not receive passive range of motion (PROM) exercises to the lower extremities on multiple occasions. The Restorative Administration Record and Weekly/Monthly Progress Report for Resident 2 were incomplete, with no documentation of treatment provided or refused on specific dates. Resident 53, who had diagnoses including neuropathy and hemiplegia, also did not receive PROM exercises to the left upper extremity and both lower extremities as ordered. The resident's records indicated that the RNA did not perform the exercises on several dates, and the Weekly/Monthly Progress Report lacked documentation for a specific week. Resident 53 confirmed that RNA services were not provided as frequently as ordered. Resident 71, who had reduced mobility and muscle weakness, did not receive ambulation using a platform walker and active range of motion (AROM) exercises to the upper extremities as ordered. The Restorative Administration Record and Weekly/Monthly Progress Report for Resident 71 were incomplete, with blank spaces indicating that the treatment was not documented. Interviews with staff confirmed that the documentation was not properly maintained, and the treatments were not consistently provided, putting the residents at risk for functional decline.
Failure to Account for Controlled Substances and Inadequate Documentation
Penalty
Summary
The facility failed to account for controlled substances (CS) for several residents, leading to discrepancies in medication counts and documentation. During an observation, it was found that one dose of lorazepam was missing for a resident, and one dose of phenobarbital was missing for another resident. The Licensed Vocational Nurse (LVN) responsible admitted to administering the medications but failing to document the administration, which is against the facility's policy. This failure in documentation could lead to medication errors and potential harm to the residents involved. In another observation, it was found that there were extra doses of hydrocodone-acetaminophen and oxycodone in the medication bubble packs for two other residents. The LVN responsible had documented the preparation of these medications but did not administer them, again failing to follow the facility's policy. This inconsistency in documentation could lead to untreated pain and discomfort for the residents. Additionally, the facility's Director of Nursing (DON) failed to include verifying signatures on the Controlled or Antibiotic Drug Record accountability logs for two sampled months. This lack of verification could lead to inaccuracies in medication records and potential diversion of controlled substances. The DON acknowledged the failure to follow the facility's policy and the need for a consistent process to ensure accountability and prevent harm to residents.
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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 Los Angeles
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Palazzo Post Acute | 0 mi | ★★★★★ | 23 | 0 |
| Hollywood Premier Healthcare Center | 0 mi | ★★★★★ | 6 | 0 |
| The Meadows On Sunset Post Acute | 0.6 mi | ★★★★★ | 45 | 0 |
| Alexandria Care Center | 0.6 mi | ★★★★★ | 47 | 0 |
| Hollywood Presbyterian Medical Center D/p Snf | 1.1 mi | ★★★★★ | 22 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.