Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Glendale Post Acute Center during CMS and state inspections, most recent first.
A resident with quadriplegia and atrial fibrillation reported feeling unwell, with a pounding headache and heart racing, after repeated calls for help were not answered. An LVN later obtained a BP of 178/105, gave the resident angina medication, and rechecked the BP about an hour later, but did not document the elevated reading or notify the MD. The DON confirmed there was no documentation of the high BP or physician notification, despite the resident’s care plan calling for monitoring and reporting significant abnormalities.
A resident with multiple right foot and ankle fractures had physician orders for routine pain assessment, non-pharmacological interventions, and PRN Lyrica, Tramadol, and Tylenol based on pain scale scores, with care plans requiring administration of ordered medications and evaluation of intervention effectiveness. On one shift, the MAR documented an 8/10 pain score, but only non-pharmacological measures such as reassurance and diversion were provided, with no PRN pain medication given and no reassessment of pain or intervention effectiveness recorded. In interviews, the resident reported ongoing ankle pain and swelling, stated that staff did not provide pain medication when he reported pain, and expressed that non-pharmacological measures did not relieve his pain. An LVN stated she used non-pharmacological interventions first and had not documented their effectiveness, while an RN supervisor and the DON confirmed that no pharmacological intervention or reassessment was documented despite orders and facility policy requiring monitoring of pain and intervention effectiveness.
Resident Council Meetings Held With Staff Present: Three cognitively intact residents with diagnoses including DM, ESRD, HTN, dysarthria, and CVA stated they did not want the DON, ADM, or AD present during Resident Council meetings and had not been told the meetings could be held privately. An AA reported that a facility staff member was always present, and the AD and DON both confirmed staff routinely attended the monthly meetings and were unaware of the residents' right to meet without staff present; the facility policy stated staff may attend only if invited by the resident group.
A resident with paraplegia, an underweight BMI, and existing stage 4 pressure ulcers was found with a LAL mattress set to alternating therapy mode and comfort level 2, despite staff stating it should have been level 1 based on her weight and comfort. The resident reported the mattress felt different and that staff had not listened to her concerns. Her care plan called for setting the mattress according to weight or comfort, but the setting observed did not match the resident’s needs.
A resident with severe cognitive impairment and high fall risk was found on the floor behind a closed privacy curtain, with staff confirming the curtain blocked monitoring and no bed alarm was present. In another event, an LVN and the DON confirmed that a resident receiving O2 did not have the required No Smoking/Oxygen in Use sign posted. The facility also allowed a wheelchair-dependent resident to smoke without staff present, and the MDS nurse stated the resident lacked a current smoking assessment and was not safe to smoke unsupervised.
An open box of pie shells, an open container of dill pickle relish, and an open bag of brownie powder were found without used by dates in the kitchen. During meal service, a CNA handled soiled cups and discarded a newspaper, then passed meal trays to three residents without hand hygiene between tasks or before handling food. The DON stated CNAs are expected to clean their hands before and after handling trays, and kitchen food should be labeled with a use by date.
Improper garbage and refuse disposal was observed in the facility’s garbage area when two of three metal dumpsters could not close completely because they were overfilled with trash bags. Opened boxes were on the ground and a wooden pallet was also present in the area. The DS stated the dumpsters could not fully close due to too much trash, and the DON stated the area should be kept clean and free of litter, with dumpster lids completely closed.
A resident on EBP due to G-tube status was observed receiving close-contact care by a CNA who did not wear an isolation gown, despite signage and staff statements that gown use was required for hygiene and brief changes. In a separate issue, another resident with chronic respiratory failure and interstitial pulmonary disease had oxygen equipment that was not labeled as ordered: the NC lacked the resident’s name and date, and the humidifier lacked the resident’s name. The DON and LVNs stated the equipment should have been labeled per the physician’s order and facility policy.
A facility failed to maintain dignity and privacy for two residents. An LVN left a resident with severe cognitive impairment uncovered and exposed after vital signs were taken, with the gown lifted and the brief visible. The facility also had a TN assist another resident with feeding while standing over the resident instead of at eye level; that resident had malnutrition, dysphagia, and normal cognitive function. Staff and the DON acknowledged the feeding approach was a dignity issue, and the facility policy required meals to be provided with consideration of safety, comfort, and dignity.
Call lights were found on the floor and out of reach for two residents who relied on them for assistance. One resident was legally blind and needed help with ADLs and transfers, and the other had dementia, polyneuropathy, and limited mobility. Both care plans included keeping the call light within reach, and staff confirmed the devices should always be accessible.
Incorrect Wall Clock Time in Resident Room: Two residents shared a room where the wall clock was observed displaying the wrong time instead of the actual time. One resident had severe cognitive impairment and the other had moderate cognitive impairment, and both were dependent with several ADLs. An LVN and the DON stated that accurate room clocks are part of a homelike environment and help prevent disorientation, and a family member reported that one resident had been frustrated earlier about the incorrect time.
Failure to Notify Resident/Representative of Bed-Hold Policy: A resident with severe cognitive impairment, Lewy body neurocognitive disorder, pressure ulcer, and DM was transferred to a GACH for further evaluation due to altered mental status and failure to thrive. The chart lacked documentation that the responsible party was informed in writing of the bed-hold policy, lacked a physician order to place the bed on hold, and the DON could not provide a bed-hold notification form; census records showed the room remained empty with no indication of bed-hold status.
Failure to develop comprehensive care plans for two residents: one resident received Ambien PRN for insomnia for an extended period, but the care plan did not address monitoring, side effects, or effectiveness of the psychotropic medication; another resident was on hospice with respiratory failure, heart failure, COPD, oxygen therapy, and severe cognitive impairment, but the care plan did not include hospice-related care and guidance. Staff interviews confirmed the missing care plans and identified that the assigned nurse should have initiated them.
IV dressings were left undated and uninitialed. A resident with IV therapy, acute embolism, thrombosis, and respiratory failure had bilateral peripheral IV dressing sites observed without the date of the dressing change or staff initials. RN and DON interviews confirmed the dressings should be dated and initialed per the order and facility policy.
A resident with anemia, hemiplegia, hemiparesis, and diabetes was ordered Retacrit 6,000 units SQ three times weekly. During a med pass, an LVN administered only 3,000 units SQ instead of the ordered dose, and both the LVN and DON confirmed the medication error after reviewing the order and vial.
Dirty Resident Room Floor and Poor Housekeeping: A resident with DM2 and HTN had a dusty floor under the bed with debris, cups, a cotton swab, food condiments, and old dry liquid stains. The resident said the floor had not been cleaned for weeks and that staff only picked up trash, while the MS confirmed housekeeping did not mop daily and had no record of when the room was last cleaned. The facility policy stated the environment should be safe, clean, and comfortable.
Insufficient Bedroom Square Footage: The facility failed to provide the required minimum room size in 34 of 45 resident bedrooms, including multiple 3-bed rooms and 2-bed rooms that measured below the required square feet per resident. A review of the CAA showed several rooms at 73.3 sq. ft. per resident and others at 71.5 sq. ft. per resident. Staff, residents, and an RP stated there was enough space to provide care and transfers, and the ADM said the facility was seeking a room waiver.
A resident with multiple comorbidities and critical electrolyte imbalances was ordered IV hydration and potassium replacement, but nursing staff were unable to start the IV and did not notify the physician of the failed attempts or the delay in treatment. The information was only passed to the next shift, and the physician was not informed, resulting in a breakdown of communication and failure to follow facility protocols.
A resident with multiple comorbidities experienced a critically low potassium level, but staff failed to promptly notify the physician, assess the resident, or initiate required interventions. There was a significant delay in administering ordered potassium and IV fluids, and the resident was not monitored for complications as outlined in the care plan. The resident was later found unresponsive and expired despite resuscitation efforts.
A resident with end stage renal disease and cognitive intactness reported feeling threatened and upset after an encounter with another resident's responsible party, but no individualized care plan was developed to address her psychosocial needs or guide staff monitoring, despite facility policy requiring such plans after significant events.
The facility did not provide adequate nursing staff daily to meet all residents' needs and failed to have a licensed nurse in charge on every shift, as required.
A facility area was not kept free from accident hazards, and supervision provided was inadequate to prevent accidents, as observed by surveyors.
A resident with severe cognitive impairment and mobility issues developed new skin redness and breakdown in the lower abdomen, which was observed by CNAs and treated by a nurse without physician notification, documentation, or a physician's order. The responsible party was not informed until they inquired, and the DON confirmed that required notifications and documentation were not completed.
A resident with dementia and severe cognitive impairment, who required significant assistance with transfers, was provided with a wheelchair that had a malfunctioning brake. Although some staff were aware of the issue and reported it verbally, there was no documentation or follow-up for repair, and the maintenance team and DON were not informed until the survey. The facility's policy to maintain and repair assistive devices was not followed.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors.
A resident with severe cognitive impairment and multiple care needs was transferred using a shared wheelchair that was not cleaned or disinfected between uses. Staff confirmed the presence of food particles on the wheelchair and acknowledged that cleaning protocols were not followed, despite facility policy requiring disinfection of reusable equipment between residents.
A resident with a history of methamphetamine use was not properly monitored or supervised for substance abuse, despite positive toxicology screens and ongoing risks. The facility failed to update care plans, inform staff, or secure hazardous items such as lighters and a meth pipe, even though the resident was on continuous oxygen therapy. This lack of oversight led to a medical emergency requiring hospital transfer and intubation, with subsequent discovery of narcotics and smoking paraphernalia in the resident's room.
Nursing staff failed to document the removal and administration of controlled substances at the time of administration, resulting in discrepancies between medication counts and records for multiple residents. Additionally, controlled medications belonging to residents who were transferred or had expired were not removed from the medication cart or stored securely, contrary to facility policy. The DON confirmed that these actions did not comply with established procedures for handling controlled medications.
A resident with severe cognitive and physical impairments did not receive timely or consistent Restorative Nursing Assistant (RNA) services as ordered by the physician, including interventions for range of motion and use of supportive devices. RNA services were delayed by over two weeks, and documentation showed multiple missed or undocumented days of treatment. Staff and the DON confirmed that physician orders were not followed and that a required care plan for RNA services was not developed or implemented.
A resident with significant medical needs, including tube feeding and cognitive impairment, experienced a 10-pound weight loss over five months due to the facility's failure to perform weekly weights, follow RD recommendations for increased free water and probiotics, notify the physician of these recommendations and the weight loss, implement SBAR communication, and develop a care plan for the weight loss. Staff interviews confirmed that facility policies and procedures for nutritional assessment and care planning were not followed.
A resident with dementia and high fall risk experienced multiple unwitnessed falls due to the facility's lack of a fall prevention program. The facility also failed to follow physician orders for laboratory tests and urine collection, leading to delayed diagnosis and treatment of a urinary tract infection. These deficiencies resulted in severe health complications, including hypernatremia, dehydration, and severe sepsis, necessitating the resident's transfer to a hospital.
A facility failed to protect a cognitively impaired resident from sexual abuse by a CNA, who engaged in non-consensual sexual contact with the resident. The incident was captured on a hidden camera, leading to the CNA's arrest. The resident, who was unable to consent or defend himself, experienced significant negative psychosocial impacts. The facility's failure was identified as an Immediate Jeopardy situation by the California Department of Public Health.
A resident was improperly administered Depakote for seizures without a seizure diagnosis, and later for mood swings without adequate assessment. The facility failed to monitor the medication's efficacy and side effects, leading to the resident's hospitalization for adverse consequences. Additionally, a follow-up with a psychiatrist was not arranged as ordered.
A facility failed to implement an effective infection prevention and control program during a GI outbreak, affecting 26 residents and 16 staff. The facility did not place symptomatic residents on transmission-based precautions or prohibit symptomatic staff from working. Additionally, the facility failed to investigate the outbreak, notify the local health department timely, and ensure proper hand hygiene, leading to confirmed Norovirus 2 cases.
The QAPI committee at a facility failed to address a GI illness outbreak affecting 26 residents and 16 staff. Preventative measures were not implemented, and the local health department was not notified promptly. The committee did not meet as required, and the outbreak was not discussed, leading to inadequate response and continued spread of illness.
A facility failed to create a comprehensive care plan for a resident with anxiety disorder, despite the resident's admission diagnoses including bipolar disorder, anxiety disorder, and malignant neoplasm of the kidney. The MDS Nurse and DON confirmed the absence of a care plan for anxiety, which is required by the facility's policy to ensure proper care.
A resident did not receive their prescribed medications on three occasions due to a failure in documentation by a Licensed Vocational Nurse. The resident, with conditions such as diabetes and hypertension, had their Medication Administration Record (MAR) unmarked for specific dates, indicating non-administration. The Director of Nursing confirmed that the absence of documentation meant the medications were not given, as per facility policy.
A resident was not readmitted to their original facility after hospitalization due to a failure to follow bed-hold policies. The resident, with conditions including metabolic encephalopathy and psychosis, was transferred to a GACH for altered mental status. Despite being stable for discharge, the facility's ADM did not place the resident on bed hold, citing a need for a higher level of care. This decision was made without an IDT meeting or family involvement, leading to the resident's transfer to another facility.
The facility did not ensure that an RN and an LVN completed their annual competency assessments, as required by policy. Both nurses had initial skills checklists upon hiring, but no further evaluations were documented. The DON confirmed that the facility had not conducted the annual skills competency fair, risking substandard care for residents.
The facility failed to follow food storage and egg handling policies, leading to potential foodborne illness risks. Opened dry food items were improperly stored without labels, and unpasteurized eggs were used in meals, contrary to policy. The Dietary Supervisor and RN confirmed these practices could lead to contamination and illness.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with multiple wounds and a Foley catheter. A CNA was observed providing care without wearing the required PPE, specifically an isolation gown, despite the resident's need for EBP due to wounds. The facility's policy mandates PPE use during high-contact care activities to prevent infection spread, but this was not followed, placing residents at risk.
A resident with Parkinson's disease, depression, and hypothyroidism was transported in a shower chair through a hallway without proper body coverage, exposing their buttocks. The CNA involved was unaware of the exposure, and facility staff emphasized the importance of maintaining resident dignity and privacy during such transports.
A resident was found with 17 bottles of medications at her bedside, which she self-administered without a physician's order or facility assessment. The facility's IDT did not evaluate her cognitive and physical abilities to self-administer, nor did they monitor for side effects or ensure medications were stored securely. Interviews with staff confirmed the lack of assessment and monitoring, contrary to facility policies.
The facility failed to ensure call lights were within reach for two residents, risking delayed care and potential accidents. One resident with severe cognitive impairment and another with intact cognition but limited mobility were both found with call lights on the floor. Staff confirmed the importance of accessible call lights to prevent falls, as outlined in the residents' care plans and facility policy.
The facility failed to maintain current copies of advance directives in the medical records for two residents. One resident, with multiple serious diagnoses, had an advance directive noted but not followed up on, while another resident's records showed conflicting information about the existence of an advance directive. The Social Services Director and DON acknowledged the importance of having these documents readily available, as per facility policy.
A resident experienced a significant weight loss of 23 pounds over 15 days, but the facility failed to notify the physician or update the care plan. Despite the resident's moderate cognitive impairment and dietary needs, no Change of Condition or Comprehensive Care Plan was completed. Interviews confirmed the oversight, which was against the facility's policies requiring documentation and physician notification for significant changes.
Two residents were unsafely discharged against medical advice (AMA) due to inadequate discharge planning and lack of proper documentation. One resident was informed she did not meet criteria to stay and was not informed of her right to appeal, while another was not allowed to return after going out on pass. Both residents did not receive necessary post-discharge resources, and the facility failed to follow its policies and procedures.
A resident with chronic conditions experienced daily pain, but the facility failed to revise the care plan to address ongoing pain management needs. Despite receiving pain medication, the resident's care plan was not updated to include alternative interventions, as confirmed by the DON and MDSC. The facility's policy required ongoing assessments and revisions, which were not followed in this case.
A resident's prescription glasses were broken by a CNA, and despite notifying multiple staff members, the facility failed to promptly assist in obtaining new glasses. The Social Service Assistant delayed contacting the optometrist, and the Director of Nursing was unaware of the prolonged issue. The facility lacked a specific policy for eyeglasses services, leading to the resident managing with broken glasses.
A resident with multiple health conditions received oxygen therapy without clear physician parameters, leading to potential risks. The LVN administered oxygen at 3L/min when the resident's saturation was 89%, despite the order being for 2L/min. The DON confirmed that orders should include parameters, which were missing in this case.
Failure to Document and Report Elevated BP
Penalty
Summary
The facility failed to provide care and services according to physician orders and the resident’s care plan for one resident with diagnoses including quadriplegia and atrial fibrillation. The resident’s care plan for altered cardiovascular status directed staff to monitor vital signs as ordered and notify the MD of significant abnormalities, including signs and symptoms of malignant hypertension. The resident’s record showed the resident had capacity to understand and make decisions and required extensive assistance with activities of daily living. On 5/17/2026, the resident reported not feeling well, pressed the call light, called the facility, and went to the nursing station after no one responded to his requests for help. The resident stated he had a pounding headache, felt his heart racing, and was upset that staff did not respond. LVN 1 later assessed the resident and obtained a BP of 178/105, then gave the resident his angina medication and rechecked the BP about one hour later, when it had returned to baseline. The resident’s progress notes from 5/15/2026 through 5/18/2026 did not document the elevated BP, monitoring for the elevated BP, or notification of the MD. LVN 1 stated she forgot to document the elevated BP and did not notify the physician because she assumed the BP was high due to the resident being upset. The DON confirmed there was no documentation of the elevated BP on 5/17/2026 and stated the physician should have been notified immediately and the resident’s vitals and assessment should have been documented.
Failure to Administer and Reassess PRN Pain Management for Fracture-Related Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide effective pain management for one resident with multiple right foot and ankle fractures and dislocations. The resident was admitted with diagnoses including displaced fracture of the anterior process of the right calcaneus, fracture of the right talus, fracture of the scaphoid of the right foot, and dislocation of the tarsometatarsal joint of the right foot. The resident’s history and physical documented that he had capacity to understand and make decisions, and his MDS indicated he had occasional pain. Physician orders directed staff to monitor pain every shift using a 0–10 pain scale, implement non-prescription behavioral interventions every shift with documentation of effectiveness, and administer PRN pain medications: Lyrica 100 mg for severe pain (7–10), Tramadol 50 mg twice daily PRN for moderate pain (4–6), and Tylenol 325 mg twice daily PRN for mild pain (1–3). The care plans for fracture-related conditions and risk for pain required staff to administer medications as ordered, assess pain intensity, monitor pain characteristics and side effects, and evaluate and document the effectiveness of pain interventions. On a specific date in January, the MAR showed that during the 7 AM to 3 PM shift the resident reported pain at 8/10. Documentation indicated that only non-pharmacological interventions—reassurance, diversion, redirection, verbal cues, and reassuring—were provided by an LVN. No PRN pain medication was administered despite the order for Tramadol for pain levels 7–10, and there was no documented reassessment of the effectiveness of the non-pharmacological interventions. The MAR for that date and shift contained no entry showing that the resident’s pain was reevaluated after these interventions. Review of the MARs from December through January confirmed that on that date no pharmacological intervention was provided and no reevaluation was documented for the high pain score. In interviews, the resident reported ongoing right ankle pain and swelling and stated that when he reported pain to nursing staff, they did not provide pain medication and that his pain was not being taken seriously. The LVN involved stated she was not informed that the resident was experiencing pain and also stated that the treatment nurse monitored residents for pain; she later explained that she provided non-pharmacological interventions first when a resident reported pain and acknowledged she had not documented their effectiveness. The RN supervisor confirmed that no pharmacological intervention or reassessment was documented for the 8/10 pain episode and stated that pain medication such as Tramadol should have been administered. The DON also confirmed that there was no reevaluation documented for the non-pharmacological interventions and stated that if the resident still had pain after such interventions, pain medications should have been given. The resident expressed a preference for pain medications over non-pharmacological interventions, stating that the latter did not relieve his pain and that he felt no one cared about his pain. The facility’s pain assessment and management policy required appropriate assessment and treatment of pain and monitoring for the effectiveness of interventions.
Resident Council Meetings Held With Staff Present
Penalty
Summary
The facility failed to ensure that Resident Council meetings could be held privately without facility staff present for three residents who participated in the council. Resident 59 was admitted with diagnoses including diabetes mellitus and End Stage Renal Disease, and the MDS dated 10/16/2025 indicated intact cognition. Resident 72 was admitted with diagnoses including HTN, dysarthria, and cerebral infarction, and the MDS indicated intact cognition. Resident 84 was admitted with diagnoses including HTN and cerebrovascular accident with no residual effect, and the MDS indicated intact cognition. During a Resident Council meeting on 12/2/2025, Residents 59, 72, and 84 stated they did not want the DON, ADM, or AD present at Resident Council meetings and said they had not previously been made aware that the meetings could be conducted without facility staff present. An AA stated that either the DON, ADM, or AD was always present at Resident Council meetings, and sometimes the AD asked the AA to attend. The AD stated there was always a facility staff present during the monthly meetings to help resolve resident issues and that she had never reviewed with residents their right to conduct meetings without staff present. The DON also stated that either the DON, ADM, or AD was always present at the monthly meetings and later stated she was not aware of the residents' right to conduct Resident Council meetings without facility staff present. The facility's Resident Council policy dated 2/2021 stated that staff, visitors, or other guests may attend the meetings if invited by the resident group.
Low Air Loss Mattress Not Set According to Resident Weight and Care Plan
Penalty
Summary
The facility failed to maintain the low air loss mattress at the proper inflation, weight, and therapy settings and did not follow Resident 40’s care plan for mattress adjustment. During a concurrent observation and interview, the mattress in the resident’s room was set to alternating therapy mode with a normal pressure system status and a comfort level of two. Manufacturer specifications indicated comfort level one supports residents up to 120 pounds, while levels two through five support up to 500 pounds. Resident 40, who weighed 87 pounds, stated the mattress felt different from previously used low air loss mattresses and that she never felt the air moving around as expected. Resident 40’s record showed admission diagnoses including a sacral pressure ulcer, irritable bowel syndrome, and paraplegia. The resident’s H&P indicated she had capacity to understand and make decisions. Her Braden Scale score was 13, indicating moderate risk for pressure sores, and the MDS showed intact cognition, occasional pain, pressure ulcer/injury, risk for developing pressure ulcers/injuries, and three stage four pressure ulcers. The nutrition assessment identified her as underweight and noted a fortified/high protein diet and Pro-Stat supplementation. The care plan for the low air loss mattress included a goal for the resident’s skin to remain intact and interventions to set the mattress according to the resident’s weight or comfort and provide education regarding the risks and benefits of low air loss mattress use. The treatment nurse stated the resident was under 100 pounds and that pressure ulcer prevention interventions included repositioning, high protein meals and snacks, and a low air loss mattress. The nurse also stated the mattress should have been set at level one based on the resident’s weight and verbalized comfort, and that incorrect settings could result in worsening of pressure injuries and increased pain and suffering. Facility policies on support surfaces and pressure injury prevention directed staff to select appropriate support surfaces based on risk factors and monitor regularly for comfort and signs of pressure-related injury.
Unsafe supervision and missing oxygen signage
Penalty
Summary
The facility failed to maintain a safe environment for a resident with severe cognitive impairment and high fall risk when the resident was found on the floor in his room with the privacy curtain drawn completely around the bed. Resident 23 had diagnoses including fractures of the left femur, metabolic encephalopathy, and Alzheimer's disease, and records indicated he lacked capacity to understand and make decisions. His assessments and care plans described severe cognitive impairment, high fall risk, and spontaneous behavior of getting out of bed or chair, with interventions calling for frequent visual checks, fall precautions, and supervised mobility. During observation, the room was dark, the curtain blocked visibility, and no bed alarm was present. Staff interviews confirmed the resident should have been monitored more closely and that the curtain should not have been closed because it prevented proper observation. The facility also failed to post required No Smoking/Oxygen in Use signage for a resident receiving supplemental oxygen. Resident 135 had diagnoses including chronic respiratory failure with hypoxia and interstitial pulmonary disease, and the physician's order summary indicated oxygen via nasal cannula. When the room was observed, there was no No Smoking/Oxygen in Use sign posted outside the room. An LVN confirmed the sign was missing while the resident was receiving oxygen and stated the sign was important to alert staff and visitors to the presence of oxygen and the need to avoid open flames. The DON also confirmed the sign should have been posted and stated the facility was not following the physician's orders. The facility further failed to supervise a resident during smoking. Resident 10 had diagnoses including major depressive disorder and bipolar disorder, was wheelchair dependent, and required assistance with multiple activities of daily living. The resident was observed smoking in the designated smoking area when no staff or other residents were present. The resident stated staff were only present during designated smoking break times. The MDS nurse stated the resident's smoking assessment had not been completed after the prior quarterly assessment and that, without a current assessment, the resident was not safe to smoke without supervision. The DON stated that if a resident missed a quarterly smoking assessment and continued smoking without supervision, there was a risk to resident safety because the resident's medical condition could have changed since the last assessment.
Food Labeling and Hand Hygiene Lapses During Meal Service
Penalty
Summary
Food items in the kitchen were observed without a used by date label during an initial kitchen tour with the Dietary Supervisor. In the freezer, an open box with five pieces of pie shell was found without a label. In the refrigerator, an open plastic container of dill pickle relish was found without a label. In the dry storage area, an open bag of brownie powder was also found without a label. The Dietary Supervisor stated these items were used to prepare food for residents and that they should have a used by date label to ensure freshness and avoid serving potentially old or contaminated food. During a dining observation, CNA 4 did not perform hand hygiene after handling multiple soiled cups from residents and after discarding a newspaper into a trash bin. She then picked up and set up meal trays for Resident 64, Resident 119, and Resident 134 without performing hand hygiene between tasks or before handling the trays. In interview, CNA 4 stated she did not clean her hands after collecting the soiled cups or throwing away the newspaper, and she acknowledged she should perform hand hygiene after each task that could contaminate her hands and before handling food. Resident 64 had diagnoses including unspecified dementia and hyperlipidemia and was assessed as having severely impaired cognitive skills, requiring assistance with eating and oral hygiene and being dependent for several activities of daily living. Resident 119 had diagnoses including unspecified dementia and hypertension and was assessed as having severely impaired cognition and memory, with substantial to maximal assistance needed for multiple care tasks. Resident 134 had diagnoses including type II diabetes mellitus and hypertension and was assessed as having moderately impaired cognition and memory, with assistance needed for several hygiene and transfer tasks. The DON stated CNAs are expected to perform hand hygiene before and after handling meal trays for each resident, and that kitchen food should be labeled with a use by date.
Improper Garbage and Refuse Disposal
Penalty
Summary
Improper disposal of garbage and refuse was identified in the facility’s garbage area when surveyors observed that two of three metal dumpsters could not close completely because they contained too many garbage bags. During the same observation, opened boxes were seen on the ground and a wooden pallet was present in the garbage area. The Dietary Supervisor stated that the dumpsters could not completely close because of the amount of trash bags and that the garbage area should always be clean without opened boxes or a wood pallet. The Director of Nurses stated that the dumpsters’ lids should be completely closed and the surrounding garbage area should be clean and free of litter, including opened boxes and a wooden pallet. A review of the facility policy titled Food-Related Garbage and Refuse Disposal indicated that garbage and food waste are to be stored in a manner inaccessible to pests and that outside dumpsters are to be kept closed and free of surrounding litter.
Failure to Use Isolation Gown During EBP Care and Label Oxygen Equipment
Penalty
Summary
The facility failed to implement infection prevention and control practices for a resident on Enhanced Barrier Precautions due to G-tube status. The resident had diagnoses including respiratory failure, end stage renal disease, and dysphagia, and was documented as severely cognitively impaired and dependent for all ADLs. During observation, the resident was receiving enteral feeding via G-tube, and the door displayed signage for Enhanced Barrier Precautions requiring staff to wear gloves and an isolation gown during high-contact care activities. During a later observation, CNA 2 was seen providing care to the resident and then came out from behind the privacy curtain without wearing an isolation gown. CNA 2 stated she had washed the resident’s face, cleaned the mouth, and changed the brief, and said she did not use the isolation gown because she forgot. CNA 2 also stated that she could spread infection by not wearing the isolation gown. LVN 3 stated that close contact care for a resident on EBP requires PPE including an isolation gown, and that hygiene care and brief changes are considered close contact care. The Infection Preventionist Nurse and DON both stated that the resident was on EBP because of the G-tube and that isolation gown use during close contact care was expected. The facility also failed to label a resident’s oxygen equipment in accordance with the physician’s orders and facility policy. The resident had diagnoses including chronic respiratory failure with hypoxia and interstitial pulmonary disease, and had capacity to understand and make medical decisions. The physician’s orders required the oxygen humidifier and nasal cannula to be changed weekly on Monday and as needed, with the resident’s name and date label. During observation, the nasal cannula had no label with the date or resident’s name, and the humidifier had the date but not the resident’s name. LVN 1 and the DON stated the equipment should have been labeled, and the DON stated the facility was not following its oxygen administration policy.
Failure to Maintain Resident Dignity and Privacy During Care and Feeding Assistance
Penalty
Summary
The facility failed to maintain dignity and privacy for Resident 23 when an LVN completed vital signs and then left the resident lying in bed uncovered and exposed. Resident 23 had diagnoses including fracture of the left femur, metabolic encephalopathy, and Alzheimer's disease, and the H&P stated the resident did not have the capacity to understand and make decisions. The MDS indicated severe cognitive impairment and need for assistance with showering, dressing, personal hygiene, and sit-to-stand positioning. During observation, the resident was left in a hospital gown that was lifted, exposing the brief, and no blanket was in place to cover the body. The facility also failed to provide feeding assistance to Patient 101 in a manner that maintained dignity and respect. Patient 101 was admitted with moderate protein-calorie malnutrition and dysphagia, and the MDS indicated the resident was alert, oriented, and had a BIMS score of 13. During dinner in the dining room, the TN assisted the resident with eating while standing next to the resident, who was seated in a wheelchair and had to look up at the nurse. The TN stated staff must be at the resident's eye level when providing feeding assistance, and the DON stated that providing feeding assistance while standing is a dignity issue. The facility policy on Assistance with Meals stated residents are to be fed with consideration of safety, comfort, and dignity and staff will not assist while standing over residents.
Call Lights Left Out of Reach for Two Residents
Penalty
Summary
Reasonably accommodate the needs and preferences of each resident was not maintained when call lights were found out of reach for two sampled residents. Resident 88 was admitted with diagnoses including peripheral vascular disease, legal blindness, and absence of the left great toe. Her H&P noted fluctuating capacity to understand and make decisions, and her MDS showed she required partial/moderate assistance with toileting, bathing, dressing, and personal hygiene, and substantial/maximal assistance with chair/bed-to-chair transfer. Her care plan for fall risk, revised 6/17/2025, included ensuring the call light was within reach. During a concurrent observation and interview, Resident 88 was found asleep in bed with her call light on the floor. The CNA stated the call light needed to always be within reach, and the LVN stated the resident used it for assistance and could potentially fall and/or injure herself trying to reach it. Resident 127 was admitted and later readmitted with diagnoses including polyneuropathy, dementia, muscle wasting, and difficulty walking. Her MDS indicated cognitive skills were intact and that she required partial/moderate assistance with personal hygiene and was dependent for toileting, bathing, dressing, and chair/bed-to-chair transfer. Her care plan for fall risk, revised 4/17/2025, included ensuring the call light was within reach. During observation and interview, Resident 127 was awake and alert in bed with her call light on the floor and out of reach. She stated she did not know why it was on the floor and could not reach it to call for assistance, and said she relied on it to get staff help. The TN stated the call light should never be on the floor and must always be within the resident's reach, and the DON stated it was facility policy for call lights to be within reach.
Incorrect Wall Clock Time in Resident Room
Penalty
Summary
The facility failed to provide a homelike environment for two residents by not ensuring the wall clock in their shared room displayed the accurate time. Resident 100 was admitted with diagnoses including hemiplegia and hemiparesis, hypertension, and lack of coordination, and the MDS dated 10/19/2025 indicated severe cognitive impairment and dependence with toileting, bathing, dressing, and personal hygiene. Resident 42 was originally admitted on 7/1/2024 and readmitted later with diagnoses including diabetes, mild cognitive impairment, and anemia, and the MDS dated 10/19/2025 indicated moderate cognitive impairment and dependence with toileting, bathing, dressing, and personal hygiene. During a concurrent observation and interview on 12/1/2025 at 10:29 AM, the wall clock in the shared room of Resident 100 and Resident 42 displayed 4:25 while the actual time was 10:29 AM. An LVN stated that maintaining accurate time on the wall clock supports a homelike environment and helps prevent disorientation, especially for alert or confused residents. A family member stated that Resident 100 was becoming more alert and benefited from proper orientation, and also reported that Resident 42 had expressed frustration earlier that morning about the incorrect time. Later that day, the clock was observed displaying the correct time, and the DON stated that providing the right time on residents' wall clocks is part of the facility's responsibility to provide a homelike environment.
Failure to Notify Resident/Representative of Bed-Hold Policy
Penalty
Summary
The facility failed to ensure that Resident 129 and/or the resident’s representative were informed in writing of the facility’s bed-hold and return policy when the resident was transferred to a General Acute Care Hospital on 9/9/2025. Resident 129 had diagnoses including pressure ulcer of the sacral region, neurocognitive disorder with Lewy bodies, and diabetes, and the MDS dated 6/18/2025 indicated severely impaired mental status cognition requiring total assistance with activities of daily living. The nursing note for the hospital transfer did not document that the responsible party was notified of the bed-hold option. Record review also showed the order summary for the transfer did not include a physician’s order to place the resident’s bed on hold for 7 days, and the transfer form documented the transfer for further evaluation due to altered mental status and failure to thrive. Facility census reports showed the resident’s room was listed as empty from 9/9/2025 through 9/18/2025, with no indication that the bed was on hold. During interview and record review, the DON stated there was no documented evidence that the physician ordered the bed hold when the resident was transferred and that the facility could not provide a bed-hold notification form. The facility policy stated residents and/or representatives are informed in writing of the facility and state bed-hold policies.
Failure to Develop Care Plans for Psychotropic Medication and Hospice Care
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident 55 related to the use of Ambien. Resident 55 was admitted with diagnoses including panic disorder and type II diabetes mellitus, had intact cognition on the MDS dated 10/16/2025, and was receiving Ambien 5 mg by mouth every 24 hours as needed for insomnia. The MAR showed the resident received Ambien as needed for 25 days from 11/1/2025 through 12/2/2025, but the care plan did not include the care and interventions to be followed while the resident was taking Ambien. During interview and record review, LVN 4 stated the nurse who received the initial Ambien order was responsible for initiating the care plan and that no care plan was in place to address monitoring for adverse reactions, side effects, or effectiveness of the medication. The DON also stated the assigned nurse did not develop a care plan for the use of Ambien and that the nurse should have initiated it to ensure safe and appropriate care for the resident. The facility policy stated comprehensive person-centered care plans are to be developed for each resident within seven days of completion of the required MDS assessment and no more than 21 days after admission. The facility also failed to develop a comprehensive care plan for Resident 35 related to hospice care. Resident 35 was admitted with diagnoses including acute and chronic respiratory failure with hypoxia, heart failure, and COPD. The H&P indicated fluctuating capacity to understand and make decisions, and the MDS dated 10/17/2025 indicated severe cognitive impairment, oxygen therapy, and hospice care. The order summary showed the resident was admitted to hospice due to chronic respiratory failure with hypoxia, but the comprehensive care plan dated 7/11/2025 did not include hospice care information. The RNS and DON stated a hospice care plan should have been developed and that without it staff would not know who to contact or what to do for the resident.
IV dressings were left undated and uninitialed
Penalty
Summary
The facility failed to ensure that the peripheral IV dressings for one resident were dated and initialed by the staff who changed them in accordance with the facility policy and the physician's order. The resident was admitted with diagnoses including acute embolism, thrombosis of the left femoral vein, and respiratory failure. The MDS indicated the resident had moderate impairment in memory and thinking and was dependent on staff for most activities, including dressing, personal hygiene, showering, and toileting hygiene. An order summary dated 12/1/2025 directed that the resident's peripheral IV dressing be changed every 7 days, with site changes as needed and every Sunday. During an observation in the resident's room, both the right and left peripheral IV dressing sites were seen without the date the dressing was changed and without the initials of the staff member who changed it. A concurrent interview with RN2 confirmed that IV dressings should be changed every Sunday and dated so staff can monitor when the dressing needs to be changed and assess for signs of infection. The DON also stated it was important to have the date the IV was inserted and when the dressing was changed to know when it should be changed again, as indicated in the facility's policy and procedure. The facility policy titled Peripheral and Midline IV Dressing Changes required labeling the dressing with the date and time of the dressing change and initials.
Medication Error: Incorrect Retacrit Dose Administered
Penalty
Summary
Resident 102 was admitted with diagnoses that included hemiplegia, hemiparesis, anemia, and diabetes. The resident’s H&P indicated the resident had the capacity to understand and make decisions, and the MDS later documented the resident as cognitively intact. The physician ordered Retacrit 6,000 units subcutaneously every Monday, Wednesday, and Friday for anemia starting 11/19/2025. During a medication pass observation, LVN 4 was observed drawing up and administering Retacrit 3,000 units subcutaneously to Resident 102 instead of the ordered 6,000 units. When questioned, LVN 4 reviewed the vial label and physician order and stated a medication error had been made and that another dose needed to be administered. The DON and LVN 4 later reviewed the order and medication vial and confirmed that 3,000 units had been given, resulting in an underdose of the ordered medication.
Dirty Resident Room Floor and Poor Housekeeping
Penalty
Summary
The facility failed to maintain a safe and sanitary environment for one of four sampled residents, Resident 55. Resident 55 was admitted on 1/16/2025 with diagnoses including type II diabetes mellitus and hypertension. The MDS dated 10/16/2025 indicated the resident had intact cognition and required setup or clean-up assistance with eating, and supervision or touching assistance with oral hygiene, toileting hygiene, personal hygiene, chair/bed-to-chair transfer, and shower/bathe self. During an observation on 12/1/2025 at 9:06 AM, the floor under Resident 55's bed was observed to be dusty with small debris particles, a drinking cup, a medication cup, a piece of cotton swab, a pack of food condiments, and old dry liquid stains. On 12/2/2025 at 11:45 AM, the floor remained dirty as previously observed, and Resident 55 stated the floor was very dirty, no one had come to clean and mop it, and staff had only come to pick up trash. Resident 55 stated the floor had not been cleaned for three to four weeks and that the dirty floor made him uncomfortable. At 11:56 AM, the Maintenance Supervisor stated the floor was dirty, housekeeping did not clean and mop every day, there was no document showing when the room was last cleaned, and housekeeping staff should clean and mop every resident's floor daily to provide a clean and sanitary environment. The facility's Homelike Environment policy stated the facility is to provide a safe, clean, and comfortable environment.
Insufficient Bedroom Square Footage
Penalty
Summary
The facility failed to provide the required minimum of 80 square feet per resident in 34 of 45 resident bedrooms. Based on observation, interviews, and record review, Resident Bedrooms 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 14, 15, 16, 18, 19, 23, 24, 25, 26, 28, 29, 30, 31, 32, 33, 34, 41, 42, 43, 44, 45, 46, and 47 were measured and found to provide less than 80 square feet per resident. These rooms included 31 three-bed bedrooms and three two-bed bedrooms. A review of the Client Accommodation Analysis completed by the facility showed that the 34 bedrooms measured less than 80 square feet per resident care area. The report listed multiple three-bed rooms measuring 220 square feet total, or 73.3 square feet per resident, and two-bed rooms measuring 143 square feet total, or 71.5 square feet per resident. The facility also submitted a request for an additional room waiver dated 12/1/2025, stating that the waiver was needed to avoid unreasonable financial hardship and that care and services could still be provided without adversely affecting resident health and safety. During interviews, CNA 1, LVN 2, LVN 7, CNA 6, residents, and a responsible party stated there was enough space in the bedrooms to provide care and transfer residents, and staff described moving bedside tables, beds, or wheelchairs as needed to make room for care. The surveyor also documented that, during the recertification survey, the listed bedrooms had sufficient space for residents' freedom of movement, nursing care, privacy during care, and maneuvering of resident care equipment. The Administrator stated the facility wanted to request a room waiver and reported that residents, families, and staff had not complained about the space being too small or about inability to care for residents because of the space.
Failure to Notify Physician of Inability to Initiate IV Therapy
Penalty
Summary
The facility failed to notify the attending physician when nursing staff were unable to initiate an intravenous (IV) line for a resident who had a critical need for IV hydration and electrolyte replacement. The resident, who had a history of diabetes mellitus, fatty liver disease, acute kidney failure, hypertension, and cardiomegaly, was admitted with persistent nausea, vomiting, and impaired cognitive function. Laboratory results revealed critical electrolyte imbalances, including a potassium level of 2.7 mEq/L, elevated sodium, and low magnesium, prompting the physician to order immediate potassium replacement, D5W IV fluids, and magnesium supplementation. Despite these orders, the assigned RN attempted to start the IV line twice without success and then contacted a third-party IV provider, who was unable to send an IV nurse until the following morning. The RN did not inform the physician of the failed IV attempts or the resulting delay in administering the ordered IV fluids and medications. Instead, the information was only endorsed to the oncoming nurse, and no further attempts to notify the physician were documented. The physician was therefore not made aware that the resident's critical treatment could not be initiated as ordered. Interviews with nursing staff and the Director of Nursing confirmed that the facility's protocol required the physician to be notified if IV access could not be established, so that alternative interventions could be considered, such as hospital transfer or ordering a PICC or midline catheter. The facility's policy also required notification of the physician, supervisor, and oncoming shift in the event of complications with IV therapy. The failure to notify the physician of the inability to start the IV and the delay in treatment constituted a deficiency in communication and adherence to clinical protocols.
Failure to Provide Timely Intervention and Monitoring for Critically Low Potassium
Penalty
Summary
The facility failed to provide care in accordance with professional standards of practice for a resident with a critically low potassium level. After the laboratory notified the facility of a critical potassium result of 2.7 mEq/L, the nurse who received the result did not notify the physician, did not assess the resident, and did not initiate a Change in Condition Evaluation Form (CIC). There was no documentation of any assessment or communication regarding the abnormal lab result until several hours later, when another nurse became aware of the situation and contacted the physician. Following the physician's orders for urgent potassium replacement and IV hydration, there was a significant delay in administering the ordered potassium, as it was not given until approximately five hours after the order was placed and after a reminder from the supervising nurse. Additionally, the ordered IV fluids for hydration were not administered because staff were unable to establish IV access, and the physician was not notified of this delay. Documentation did not show that the resident was monitored for complications of hypokalemia, such as cardiac symptoms, as required by the care plan. The resident had a complex medical history, including diabetes, acute kidney failure, hypertension, and cognitive impairment, and was dependent on staff for all activities of daily living. Despite the critical nature of the lab results and the resident's vulnerability, the facility did not ensure timely notification, intervention, or monitoring. The resident was later found unresponsive and expired despite resuscitation efforts. Interviews with staff confirmed lapses in communication, assessment, and timely intervention in response to the critical lab findings.
Failure to Initiate Care Plan After Resident Reports Feeling Threatened
Penalty
Summary
The facility failed to initiate a resident-specific care plan for a resident who verbalized feeling upset, angry, and threatened following an incident involving another resident's responsible party. The incident occurred when the responsible party demanded that the resident lower the volume on her phone, using a loud and threatening tone, which left the resident feeling scared, upset, and uncomfortable. Despite the resident's cognitive intactness and ability to participate in care planning, there was no care plan developed to address her psychosocial needs or to guide staff in monitoring her well-being during and after the incident. Record review and staff interviews confirmed that while some interventions, such as wellness checks, were implemented, there was no documentation of a comprehensive care plan with measurable objectives or timetables as required by facility policy. The Director of Nursing acknowledged that a care plan should have been created to ensure consistent interventions and staff awareness, but none was initiated. This omission meant that the resident's specific needs related to the incident were not formally assessed or addressed through the care planning process.
Insufficient Nursing Staff and Licensed Nurse Coverage
Penalty
Summary
The facility failed to provide enough nursing staff each day to meet the needs of every resident and did not ensure that a licensed nurse was in charge on each shift. This deficiency was identified based on observations and findings that indicated staffing levels and licensed nurse coverage were insufficient to comply with regulatory requirements. No additional details about specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. This deficiency was identified based on observations and findings by surveyors, indicating that the environment posed risks for accidents and that supervision measures in place were insufficient to prevent such incidents.
Failure to Notify Physician and Responsible Party of Resident's Change in Skin Condition
Penalty
Summary
The facility failed to notify the physician and responsible party when a resident experienced a change in condition involving new skin redness between the skin folds of the lower abdomen. The resident, who had diagnoses including dementia and impaired mobility, was found by a CNA to have skin breakdown during a scheduled shower. The CNA reported the abnormal skin condition to the Treatment Nurse, who assessed the area and applied Zinc Oxide cream without obtaining a physician's order or documenting the condition in the resident's records. The Treatment Nurse did not notify the physician or the responsible party about the skin redness, assuming it was due to heat and would resolve in a few days. Further interviews revealed that another CNA also noticed discoloration and itchiness in the same area and reported it to the nursing staff, but there was still no documentation or notification to the physician or responsible party. The Director of Nursing confirmed that the facility's policy requires nurses to document changes in condition and notify both the physician and responsible party. The lack of timely communication and documentation regarding the resident's skin condition constituted a deficiency in care.
Failure to Maintain Functional Wheelchair Brakes for Resident with Severe Impairment
Penalty
Summary
The facility failed to provide a safe and functional wheelchair for a resident with dementia and severe cognitive impairment, who required substantial assistance with transfers and was dependent for toileting and bathing. The resident's wheelchair had a malfunctioning left brake that could not lock the wheel securely, as observed by staff and confirmed during interviews. The issue was known to some staff members, including a CNA who reported the problem to the maintenance supervisor and assistant, but there was no documentation of a maintenance request or repair for the wheelchair in the facility's maintenance log for the past three months. Despite the resident using the wheelchair daily for activities and transfers, the malfunctioning brake was not addressed or communicated effectively to the maintenance team or the Director of Nursing. Multiple staff members, including the restorative nursing assistant and CNA, acknowledged the brake issue and its potential to cause harm, but the maintenance staff and DON were unaware of the problem until the day of the survey. The facility's policy required that assistive devices be maintained and repaired as needed, but this was not followed in the case of the resident's wheelchair.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation or review, indicating that the required protocols for protecting confidential information and proper record-keeping were not consistently followed. No additional details regarding specific residents, their medical history, or the exact circumstances of the deficiency are provided in the report.
Failure to Clean and Disinfect Shared Wheelchair
Penalty
Summary
The facility failed to provide a sanitary environment for one of five sampled residents by not ensuring that a wheelchair used by the resident was clean. Observation revealed food particles on the right side of the wheelchair next to the resident's bed. Staff interviews confirmed that the wheelchair was shared among residents and was not cleaned or disinfected after each use, contrary to facility policy. The Restorative Nursing Assistant acknowledged that the wheelchair should have been cleaned and disinfected before and after each use, but this was not done. The resident involved had a history of Alzheimer's Disease and hypertension, with severely impaired cognitive skills and required significant assistance with daily activities, including transfers and hygiene. The facility's policy required reusable items, such as wheelchairs, to be cleaned and disinfected between residents, but this procedure was not followed. The Infection Preventionist also confirmed that staff were expected to use disinfectant wipes on the wheelchair before and after each use to maintain a sanitary environment and prevent infection.
Failure to Monitor and Supervise Resident with Substance Abuse History and Oxygen Use
Penalty
Summary
The facility failed to identify and implement appropriate monitoring and supervision for a resident with a known history of methamphetamine use, despite multiple documented instances of positive toxicology screens for amphetamines. After a hospital toxicology report indicated a positive result for amphetamines, the facility's interdisciplinary team only provided education to the resident about the risks of recreational drug use and did not establish a care plan or interventions to monitor for ongoing substance abuse. There was no evidence that staff were informed of the resident's drug history, nor were there protocols in place to monitor for signs of substance use or to update the resident's care plan accordingly. Additionally, the facility did not secure or prevent the resident from possessing smoking items, such as cigarettes, a glass pipe, and lighters, even though the resident was assessed as a non-smoker and had active orders for continuous oxygen therapy. Staff discovered lighters in the resident's room on multiple occasions, but there was no documentation of a personal belongings inventory update or consistent monitoring of the resident's possessions. The facility's policies required confiscation and documentation of hazardous items, but these procedures were not followed, and staff were unaware of the presence of these items until after a critical incident occurred. The lack of monitoring and supervision resulted in the resident experiencing a medical emergency characterized by tachycardia, oxygen desaturation, and shortness of breath, necessitating emergency transport to a hospital where the resident tested positive for amphetamines and methamphetamines and required intubation. Subsequent investigation revealed the presence of narcotics and a meth pipe in the resident's room, as well as multiple lighters, despite facility policies prohibiting such items for residents on oxygen. Staff interviews confirmed that there was no training on recognizing signs of methamphetamine use, no communication about the resident's drug history, and no updated inventory of the resident's belongings.
Failure to Accurately Account for and Secure Controlled Medications
Penalty
Summary
The facility failed to accurately account for controlled medications for six out of seven residents in one of two inspected medication carts. Nurses did not document the removal and administration of controlled substances on the Controlled Medication Count Sheet (CMCS) at the time the medications were administered. For example, a nurse counted fewer tablets in the prescription bottle than recorded on the CMCS for a resident prescribed Amphetamine/Dextroamphetamine, and only documented the administration several hours after the scheduled time, expressing uncertainty about whether the medication had been given. Similar discrepancies were found for other residents, where the number of tablets in medication cards did not match the CMCS, and the nurse admitted to not documenting doses at the time of administration. Additionally, the facility failed to remove and securely store controlled medications belonging to residents who were no longer present in the facility. Medications for a resident who had been transferred to the hospital and another who had expired were found mixed with current residents' medications in the medication cart. The Director of Nursing (DON) confirmed that medications for residents who are no longer in the facility should be removed from the cart and stored securely until destruction, as per facility policy. The facility's policies require that licensed nurses immediately document the date, time, amount administered, and their signature on the accountability record when a controlled medication is removed from the supply, and to store discontinued or leftover controlled medications in a double-locked area until destroyed. These procedures were not followed, as evidenced by the discrepancies in medication counts, lack of timely documentation, and improper storage of medications for discharged or deceased residents.
Failure to Provide Timely and Consistent Restorative Nursing Services per Physician Orders
Penalty
Summary
The facility failed to provide timely and consistent Restorative Nursing Assistant (RNA) services as ordered by the physician for a resident with significant physical and cognitive impairments. Despite physician orders dated 1/10/2025 for daily and weekly RNA interventions—including left upper extremity (UE) elbow extension, left hand-roll, passive range of motion (PROM) for the left UE, and active assisted range of motion (AAROM) for the right UE—these services were not initiated until 16 to 19 days after the orders were given. Documentation showed that the resident received only a few days of the prescribed treatments in January, and there were additional missed or undocumented days in February and March. The resident in question had a history of cerebral infarction resulting in hemiplegia and hemiparesis, adult failure to thrive, and muscle wasting and atrophy. The resident was severely cognitively impaired, dependent on staff for all self-care and mobility, and unable to make decisions. The Minimum Data Set (MDS) indicated that the resident was supposed to be on restorative nursing programs, but actual service delivery did not match the orders or the care plan requirements. Interviews with staff, including the RNA and the Director of Nursing (DON), confirmed that the physician's orders were not followed and that the required care plan for RNA services was not developed or implemented. The DON acknowledged that without a care plan, staff had no guidance for providing the ordered services. Observations and interviews with the resident's responsible party and emergency contact further corroborated that the resident was not consistently receiving the prescribed RNA interventions, and documentation gaps were evident in the facility's records.
Failure to Prevent Weight Loss and Follow Nutrition Recommendations for Tube-Fed Resident
Penalty
Summary
The facility failed to prevent weight loss for a resident who was dependent on a gastrostomy tube for nutrition. Upon admission, the resident had multiple diagnoses, including cerebral infarction with hemiplegia, adult failure to thrive, and required tube feeding. Despite recommendations from the Registered Dietician (RD) to perform weekly weights, increase free water flushes, add a probiotic, and obtain new laboratory tests, these interventions were not implemented as documented in the resident's records. The facility did not perform weekly weights as recommended, nor did they follow through with the RD's nutrition care recommendations or notify the physician of these recommendations and the resident's ongoing weight loss. The staff also failed to implement a Situation, Background, Assessment, and Recommendation (SBAR) communication for the resident's weight loss, as required by facility policy. There was no evidence that a change of condition was documented or communicated to the physician, and the facility did not develop or update a care plan to address the resident's weight loss. Interviews with facility staff, including the Restorative Nursing Assistant, RD, Registered Nurse Supervisor, and Director of Nursing, confirmed that these steps were not taken, and acknowledged that the facility's policies and procedures regarding nutritional assessment, unplanned weight loss, and care planning were not followed. As a result of these deficiencies, the resident experienced a weight loss of 10 pounds over five months. The lack of adherence to recommended monitoring, communication, and care planning placed the resident at risk for further weight loss and potential harm, as directly stated in the report. The facility's failure to follow its own protocols and the RD's recommendations contributed to the resident's unaddressed nutritional decline.
Failure to Implement Fall Protocol and Follow Physician Orders
Penalty
Summary
The facility failed to follow physician orders for laboratory services and implement fall care plan interventions for a resident diagnosed with dementia and assessed at high risk for falls. The facility did not have a fall protocol or fall prevention program in place, as indicated in the resident's care plan and physician orders. This lack of protocol contributed to the resident experiencing multiple unwitnessed falls, resulting in acute pain and trauma. Additionally, the facility did not follow up with laboratory services when a blood sample could not be obtained due to excessive bruising. The resident's physician had ordered a complete blood count and comprehensive metabolic panel, but the facility staff did not ensure these tests were completed. Furthermore, the facility failed to collect a urine sample for culture and sensitivity after a probable contamination was identified, delaying the diagnosis and treatment of a urinary tract infection. As a result of these deficiencies, the resident experienced severe health complications, including hypernatremia, dehydration, urinary tract infection with severe sepsis, and thrombocytopenia. The resident was eventually transferred to a general acute care hospital for further treatment. The facility's failure to implement a fall prevention program and follow physician orders for laboratory tests and urine collection significantly impacted the resident's health and safety.
Facility Fails to Protect Resident from Sexual Abuse by CNA
Penalty
Summary
The facility failed to protect a resident from sexual abuse by a Certified Nurse Assistant (CNA). The incident occurred when the CNA engaged in non-consensual sexual contact with the resident, who was severely cognitively impaired and unable to consent or defend himself. The abuse was captured on a hidden camera installed by the resident's emergency contact, which showed the CNA using the resident's hand to stroke his own penis. This incident was reported to the police, leading to the CNA's arrest. The resident involved in the incident had a history of severe cognitive impairment, cerebral infarction, and was dependent on facility staff for all self-care and mobility. The resident's condition made him unable to communicate verbally or physically defend himself. The abuse had a significant negative psychosocial impact on the resident, as noted by the facility's social services director and a psychologist, who observed changes in the resident's behavior, including difficulty sleeping, hopelessness, and frustration. The facility's failure to protect the resident from abuse was identified as an Immediate Jeopardy situation by the California Department of Public Health. The facility was notified of this situation due to their non-compliance in ensuring the resident's safety from non-consensual sexual contact. The incident highlighted a severe deficiency in the facility's ability to safeguard residents from abuse, particularly those who are cognitively impaired and unable to advocate for themselves.
Removal Plan
- Resident 1 was assigned a different Certified Nurse Assistant.
- The Administrator reported the incident to the California Department of Public Health and Ombudsman.
- The Administrator reported initiation of sexual abuse allegation investigation to the Medical Director.
- A change of condition documentation for sexual abuse allegation was completed by a licensed nurse on Resident 1 notifying his primary physician and responsible parties.
- A head-to-toe body assessment was conducted by a licensed nurse with no new skin discoloration or impairments noted.
- Resident 1 was placed on every shift monitoring for a change of condition related to sexual abuse allegation.
- Plan of care was updated by licensed nurses to provide resident with 2 CNAs when providing care.
- Resident 1 was placed under a one-to-one supervision and monitoring utilizing the one-to-one observation daily monitoring form to document supervision and monitoring.
- Resident 1 was seen by primary physician with no new orders.
- The Psychiatrist assessed and evaluated Resident 1 and was found with no signs of agitation. Succeeding psychiatrist visits would be scheduled monthly for 3 months and as needed.
- The Social Services Director conducted visits to Resident 1 to provide psychosocial support.
- Resident 1's plan of care was reviewed and updated by a licensed nurse to reflect current needs and monitoring.
- A Quality Assurance Performance Improvement plan was developed surrounding Abuse Management and was discussed by the Administrator, Director of Nursing, and Medical Director.
- CNA 1 was terminated by the Administrator and reported to the CNA licensing body for gross misconduct.
- Director of Nursing, Activities Director, and EC 1 met and discussed recent alleged abuse event.
- The IDT members conducted an interview and observation to all other residents utilizing the Sexual Screening Assessment tool.
- The Director of Staff Development provided the initial in-service education to Department Manager, nursing staff regarding Abuse prohibition and Management.
- A total of actively employed facility staff were provided an in-service. The Inservice re-education would continue until 100% was achieved.
- The Director of Staff Development and/or designee would facilitate background checks and at least two reference checks prior to hire and quarterly background checks thereafter.
- The Director of Staff Development and/or designee would conduct abuse training to facility staff upon hire and quarterly thereafter.
- The Sexual Screening Assessment tool would be utilized by licensed nurses for incidents involving sexual abuse allegations.
- The IDT would conduct an abuse risk assessment during the scheduled quarterly care conference meetings.
- The Sexual Capacity Assessment tool for residents would be completed as part of the admission assessments for new admissions and/or re-admissions.
- The Department Managers and other staff assigned would continue to complete daily Resident Care Room Rounds.
- Licensed nurses would conduct verbal endorsement daily at the start of each shift with licensed nurses and CNAs.
- The Administrator and/or Designee would conduct random observation rounds weekly.
- Social Service and/or Designee, would conduct a resident council meeting twice within the next 30 days.
- The Administrator and/or designee would discuss any pattern of findings related to any alleged abuse investigation with the Medical Director and QAA committee monthly.
Failure to Manage Psychotropic Medication
Penalty
Summary
The facility failed to manage a resident's psychotropic medication, Depakote, in accordance with its policies and procedures. The resident was administered Depakote for seizures from 12/11/2024 to 12/18/2024, despite not having a seizure disorder or diagnosis. The diagnosis for Depakote use was later changed to mood swings without adequate clinical assessment or a comprehensive review of the resident's condition. Additionally, the facility did not develop a comprehensive care plan for the administration of Depakote, which should have included guidelines for medication management and monitoring for side effects. The facility's licensed nurses did not adequately monitor or document the efficacy and adverse consequences of Depakote from 12/11/2024 to 12/28/2024. The resident was observed to be quiet, drowsy, sedated, and with poor oral intake, but these symptoms were not properly addressed. The resident's responsible party repeatedly requested the discontinuation of Depakote due to these symptoms, but the facility staff did not evaluate the resident or communicate these concerns to the psychiatrist in a timely manner. Furthermore, the facility failed to arrange a follow-up visit with the psychiatrist to reevaluate the resident's psychotropic medication as ordered by the attending physician. The resident was not reassessed by a psychiatrist from 12/11/2024 to 12/28/2024, and there was no documented evidence of monitoring for side effects or laboratory tests for Depakote levels. These failures resulted in a delay in managing the resident's adverse consequences, leading to hospitalization with diagnoses including lower gastrointestinal bleed, hypernatremia, and dehydration.
Failure to Implement Effective Infection Control Measures During GI Outbreak
Penalty
Summary
The facility failed to implement an ongoing infection prevention and control program (IPCP) to prevent and control the spread of gastrointestinal (GI) infections among residents and staff. This deficiency was observed in 26 of 106 sampled residents and 16 of 150 facility staff who presented with GI illness symptoms over a 14-day period. The facility did not place affected residents on transmission-based precautions, nor did it prohibit symptomatic staff from working until they were symptom-free for at least 48 hours. Additionally, the facility failed to collect stool specimens from affected residents to identify the infection source. The facility did not ensure that residents with symptoms of vomiting and diarrhea were placed on transmission-based precautions. Staff members, including CNAs, who exhibited active symptoms of diarrhea and vomiting, were not prohibited from providing care to residents, increasing the risk of further infection spread. The facility also failed to investigate the outbreak to identify individual cases and trends, which would have allowed for appropriate preventative interventions. The Infection Preventionist (IP) nurse did not start the facility's surveillance tracking tool to monitor the outbreak effectively, and the local health department was not notified in a timely manner. Furthermore, the facility did not ensure that staff followed proper hand hygiene procedures, which had the potential to cross-contaminate food and beverages, such as ice served to residents. There was no properly installed handwashing sink near the ice dispensing room, and staff were observed not washing their hands before handling ice. These practices placed residents and staff at risk for complications from GI infections, including dehydration, hospitalization, and possible death. Laboratory results confirmed Norovirus 2 in two residents, highlighting the severity of the outbreak.
Removal Plan
- Notification to the local health department that an outbreak investigation had been initiated.
- The facility's IP nurse completed and updated the cumulative line listing of Residents with GI symptoms.
- The facility will send the updated line listing/contract tracing to the local health department daily until further notice from the Public Health Department.
- The facility has posted a Notice to all visitors of a declared outbreak for the investigation of GI related illness on all facility entrances.
- All visitors are subject to registration before entering the premises and are required to complete a questionnaire screening.
- The DON and the IP nurse completed an evaluation and assessment of all residents to ensure no other residents have been identified with GI symptoms.
- Symptomatic Residents identified had action plans initiated including change of condition completion, developed care plans, notification to each resident's attending physician, and environmental cleaning and sanitation.
- Nursing personnel are conducting clinical assessments of all symptomatic Residents to manage symptoms and prevent fluid deficits and discomfort.
- The contracted Registered Dietitian Resources made a service visit to assess active cases and monitor affected Residents.
- Current symptomatic nursing employees had been removed from work schedules pending resolution of symptoms.
- An educational in-service training was initiated and completed by the Regional IP-Director of Staff Development Resource with all Dietary on foodborne illness prevention, handwashing, and appropriate dress code.
- An all-staff educational in-service was initiated for all Nursing and Non-Nursing personnel to address identification, prevention, and management of GI related illness.
- The Nursing Department will continue to complete shift huddle/handoff to identify any changes of condition related to GI symptoms.
- For the facility's Ice Process: The Dietary and Nursing personnel will complete handwashing hygiene with soap and water before handling ice.
- Food service workers were in-serviced by the Regional IP-DSD Resource on foodborne illness and hand hygiene.
- The food service workers were screened prior to commencement of duties to ensure they are free of gastrointestinal symptoms.
- The IP nurse included Environmental services personnel within the offered in-service and have been directed to increase disinfection of high touch surfaces.
- Laundry personnel will continue to monitor linen handling, washing, and drying to ensure proper processing temperatures and sanitizing is maintained.
- The IP and the DON will continue to monitor the above measures in collaboration with the local health department.
- The facility regional consultant provided an in-service for the facility leaders regarding reportable diseases and conditions.
- The facility regional consultant provided a one-on-one in-service to the facility IP nurse regarding proper identification of health illnesses that constitute a reportable condition.
QAPI Committee Fails to Address GI Illness Outbreak
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to systematically identify and address an outbreak of gastrointestinal (GI) illness among residents and staff. The committee did not implement or evaluate preventative measures in response to the outbreak, which affected 26 residents and 16 staff members. The outbreak, characterized by symptoms such as vomiting and diarrhea, persisted over a 14-day period without adequate intervention or follow-up from the QAPI committee. The QAPI committee also failed to ensure that appropriate transmission-based precautions were implemented for affected individuals. Despite the presence of symptoms in both residents and staff, the committee did not take necessary actions to mitigate the spread of the illness. Additionally, the facility did not notify the local health department in a timely manner, delaying the response to the outbreak and potentially exacerbating the situation. Interviews with facility staff, including the Administrator and Director of Nursing, revealed that the QAPI meetings were not conducted as required, and the increasing number of GI illness cases was not brought to the committee's attention. The facility's policy on QAPI, which outlines the need for a data-driven approach to quality improvement, was not adhered to, resulting in a lack of coordinated efforts to address the outbreak effectively.
Failure to Develop Comprehensive Care Plan for Resident with Anxiety
Penalty
Summary
The facility failed to ensure a comprehensive care plan was developed and implemented for a resident diagnosed with anxiety disorder. The resident, who was admitted with diagnoses including bipolar disorder, anxiety disorder, and malignant neoplasm of the kidney, did not have a care plan addressing their anxiety. This oversight was identified during a review of the resident's care plan, which was based on their history and physical, diagnosis, and progress notes. The MDS Nurse confirmed that all diagnoses should have corresponding care plans to guide staff in providing appropriate care. The Director of Nurses acknowledged the absence of a care plan for the resident's anxiety and emphasized the importance of having one to ensure proper care. The facility's policy on comprehensive, person-centered care plans, revised in March 2022, mandates the development and implementation of care plans with measurable objectives and timetables to meet residents' needs. The lack of a care plan for the resident's anxiety disorder was a deviation from this policy, potentially leading to inadequate and incomplete care for the resident.
Failure to Administer and Document Medications
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident by not administering medications as ordered by the physician on three separate occasions. The resident, who was admitted with diagnoses including diabetes mellitus and hypertension, did not receive their prescribed medications on specific dates in November 2024. This failure was identified through a review of the resident's Medication Administration Record (MAR), which lacked documentation indicating that the medications were administered on those dates. The resident's MAR for November 2024 showed that medications due at 9 AM on 11/4, 11/5, and 11/12 were not documented as given. The medications included treatments for high blood pressure, diabetes, and other conditions. The Director of Nursing confirmed that the absence of documentation meant the medications were not administered, as per the facility's standard practice. The Licensed Vocational Nurse responsible for administering the medications admitted to forgetting to document the administration, acknowledging that if it was not documented, it was not done. The facility's policy on medication administration documentation, revised in 2022, requires that all medications administered be documented immediately after being given. This policy was not followed, leading to the deficiency. The lack of documentation and administration of medications could have potentially impacted the resident's health, given their medical conditions, although the report does not specify any direct consequences that occurred as a result.
Failure to Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to ensure that a resident, who was transferred to a General Acute Care Hospital (GACH) due to a change in condition, was provided with written information regarding the facility's bed-hold policies and was permitted to be readmitted back to the facility on the first available bed. The resident, who had been admitted to the Skilled Nursing Facility (SNF) with diagnoses including metabolic encephalopathy, unspecified psychosis, and Type 2 diabetes, was transferred to the GACH via 911 emergency services due to altered mental status. Despite being medically stable for discharge back to the SNF, the resident was not readmitted and had to remain in the GACH for an additional six days before being transferred to another facility. The facility's failure to place the resident on a bed hold and provide the family with written information about the bed-hold policies was a significant oversight. The facility's Administrator (ADM) decided not to place the resident on bed hold, believing the resident required a higher level of care and that the GACH could assist in finding a new placement. This decision was made without conducting an interdisciplinary team (IDT) meeting or involving the resident's family in discharge care planning. The facility's Director of Nursing (DON) confirmed that the resident was not placed on bed hold, and the family was not notified about the seven-day bed hold policy. Interviews with facility staff and the GACH Social Service Director revealed that the ADM had requested psychiatric and medical clearances before considering the resident's readmission. Despite receiving the necessary clearances, the ADM did not proceed with the readmission, citing the need for additional paperwork. The facility's actions were contrary to their policy and the California Standard Admission Agreement, which required them to offer the next available appropriate bed if the bed-hold notification procedure was not followed.
Failure to Complete Annual Competency Assessments for Nursing Staff
Penalty
Summary
The facility failed to ensure that two licensed nurses, an RN and an LVN, completed their annual competency assessment and evaluation as required by the facility's policy and procedure. The RN was hired on January 16, 2023, and the LVN on March 27, 2023. Both had initial skills checklists signed by the employee and the DON on their respective hire dates. However, there was no documented evidence of a skills competency evaluation being completed for either nurse since their hiring. During an interview and record review with the DON, it was confirmed that the facility had not conducted a skills competency evaluation for the current year. The DON explained that the facility typically holds a Skills Competency and Evaluation fair annually to ensure all nursing staff are assessed simultaneously. The absence of this evaluation placed residents at risk of receiving care that did not meet the standard of practice, potentially affecting their quality of life and care. The facility's policy emphasized the importance of competency in identifying, documenting, and reporting resident changes of condition, which is monitored by nursing leadership.
Food Storage and Egg Handling Deficiencies
Penalty
Summary
The facility failed to adhere to its policy and procedure guidelines to prevent food contamination and the spread of foodborne illness in the kitchen. During an observation, multiple opened dry food items in the kitchen's dry goods storage area were found to be improperly stored. These items, including pasta bags, gelatin powder, and gravy bags, were wrapped in transparent plastic wrap without labels indicating the date they were opened or their expiration dates. The Dietary Supervisor confirmed that the facility's policy requires opened food items to be stored in sealable plastic bags and labeled with the product name, opened date, and expiration date to prevent food contamination and the use of expired food items. Additionally, the facility was found to be using unpasteurized eggs as ingredients in foods served to residents, which is against their policy. Two boxes of eggs in the kitchen's walk-in refrigerator did not have labels indicating they were pasteurized. The Dietary Supervisor acknowledged that the facility only orders pasteurized eggs, but due to an out-of-stock situation, they received a substitute that was not pasteurized. The facility's policy mandates the use of pasteurized eggs for certain preparations to prevent foodborne illnesses. The Registered Nurse confirmed that using unpasteurized eggs could potentially make residents sick.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement its infection control policy regarding Enhanced Barrier Precautions (EBP) for a resident with multiple wounds and a Foley catheter. This deficiency was observed when a Certified Nursing Assistant (CNA) provided care to the resident without wearing the required personal protective equipment (PPE), specifically an isolation gown. The resident, who was admitted with diagnoses including a urinary tract infection and pressure ulcers, was identified as requiring EBP due to the presence of wounds. The CNA admitted to forgetting to wear the gown, which is necessary to prevent the spread of infections. The facility's policy, revised in April 2024, mandates the use of gowns and gloves during high-contact resident care activities for residents with wounds or indwelling medical devices. Despite this, the CNA was observed providing a bed bath without the appropriate PPE. Interviews with the CNA, a Licensed Vocational Nurse (LVN), and the Director of Nursing (DON) confirmed the requirement for EBP and the importance of using PPE to prevent infection transmission. The failure to adhere to these precautions placed the resident and others at risk of infection spread.
Resident Dignity Compromised During Transport
Penalty
Summary
The facility failed to ensure that a resident was treated in a dignified and respectful manner, as required by their policy on dignity. During an observation, a certified nursing assistant (CNA) was seen transporting a resident in a shower chair through the hallway without adequately covering the resident's body, resulting in the resident's buttocks being exposed. This incident occurred despite the facility's policy that emphasizes the importance of maintaining resident privacy and dignity during personal care and treatment procedures. The resident involved had been admitted to the facility with diagnoses including Parkinson's disease, depression, and hypothyroidism, and was capable of understanding and making decisions. The CNA involved was unaware of the exposure and acknowledged the importance of covering the resident to protect their privacy. Interviews with the Director of Staff Development and the Director of Nursing highlighted the significance of ensuring residents are fully covered during transportation to uphold their dignity, especially in public areas like hallways.
Failure to Assess Resident's Ability to Self-Administer Medications
Penalty
Summary
The facility's interdisciplinary team (IDT) failed to accurately assess a resident, identified as Resident 90, for the ability to safely self-administer medications. The resident had 17 bottles of medications stored at her bedside, which were not prescribed or ordered by a physician for self-administration. The facility did not conduct an IDT meeting to evaluate the resident's cognitive and physical abilities to self-administer these medications. Additionally, there was no review of whether any of the medications were expired, discontinued, or recalled, nor was there documentation of the times when the resident self-administered her medications. Resident 90 was admitted with diagnoses including a leg fracture and malignant neoplasms of the kidney and bone. Her medical records indicated fluctuating capacity to understand and make decisions, yet her Minimum Data Set (MDS) showed intact cognition. Despite this, there was no evidence in her medical records that the facility assessed her safety in self-administering medications or monitored her for any side effects. Observations revealed multiple bottles of herbal medications and oils at her bedside, which she consumed without consulting facility staff. Interviews with facility staff, including a registered nurse (RN), pharmacist (PH), and the director of nursing (DON), confirmed the lack of assessment and monitoring for Resident 90's self-administration of medications. The facility's policies required an assessment by the IDT and a physician's order for self-administration, which were not followed. The medications were not reviewed by the pharmacist, and there was no documentation in the Medication Administration Record (MAR) regarding the resident's self-administration or any associated side effects.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to accommodate the needs of three residents by not ensuring their call lights were within reach, which could lead to delayed care and potential accidents. Resident 83, who has severe cognitive impairment and is dependent on assistance for daily activities, was observed with their call light on the floor, out of reach. This resident's care plan specifically required the call light to be within reach due to their risk of falls and impaired visual function. During an observation, a registered nurse confirmed the call light was not accessible and acknowledged the risk of accidents if call lights are not within reach. Similarly, Resident 314, who has intact cognition but requires supervision and moderate assistance for various activities, was also found with their call light on the floor, out of reach. The resident's care plan highlighted the need for the call light to be accessible due to their risk of falls related to limited mobility. A licensed vocational nurse confirmed the call light should be within reach to prevent potential falls. The Director of Nursing reiterated the importance of keeping call lights within reach to avoid delays in response and potential accidents. The facility's policy mandates that call lights be accessible and calls for assistance be answered promptly.
Failure to Maintain Advance Directives in Resident Records
Penalty
Summary
The facility failed to ensure that a current copy of a resident's advance directive was included in the medical records for two residents. Resident 53, who was admitted with diagnoses including metabolic encephalopathy, end-stage renal disease, and lobar pneumonia, had an advance healthcare directive (AHCD) noted in a multidisciplinary care conference. However, the AHCD acknowledgment form indicated that Resident 53 did not have an advance directive, and there was no follow-up from the facility staff to obtain it. The Social Services Director confirmed that a copy of the advance directive was requested but not followed up on, highlighting the importance of having it readily available in case of emergencies. Similarly, Resident 21, admitted with diagnoses including end-stage renal disease and pneumonia, had an acknowledgment form indicating no advance directive, but another document showed that an advance directive was completed. Despite this, a copy was not available in the medical records. The Social Services Director was unaware of the status of Resident 21's advance directive and did not follow up with the family. The Director of Nursing emphasized the importance of having a copy of the advance directive to ensure the resident's wishes are known and respected during emergencies. The facility's policy required obtaining and including a copy of the advance directive in the resident's medical record upon admission.
Failure to Notify Physician and Update Care Plan for Significant Weight Loss
Penalty
Summary
The facility failed to notify the physician and resident representative of a significant weight loss for a resident, identified as Resident 21, who experienced a 23-pound weight loss over 15 days. This deficiency was identified through interviews and record reviews. The resident, who was admitted with diagnoses including Parkinson's disease, cognitive communication deficit, and heart failure, was noted to have moderate cognitive impairment and was on a mechanically altered and therapeutic diet. Despite these conditions, the facility did not complete a Change of Condition (COC) or update the Comprehensive Care Plan to address the weight loss. The resident's weight was recorded as 148 pounds on one date and 125 pounds 15 days later, indicating a 15.54% weight loss. The Nutrition Assessment noted the resident's weight loss and identified nutritional risks such as variable oral intake, disease process, and psychotropic medications. However, the facility did not document a COC or update the care plan to address these changes. The Nutrition Progress Notes indicated the resident was eating well and recommended monitoring weight changes and providing snacks for weight management. Interviews with facility staff, including the Director of Nursing (DON), confirmed that there was no COC or Care Plan completed for the resident's weight loss, which should have been done according to the facility's policies. The facility's policies required documentation of changes in the resident's condition and notification of the physician for significant changes, which were not followed in this case.
Inadequate Discharge Planning and Unsafe AMA Discharges
Penalty
Summary
The facility initiated discharges for two residents without adequate reason or proper documentation, leading to unsafe discharges against medical advice (AMA). Resident 320 was informed by the Social Services Director that she did not meet the criteria to stay at the facility and was given the option to pay out of pocket or sign an AMA form. The facility failed to provide adequate discharge planning, did not inform Resident 320 of her right to appeal, and did not provide necessary post-discharge resources such as medications or home health services. The resident was not aware of her rights and felt compelled to leave due to financial constraints. Resident 111, who had moderately impaired cognition, was not allowed to return to the facility after going out on pass. The facility informed her that she could not come back despite her desire to return. The facility did not provide adequate discharge planning, resulting in an unsafe discharge AMA. The facility's records did not indicate any previous issues with Resident 111's compliance with the out-on-pass policy, and there was no documented evidence of discharge paperwork or prescriptions for her medications. The facility's policies and procedures were not followed, as evidenced by the lack of proper documentation and communication regarding the residents' rights and options. The facility failed to ensure that residents were informed of their rights to appeal and did not provide necessary support for residents who were discharged AMA. The facility's actions led to potential negative health effects for the residents due to the lack of medications and home health services.
Failure to Revise Pain Management Care Plan
Penalty
Summary
The facility failed to revise the care plan for a resident, identified as Resident 38, who continued to experience daily pain despite receiving pain medication. The resident was initially admitted in 2018 and readmitted in 2023 with diagnoses including chronic congestive heart failure, hypothyroidism, and anemia. The Minimum Data Set (MDS) assessment indicated that the resident had intact cognition and experienced occasional pain, with a numeric pain rating of nine out of ten. The resident's pain care plan, last updated in March 2024, included interventions such as evaluating for breakthrough pain and implementing nonpharmacological interventions. However, the care plan was not revised to address the resident's ongoing pain complaints. Interviews with the Director of Nursing (DON) and the MDS Coordinator (MDSC) revealed that the care plan should have been updated to reflect the resident's continued pain and to identify alternative interventions. The DON acknowledged that although the medication was helping, the facility should have explored different ways to alleviate the resident's pain. The MDSC confirmed that the care plan had not been revised since March 2024, which could lead to the resident experiencing worsening pain. The facility's policy on comprehensive, person-centered care plans emphasized the need for ongoing assessments and revisions as residents' conditions changed.
Failure to Assist Resident with Vision Services
Penalty
Summary
The facility failed to assist a resident, identified as Resident 72, in obtaining necessary vision services after his prescription glasses were broken by a Certified Nursing Assistant (CNA). Despite Resident 72's repeated notifications to multiple facility staff about the broken glasses, no timely action was taken to address the issue. The resident's care plan indicated a risk for injuries related to impaired visual function, and the need for corrective lenses was documented in his Minimum Data Set. However, the Social Service Assistant (SSA) did not contact the facility's optometrist promptly, waiting instead for a routine visit, and did not document any communication regarding the broken glasses. The Director of Nursing (DON) became aware of the issue a week before the survey and instructed Social Services to assist the resident, but was unaware that the glasses had been broken for over a month. The facility lacked a specific policy for ancillary eyeglasses services, although it was their practice to arrange appointments and obtain necessary assistive devices promptly. This inaction led to the resident having to manage with broken glasses and non-prescription reading glasses, potentially affecting his quality of life.
Failure to Administer Oxygen Therapy with Proper Parameters
Penalty
Summary
The facility failed to administer oxygen therapy according to a physician's order and without clear parameters for when to administer oxygen for a resident. The resident, who was admitted with diagnoses including Type 2 Diabetes, chronic kidney disease, and heart failure, had an order for oxygen at 2 liters per minute. However, the care plan indicated oxygen should be administered at 2-3 liters per minute to maintain oxygen saturation above 92%. During an observation, a Licensed Vocational Nurse (LVN) administered oxygen at 3 liters per minute when the resident's oxygen saturation was at 89%, without a specific parameter in the order indicating when to administer oxygen. The LVN acknowledged the lack of parameters in the order and stated she would normally administer oxygen when the resident's saturation dropped below 90% or if the resident showed signs of shortness of breath. The Director of Nursing confirmed that all oxygen orders should include parameters to guide staff on when to administer oxygen. The facility's policy on oxygen administration requires verification of a physician's order and adherence to proper administration guidelines, which was not followed in this instance.
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What surveyors actually found near you
We read the 6,391 citations issued within 25 miles in the last 12 months — including the 33 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Glendale
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Autumn Hills Health Care Center | 0.2 mi | ★★★★★ | 7 | 0 |
| Glendale Adventist Medical Center Dp/snf | 0.6 mi | ★★★★★ | 16 | 0 |
| Ararat Post Acute | 0.8 mi | ★★★★★ | 20 | 0 |
| Ararat Convalescent Hospital | 1.3 mi | ★★★★★ | 16 | 0 |
| Chestnut Ridge Post Acute Llc | 1.3 mi | ★★★★★ | 35 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.