Average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Granada Post Acute during CMS and state inspections, most recent first.
Dishwasher Temperature and Beard Restraint Food Safety Deficiencies: A dietary assistant supervisor observed the low-temp dishmachine washing dishware at 108 degrees Fahrenheit, below the facility’s required 120 to 140 degrees Fahrenheit range, while the thermometer was partially obscured by residue. In a separate observation, a cook with visible facial hair was preparing and serving resident meals without a beard net, despite facility expectations that staff with facial hair wear beard restraints during food prep and service.
Incomplete and untimely repositioning documentation affected five residents with impaired mobility and pressure injury risk. Care plans directed q2h turning/repositioning, but flow sheets and ADL records did not consistently show the interventions, some entries were late, and one CNA stated a resident refused repositioning without the refusal being documented. Staff confirmed the records could not verify whether the care was actually provided.
The facility failed to monitor the specific target behaviors for two residents receiving psychotropic medications. One resident on quetiapine for schizophrenia had no order to monitor visual hallucinations, and another resident on trazodone for depression had no order to monitor hours of sleep. Staff stated the missing monitoring was needed to assess medication effectiveness, and the DON confirmed the facility policy required documentation of target behaviors and monitoring for efficacy.
A resident with DM, muscle weakness, and prior fracture history fell while walking with two staff, twisted her ankle, and was transferred to the GACH with an acute ankle fracture and severe pain. Although her cognition was intact and she had been dependent for ADLs with limited standing ability, the MDS nurse stated no significant change MDS was completed after the injury. The DON stated the fall with injury and decline in ambulation should have triggered a significant change assessment and IDT review.
Inaccurate MDS Omitted Active Dementia Diagnosis: A resident’s MDS failed to include an active dx of dementia in Section I, even though the dx was listed in the admission record and diagnosis list. The MDS Nurse confirmed the omission and stated all active dx should be documented because the MDS drives care plans and interventions. The DON stated accurate MDS assessments are important to ensure the resident’s plan of care is comprehensive and addresses the resident’s specific needs.
PASARR Level 2 Evaluation Not Completed: A resident with pneumonia, COPD, and DM had a PASARR Level 1 screen that indicated the need for a Level 2 evaluation, but the evaluation was not completed. The SSD stated the resident either refused to participate or was not in the facility when the evaluation was attempted, and the DON stated PASARR evaluations are important to ensure appropriate placement and coordination of needed programs and services.
Failure to revise a resident's care plan after a fall with fracture. A resident with DM, muscle weakness, and dependence for ADLs fell while walking with two staff, twisted an ankle, and was sent to the GACH for evaluation after severe pain. Records showed an acute fracture of the medial malleolus and distal fibula, but the existing falls care plan was not updated with individualized interventions after the injury.
Failure to Maintain Fingernails Clean and Trimmed: Two staff-dependent residents had long, untrimmed fingernails with visible debris despite ADL care plans directing staff to keep nails clean and short. CNA and DON interviews confirmed nail care was part of routine ADL assistance and should be checked daily, but the residents’ nails were not maintained as required.
A resident with an unstageable sacral PU, contractures, muscle weakness, and high Braden risk did not receive consistent q2h repositioning, and the turning record had multiple missing entries. The resident’s family and CNA described a missed repositioning window during an afternoon shift, and the DSD stated the charting did not verify that repositioning occurred. In a separate finding, another resident’s LAM was observed set at 280 lbs despite the MD order and care plan requiring 210 lbs; the DON confirmed the setting did not match the resident’s weight and order.
Failure to Follow Ordered Orthostatic BP Monitoring: A resident with hypotension and orthostatic hypotension had physician orders for orthostatic BP checks every Sunday, but the vitals record did not show the required readings on multiple Sundays. An LVN and the DON reviewed the chart and confirmed the ordered monitoring was not documented, and the DON stated the facility could not demonstrate the assessments were completed as ordered.
A resident with hydronephrosis, obstructive reflux uropathy, cognitive impairment, and a chronic Foley catheter did not receive a timely urology consult that had been ordered for possible suprapubic catheter placement. The CM acknowledged the consult process was started late and was not followed through, and the consult was not reordered after readmission despite ongoing need and a later physician order. RN and DON interviews confirmed the consult should have been pursued because of the resident’s catheter history and specialist needs.
Pharmacist MRR Recommendation Not Addressed for Pain Management: The facility failed to ensure a consultant pharmacist’s MRR recommendation was reviewed and communicated to the physician for a resident receiving PRN Oxycodone-Acetaminophen for severe pain. The resident’s care plan called for non-pharmacological interventions, but the DON stated there was no documentation that the physician reviewed or addressed the pharmacist’s recommendation, and no documented non-pharmacological interventions were in place.
Failure to Follow Planned Menu and Standardized Recipe: A resident with DM, muscle weakness, and HTN received a lunch sandwich with cheese even though the resident did not request it and the facility's French Dip recipe did not include cheese. The DS confirmed the recipe ingredients, and an administrator stated the facility was responsible for following established recipes and documenting meal additions on the resident's meal ticket.
A resident with moderate cognitive impairment and hearing difficulties consistently refused to wear hearing aids, yet the care plan was not updated to reflect this refusal or to document alternative interventions. Staff acknowledged the ongoing refusal and communicated by speaking directly into the resident's ear, but the facility did not revise the care plan as required by policy.
A resident was not provided assistance to obtain needed vision and hearing services, resulting in a lack of access to appropriate care in these areas.
A resident with osteopenia, fractures, and contractures who was fully dependent on staff did not have a comprehensive, person-centered care plan. The care plan lacked specific details about the location of the osteopenia and did not include measurable objectives or timetables, contrary to facility policy. The DON confirmed the care plan was not sufficiently individualized to guide care.
The facility failed to accurately complete MDS assessments for three residents, leading to incorrect data transmission to CMS. One resident's MDS did not reflect dental issues, another's did not indicate the absence of natural teeth, and a third's was inaccurately coded regarding oral status. The MDS Nurse acknowledged these inaccuracies, which could result in unmet care needs.
A facility failed to submit an accurate Level I PASRR for a resident with psychosis, depression, and anxiety disorder. The initial PASRR, completed by the hospital, did not reflect these SMIs, leading to a determination that the resident did not require a Level II PASRR Mental Health Evaluation. The Social Services Director acknowledged the oversight and the need for a new assessment, as per facility policy.
The facility failed to implement care plans for two residents, one with epilepsy and another requiring oxygen therapy. Resident 288's care plan required padded siderails to prevent injury during seizures, but observations showed no padding was applied. Resident 191, dependent on supplemental oxygen, lacked a care plan for oxygen administration, and no oxygen sign was posted outside the room. Interviews confirmed these deficiencies, highlighting a lack of adherence to facility policies for comprehensive care planning.
A LTC facility failed to implement proper interventions for pressure ulcer prevention for four residents. Incorrect settings on low-air-loss mattresses (LALM) were observed for three residents, with one resident not receiving a LALM as ordered. The facility's policy for air mattresses was not followed, leading to potential risks for pressure ulcer development or worsening.
A resident with epilepsy was observed multiple times in bed without the required padding on siderails, as specified in their care plan. Despite the facility's policy and the resident's high risk for injury, the necessary safety measures were not implemented, placing the resident at risk.
A facility failed to post an oxygen signage for a resident receiving oxygen therapy, as observed during a survey. The resident, with a history of acute respiratory failure and other health issues, was receiving supplemental oxygen via nasal cannula. A nurse and the DON acknowledged the absence of the sign, which was required by the facility's policy for safety.
A resident with Parkinson's, diabetes, and seizure disorders received medications late and incorrectly, resulting in an 18.75% medication error rate. An LVN administered six medications over an hour late and applied Lidocaine cream to the wrong knee. The facility's policy requires medications to be given within one hour of the scheduled time, which was not followed.
A resident on a pureed diet was not provided with a menu or offered alternative meal options, despite expressing dissatisfaction with the meals and consuming less than 50% of them. The resident, who communicated through a digital device, reported the meals were inedible and lacked variety. Staff failed to offer alternatives, citing the pureed diet as a reason, and there was confusion over which department was responsible for providing menus. Facility policies requiring substitute food items and menu postings were not followed, impacting the resident's nutritional status and quality of life.
A facility failed to ensure staff were knowledgeable about handling unlabeled resident clothes and did not complete a belonging list upon a resident's readmission. Interviews revealed discrepancies in staff understanding of the process for managing unlabeled clothes, with some staff placing them in a donation box and others keeping them in the laundry room. Additionally, an inventory list was not created upon the resident's readmission, contrary to facility policy, potentially violating the resident's right to a safe and homelike environment.
A resident with polyneuropathy and joint replacement surgery experienced a fall, but the facility failed to conduct an IDT meeting or update the care plan with safety interventions. Despite the resident's cognitive intactness and partial assistance needs, the care plan lacked measures to prevent future falls, such as providing a reacher, which was only added nine days later. The DON confirmed the absence of documentation for an IDT meeting and the delay in care plan revision.
The facility failed to implement infection control measures by improperly cohorting residents and not posting necessary signage for contact isolation and Enhanced Barrier Precautions (EBP). A resident with MRSA was placed in a room with two others without contact precautions, and staff did not wear PPE when entering the room. Additionally, signage for EBP was missing for two residents, leading to potential risks of infection transmission.
A resident's transfer to a GACH Rehab was delayed due to the facility's failure to send complete documentation, including essential PT notes. The resident, with conditions like hemiplegia and muscle weakness, required further therapy, but the incomplete referral led to the case being closed by the rehab center. Interviews revealed that the facility's Social Services could not confirm the transmission of the missing documents, resulting in the resident not being accepted for transfer.
Dishwasher Temperature and Beard Restraint Food Safety Deficiencies
Penalty
Summary
The facility failed to ensure the low-temperature dishwashing machine reached the required sanitizing water temperature before soiled dishes were washed. During observation, the machine was actively washing dishware while the temperature gauge had dried residue obstructing the reading. After the residue was removed, the thermometer showed 108 degrees Fahrenheit during the active wash cycle. The Dietary Assistant Supervisor stated the machine should run through two or three cycles before dishware was washed so the water would reach the facility’s required operating range of 120 to 140 degrees Fahrenheit, and stated staff were responsible for verifying the temperature before loading and washing dishes. The facility also failed to ensure dietary staff followed personal hygiene practices during meal preparation and service. During observation, a cook was actively preparing and serving resident meals without a beard net while having visible facial hair extending beyond the chin area. The cook stated that staff with facial hair should wear beard nets to prevent hair from falling into food and to maintain sanitary food handling practices. The Dietary Supervisor later confirmed that dietary staff with facial hair were expected to wear beard restraints during food preparation and service, and that the facility’s personal hygiene and food safety practices required this.
Incomplete and Untimely Repositioning Documentation
Penalty
Summary
The facility failed to ensure repositioning and turning documentation was completed timely and accurately for five sampled residents, and the medical record could not be relied upon to verify care and services provided. The deficiency involved Residents 32, 7, 95, 4, and 64, all of whom had care plans directing repositioning at least every two hours and several of whom had diagnoses or assessments showing impaired mobility, pressure ulcer risk, or existing pressure ulcers. Resident 32 had diagnoses including muscle weakness, bilateral lower leg contractures, an unstageable sacral pressure ulcer, and a gastrostomy tube. The resident’s MDS showed moderately impaired daily decision-making and total dependence for ADLs, and the H&P stated the resident did not have capacity to understand and make decisions. The Braden Scale indicated very high risk for pressure injury. The turning and repositioning flow sheet did not show repositioning at several documented times, and the ADL task flow sheet contained late entries for the 3:00 p.m. to 11:00 p.m. shift. The DSD and RN stated staff were expected to document repositioning every two hours, document refusals when applicable, and complete documentation at the time care was provided; RN 1 also stated the documentation did not identify the position to which Resident 32 was repositioned. Resident 7 had diagnoses including muscle weakness, a pressure ulcer, adult failure to thrive, and MS. The resident’s MDS showed moderately impaired daily decision-making and total dependence for ADLs, and the Braden Scale showed high risk for pressure ulcer development. The care plan directed repositioning every two hours and as needed. During observations, Resident 7 was seen lying on the back at multiple times, and the turn and repositioning flow sheet did not show repositioning at two scheduled times. CNA 2 confirmed she was the assigned CNA and stated the resident refused repositioning, but the documentation did not reflect the refusals or notify the charge nurse as described by the CNA. Resident 95 had diagnoses including muscle weakness, a gastrostomy tube, and Parkinson’s disease. The resident’s MDS showed moderately impaired daily decision-making and maximal assistance needs for several ADLs, and the Braden Scale indicated risk for pressure ulcer development. The turning and repositioning flow sheet did not indicate repositioning at one afternoon time and during an overnight period. Resident 4 had diagnoses including muscle weakness, muscle wasting and atrophy, palliative care, and a right hip contracture. The resident’s MDS showed severe cognitive impairment and lower extremity range of motion impairments, and the care plan directed turning and repositioning every two hours and as needed. During observations, Resident 4 was seen positioned on the back, and the ADL task flow sheets did not contain a designated section for documenting repositioning. Resident 64 had diagnoses including muscle weakness, muscle wasting and atrophy, and dementia. The resident’s MDS showed intact daily decision-making but maximal assistance needs for several ADLs, and the care plans directed turning and repositioning every two hours and as needed. The turning and repositioning flow sheet did not show repositioning at several early morning times. The facility policy stated documentation in the medical record was to be complete and accurate.
Failure to Monitor Target Behaviors for Psychotropic Medications
Penalty
Summary
The facility failed to ensure behavior episodes and hours of sleep were monitored for two residents receiving psychotropic medications. One resident was admitted with diagnoses including COPD, pneumonia, and schizophrenia, and had fluctuating capacity to understand and make decisions. That resident’s physician order for quetiapine 25 mg every 12 hours was written for schizophrenia manifested by visual hallucinations of seeing people in the ceiling, but the medical record did not contain a physician order to monitor those visual hallucinations. During review, the LVN stated the behavior monitoring order was incorrect and that the visual hallucinations should have been the monitored behavior. A second resident was admitted with diagnoses including DM, dysphagia, and depression, and the MDS indicated no cognitive impairment. That resident had a physician order for trazodone 50 mg at bedtime for depression manifested by difficulty sleeping, but the medical record did not contain a physician order to monitor hours of sleep. The RN stated sleep should have been monitored to determine whether the medication was effective. The DON stated monitoring the indicated behavior for psychotropic medications was important to ensure the medication was effective in treating the manifested behavior, and the facility policy required documentation of specific target behaviors, expected outcomes, and monitoring for efficacy and adverse consequences.
Failure to Complete Significant Change MDS After Fall With Fracture
Penalty
Summary
The facility failed to ensure a significant change MDS assessment was completed for a resident after a fall that resulted in a left ankle fracture. The resident had diagnoses including DM, a prior right fibula fracture, and muscle weakness. Her H&P indicated she had the capacity to understand and make decisions, and her MDS dated 1/26/2026 indicated her cognitive skills for daily decision making were intact. The same MDS showed she was dependent on staff for ADLs and required supervision or touching assistance for sitting on the side of the bed and/or standing. On 1/28/2026, the resident was walking in the hallway with two staff members when she lost her balance, twisted her left ankle, and fell backward to the floor. The SBAR documented left ankle pain rated 7 out of 10, and she was transferred to the GACH for evaluation. A progress note from the same day indicated she returned to the facility with an acute fracture to the medial malleolus and distal fibula. The MDS nurse stated the fall with fracture, hospital transfer, increased pain, and decline in ability to ambulate independently should have prompted evaluation for a significant change in status assessment. The MDS nurse stated there was no documented evidence that a significant change MDS assessment was completed after the fall with fracture. The DON stated residents who experience a fall with injury should be assessed to determine whether they had a significant change in condition, and that a significant change in status MDS should be completed when the resident's condition declined and required review and revision of care and services. The DON also stated the interdisciplinary team should have evaluated the resident's fall, left ankle fracture, and need for additional safety, care, and services approaches. The facility policy indicated a comprehensive MDS assessment was mandated for any significant change in a resident's status.
Inaccurate MDS Omitted Active Dementia Diagnosis
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was accurately completed for one resident when the resident’s active diagnosis of dementia was not included in Section I of the assessment. The resident’s admission record listed diagnoses including pneumonia, COPD, DM, and dementia. A review of the resident’s H&P dated 5/12/2026 indicated the resident had the capacity to understand and make decisions, and the MDS dated 4/24/2026 documented no cognitive impairment, partial assistance with personal hygiene, substantial assistance with toileting, and setup assistance for eating. During a concurrent interview and record review on 6/17/2026, the MDS Nurse reviewed the resident’s MDS and diagnosis list and confirmed that dementia was an active diagnosis but was not entered on the MDS. The MDS Nurse stated the diagnosis should have been included because all active diagnoses should be documented in the MDS assessment, as it drives care plans and interventions. The DON stated on 6/18/2026 that accurate MDS assessments were important to ensure the resident’s plan of care was comprehensive and the resident’s specific needs were addressed. The facility policy stated MDS information should consistently reflect progress notes, plans of care, and resident observations/interviews, and the MDS Coordinator job description required informing assessment team members of the requirements for accuracy and completion of the resident assessment.
PASARR Level 2 Evaluation Not Completed
Penalty
Summary
The facility failed to ensure a Preadmission Screening and Resident Review (PASARR) Level 2 evaluation was completed for one sampled resident. The resident was admitted and later readmitted to the facility, and the medical record listed diagnoses of pneumonia, COPD, and diabetes mellitus. The resident’s H&P dated 5/12/2026 stated the resident had the capacity to understand and make decisions, and the MDS dated 4/24/2026 indicated no cognitive impairment, partial assistance with personal hygiene, substantial assistance with toileting, and setup assistance with eating. A PASARR Level 1 screening dated 1/26/2024 indicated the need for a Level 2 PASARR evaluation, but the Level 2 evaluation was not completed. During interview and record review, the SSD reviewed the Level 2 Determination Letter and medical records and stated the resident either refused to participate or was not in the facility when the evaluation was attempted. The SSD stated staff should have submitted another PASARR Level 1 screening to prompt another Level 2 evaluation. The DON stated PASARR evaluations were important to ensure resident placement was appropriate and that programs and services were coordinated depending on resident needs. The facility policy stated a Level 2 full evaluation shall be conducted when the Level 1 screen identifies MI or ID.
Failure to Revise Care Plan After Fall With Fracture
Penalty
Summary
The facility failed to revise the comprehensive care plan for a resident after a fall on 1/28/2026 that resulted in a left ankle fracture involving the medial malleolus and distal fibula. The resident had been admitted with diagnoses including DM, a prior right fibula fracture, and muscle weakness. Her H&P indicated she had the capacity to understand and make decisions, and the 1/26/2026 MDS indicated her cognitive skills for daily decision making were intact. The MDS also showed she was dependent on staff for ADLs and required supervision or touching assistance for sitting at the side of the bed and/or standing. On 1/28/2026, the resident was walking in the hallway with two staff members when she lost her balance, twisted her left ankle, and fell backward to the floor. She complained of left ankle pain rated 7 out of 10 and was transferred to the GACH for evaluation. A progress note documented that she returned to the facility the same day with an acute fracture to the medial malleolus and distal fibula. Review of the care plan titled Risk for falls, dated 10/21/2025, showed no additional or revised interventions after the fall and fracture were identified. The MDSN stated the care plan should have been revised with updated and individualized interventions after the significant change, and the DON stated the resident's comprehensive care plan should have been reviewed and revised to reflect the resident's current condition and needs.
Failure to Maintain Residents’ Fingernails Clean and Trimmed
Penalty
Summary
The facility failed to ensure that two staff-dependent residents, Resident 25 and Resident 39, had their fingernails kept clean and trimmed as identified in their care plans. Resident 25 had diagnoses including HTN, anxiety, and muscle weakness, with documentation showing fluctuating capacity to understand and make decisions in the H&P and intact cognitive skills for daily decision making on the MDS. Resident 25’s ADL care plan directed staff to keep the fingernails clean and short, but during observation the fingernails were long, untrimmed, and had dark brown debris underneath the nail bed. CNA 1 later observed the same condition and stated nail care was a CNA responsibility and that residents’ nails should be checked daily. Resident 39 had diagnoses including DM, HTN, and muscle weakness, with fluctuating capacity to understand and make decisions documented in the H&P and intact cognitive skills for daily decision making on the MDS. Resident 39 was dependent on staff for ADLs, and the ADL care plan directed staff to keep the fingernails clean and short. During observation, Resident 39’s fingernails were long, untrimmed, and had visible black debris underneath them, and the resident stated staff had not assisted with trimming or cleaning the nails. CNA 1 stated Resident 39 required staff assistance with personal hygiene and nail care, and the DON stated staff were expected to provide ADL assistance and keep residents’ fingernails clean and short, with nail care assessed daily. The facility policy also stated residents’ nails would be kept clean and trimmed to prevent infection, scratches, and injuries.
Failure to Reposition a High-Risk Resident and Incorrect Low Air Mattress Setting
Penalty
Summary
Pressure ulcer prevention interventions were not consistently implemented for Resident 32, who was admitted with muscle weakness, bilateral lower leg contractures, an unstageable sacral pressure ulcer, and a gastrostomy. The resident’s MDS showed moderately impaired cognitive skills for daily decision making, total dependence on staff for ADLs, and a Braden Scale indicating very high risk for pressure ulcer development. The care plan directed staff to check the resident at least every two hours for wetness or soiling and to turn and reposition the resident at least every two hours, and a turning schedule posted at the bedside directed repositioning every two hours by alternating between back and side positions. During observation, Resident 32 was found lying on her back in bed, and the turning schedule indicated the resident was to be positioned facing the window. The resident’s family member stated that on the prior afternoon shift the CNA did not change and reposition the resident between 2:30 p.m. and 6:30 p.m., and that the resident was not changed until 6:30 p.m. The CNA assigned to the resident during that shift stated she recalled being unable to reposition the resident at 4:00 p.m. because she was assisting another resident and said it was crucial for the resident to be cleaned and repositioned promptly given the resident’s risk for pressure ulcer development. A concurrent record review with the DSD showed the turning and repositioning flow sheet did not document repositioning on multiple dates and times in June 2026, including several 11:00 p.m. entries and one morning-to-afternoon period. The DSD stated CNAs were expected to document repositioning every two hours, document repositioning after care, and document refusals when applicable, and that documentation should be completed timely to accurately reflect care provided. The DSD stated the medical record could not verify whether repositioning was performed. Resident 52 was also found to have a low air loss mattress set at 280 pounds even though the physician order and care plan required the setting to be maintained at 210 pounds, and the DON stated the mattress should have been set according to the resident’s weight of 198 pounds and the ordered setting.
Failure to Follow Ordered Orthostatic Blood Pressure Monitoring
Penalty
Summary
The facility failed to implement and follow physician orders for orthostatic blood pressure monitoring and recording for one sampled resident. Resident 24 was admitted on 2/14/2024 and had diagnoses including depressive disorder, muscle weakness, dysphagia, hepatic encephalopathy, hypotension, and orthostatic hypotension. The resident’s MDS dated 5/22/2026 indicated mental capacity was intact and that the resident was partially dependent on staff for activities of daily living. The H&P dated 6/5/2026 stated the resident had the capacity to make medical decisions. Physician orders dated 4/10/2026 and 6/4/2026 directed staff to monitor and record orthostatic blood pressure by obtaining a lying blood pressure, waiting 5 minutes, then checking the sitting blood pressure every Sunday in the morning. The orders also directed staff to notify the medical doctor if the systolic difference was 20 mmHg or the diastolic difference was 10 mmHg or more, or if the resident complained of lightheadedness, dizziness, or vision changes. Review of the Weights and Vitals Summary for May and June 2026 did not show orthostatic blood pressure readings on 5/3/2026, 5/10/2026, 5/17/2026, 5/24/2026, 6/7/2026, and 6/14/2026. During interview and record review, the LVN stated the absence of documented orthostatic blood pressure monitoring indicated the assessments were either not completed or not recorded, and that it was important to follow the physician orders and consistently monitor orthostatic blood pressures as prescribed. The DON reviewed the same records and stated orthostatic blood pressure readings were not documented on multiple Sundays and that the facility was unable to demonstrate the ordered monitoring had been completed. The DON also stated nursing staff were expected to follow physician orders as written and accurately document completed assessments in the medical record.
Delayed Urology Consultation for Resident with Chronic Foley Catheter
Penalty
Summary
The facility failed to ensure that a urology consultation ordered for a resident with an indwelling Foley catheter was completed in a timely manner. Resident 5 was admitted with diagnoses including hydronephrosis, hypertension, presence of urogenital implants, and obstructive reflux uropathy. The resident’s H&P stated he did not have the capacity to understand or make medical decisions, and the MDS later documented moderate cognitive impairment, moderate assistance needed for personal hygiene, and substantial assistance needed for toileting and lower body dressing. A physician order dated 1/19/2026 directed a urology consultation upon availability for possible suprapubic catheter placement. During interview and record review, the CM stated she did not begin the consult process until 2/6/2026, when she faxed the resident’s face sheet to the urology office, and acknowledged she should have initiated the process sooner and followed up to ensure the appointment was scheduled. The CM also stated the urology office never called to coordinate an appointment before the resident was hospitalized. RN 1 stated the urology consult should have been initiated and completed when the original order was placed because of the resident’s chronic indwelling catheter. After the resident was readmitted to the facility, a physician order dated 6/3/2026 again indicated a urology consult when available, pending insurance authorization. LVN 3 stated the consult was requested by a family member and the physician agreed with the need for it, but the consult was not reordered on readmission. The DON stated the case manager should have followed up on the urologist consult in a timely manner, and the facility policy required timely, appropriate, and coordinated referral to medical specialists when indicated by the resident’s condition, physician recommendation, or resident/family request.
Pharmacist MRR Recommendation Not Communicated to Physician
Penalty
Summary
The facility failed to ensure the consultant pharmacist’s medication regimen review recommendation was reviewed, addressed, and followed up with the physician for Resident 3’s pain management therapy and non-pharmacological interventions. Resident 3 was admitted with diagnoses including DM, a right fibula fracture, and muscle weakness. The resident’s H&P indicated the resident had the capacity to understand and make decisions, and the MDS indicated cognitive skills for daily decision making were intact and that the resident was dependent on staff for ADLs. Resident 3’s care plan for pain directed staff to administer Oxycodone-Acetaminophen as ordered and to monitor non-pharmacological interventions. The physician order allowed Oxycodone-Acetaminophen 10-325 mg, one tablet by mouth every four hours PRN for severe pain. The consultant pharmacist’s MRR recommended pain management therapy and documentation of non-pharmacological interventions prior to each PRN dose of Oxycodone-Acetaminophen, but the MRR did not show that the physician was notified of the recommendation. The DON stated there was no documentation that the physician reviewed the MRR or addressed the recommendation, and that the consultant pharmacist’s recommendation was not communicated to the physician.
Failure to Follow Planned Menu and Standardized Recipe
Penalty
Summary
The facility failed to follow the menu and standardized recipes for one of four sampled residents, Resident 31. Resident 31 was admitted on 3/13/2026 with diagnoses including DM, muscle weakness, and HTN. His H&P dated 3/16/2026 indicated he could make needs known but could not make medical decisions, and his MDS dated 4/6/2026 indicated cognition was intact and that he was dependent on staff for ADLs. His physician diet order dated 4/2/2026 ordered a regular texture consistent carbohydrate diet with no salt added. During a concurrent observation and interview on 6/15/2026 at 12:34 p.m., Resident 31's lunch tray was observed to contain a sandwich with meat and cheese. Resident 31 stated he did not request cheese with the sandwich. The Dietary Supervisor reviewed the lunch menu recipe for French Dip Sandwich and stated the recipe included roast beef, salt, pepper, and a soft French roll, and did not include cheese. During interview, [NAME] 1 stated the facility was responsible for following established recipes and that additions such as cheese should be indicated on the resident's meal ticket; [NAME] 1 stated the facility did not follow the French dip sandwich recipe because Resident 31 did not request cheese. The facility policy and procedure for [NAME] indicated responsibilities included reviewing menus prior to preparation of food and preparing meals in accordance with planned menus and standardized recipes.
Failure to Update Care Plan for Resident's Refusal of Hearing Aids
Penalty
Summary
The facility failed to timely develop a comprehensive care plan addressing a resident's ongoing refusal to wear hearing aids. The resident, who had diagnoses including congestive heart failure and moderate cognitive impairment, was documented as having difficulty hearing and required substantial assistance with activities of daily living. Despite the care plan indicating the use of hearing aids to help the resident hear effectively, multiple staff interviews and observations confirmed that the resident consistently refused to wear the hearing aids. Staff, including a CNA, Social Services Director, and LVN, acknowledged the resident's refusal and reported communicating by speaking directly into the resident's ear, but the care plan was not updated to reflect this ongoing issue. The facility's policy required a comprehensive, person-centered care plan with measurable objectives and timetables, including documentation of services not provided due to resident refusal. However, the care plan did not address the resident's persistent refusal to use hearing aids, nor did it outline alternative interventions or document the resident's exercise of their right to refuse. This omission was confirmed by staff interviews and record reviews, indicating a failure to meet the facility's own policy and regulatory requirements for care planning.
Failure to Assist Resident with Access to Vision and Hearing Services
Penalty
Summary
A resident was not assisted in gaining access to necessary vision and hearing services. The facility failed to ensure that the resident received support to obtain these services, resulting in the resident not having access to appropriate vision and hearing care as needed.
Failure to Develop Comprehensive, Person-Centered Care Plan for Resident with Osteopenia
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan for a resident diagnosed with osteopenia, as well as other conditions including fracture, contracture, and disorders of bone density and structure in the right shoulder. The resident was totally dependent on staff for all activities of daily living and did not have the capacity to make decisions, according to the History and Physical. However, the Minimum Data Set indicated the resident was able to understand and be understood by others. The care plan in place for osteopenia included general interventions such as handling the resident gently and observing for joint pain and stiffness, but it did not specify the location of the osteopenia or provide detailed, measurable objectives and timetables tailored to the resident's specific needs. During an interview, the DON acknowledged that the care plan lacked specificity regarding the location of the osteopenia and stated that care plans are intended to guide resident care and should be more individualized. The facility's policy requires comprehensive, person-centered care plans with measurable objectives and timetables to address each resident's physical, psychosocial, and functional needs, but this was not implemented for the resident in question.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure accurate completion and documentation of the Minimum Data Set (MDS) assessments for three residents, leading to the transmission of inaccurate data to the Centers for Medicare and Medicaid Services (CMS). Resident 23's MDS, dated March 6, 2025, did not reflect the resident's dental concerns, despite observations of poor dentition and broken teeth. The MDS Nurse (MDSN) acknowledged the inaccuracy, noting that the MDS should have indicated the resident's dental issues to ensure appropriate care planning. Resident 24's MDS was also inaccurately coded, failing to reflect the resident's lack of natural teeth. During an observation, Resident 24 was seen without upper and lower teeth and consuming soft or pureed foods. The MDSN confirmed the incorrect coding of the oral/dental assessment, which could potentially result in unmet care needs and services for the resident. Similarly, Resident 19's MDS did not accurately represent the resident's oral/dental status, as the resident had no natural teeth and was on a pureed diet. The MDSN was aware of this discrepancy and acknowledged the incorrect coding. The facility's policy requires that any person completing a portion of the MDS must certify its accuracy, and the information should reflect the resident's status, which was not adhered to in these cases.
Inaccurate PASRR Assessment for Resident with SMI
Penalty
Summary
The facility failed to ensure an accurate Level I Preadmission Screening and Resident Review (PASRR) was submitted for a resident, which is a tool used to identify possible serious mental illness (SMI) and determine if specialized services are required. The resident in question was admitted with diagnoses of psychosis, depression, and anxiety disorder, yet the Level I PASRR assessment did not reflect these SMI diagnoses. Consequently, the PASRR determination letter indicated that the resident did not require a Level II PASRR Mental Health Evaluation, as the Level I assessment inaccurately showed no SMIs. The Social Services Director (SSD) acknowledged that the Level I PASRR was initially completed by the hospital before the resident's admission to the facility. Upon review, the SSD noted that the Level I PASRR did not accurately reflect the resident's SMIs and admitted that a new and accurate Level I PASRR should have been completed and submitted. The facility's policy requires that all residents have a Level I PASRR completed to ensure they receive necessary services for their SMI in the appropriate setting, which was not adhered to in this case.
Deficiencies in Care Planning for Residents with Special Needs
Penalty
Summary
The facility failed to implement a care plan for Resident 288, who was admitted with a diagnosis of epilepsy and severe cognitive impairment. The care plan, dated 3/6/2025, required padding on the siderails of the resident's bed to prevent injury during seizures. However, observations on multiple occasions revealed that the siderails were not padded, placing the resident at risk for physical harm. Interviews with the Registered Nurse Supervisor confirmed the absence of padding and acknowledged the risk of injury if a seizure occurred. For Resident 191, the facility did not develop or implement a care plan for oxygen administration, despite the resident's dependence on supplemental oxygen due to conditions such as acute respiratory failure and congestive heart failure. Observations showed that there was no oxygen sign posted outside the resident's room, and the care plan lacked specific interventions for oxygen therapy. Interviews with the Licensed Vocational Nurse and the MDS Nurse revealed that the oxygen care plan was not initiated upon readmission, leaving the resident's oxygen therapy unmonitored and without clear guidelines for staff. The facility's policies and procedures require comprehensive, person-centered care plans and additional safety measures for residents at higher risk of injury. However, the lack of adherence to these policies resulted in deficiencies in care planning and implementation for both residents, potentially compromising their safety and well-being.
Improper Use of Low-Air-Loss Mattresses in LTC Facility
Penalty
Summary
The facility failed to ensure proper interventions for preventing the development or worsening of pressure ulcers for four residents. For Residents 288, 74, and 191, the settings on their low-air-loss mattresses (LALM) were incorrect. Resident 288's mattress was set at 350 lbs, despite a physician order for a 150-lb setting, and the resident's weight was 154 lbs. Similarly, Resident 74's mattress was set at 280 lbs and later at 250 lbs, while the resident's weight was 140 lbs, and the physician order required a 150-lb setting. Resident 191's LALM was labeled with another resident's name and incorrect weight settings, leading to potential confusion and improper therapeutic support. Resident 23 did not receive a LALM as ordered by the physician, despite being at risk for developing pressure ulcers. Observations over multiple days confirmed that Resident 23 was lying in bed without the prescribed LALM. The Treatment Nurse acknowledged the absence of the LALM but could not provide a reason for this oversight. The facility's policy and procedure for air mattresses were not followed, as the mattresses were not set according to the residents' weights, and the labeling was incorrect. The Treatment Nurse and Quality Assurance Nurse confirmed these discrepancies, acknowledging that the incorrect settings and labeling could lead to the development or worsening of pressure ulcers. The Director of Nursing also stated that the LALM should be set according to the resident's weight to prevent skin breakdown.
Failure to Pad Siderails for Resident with Seizure Disorder
Penalty
Summary
The facility failed to ensure the safety of Resident 288 by not padding the siderails of the resident's bed, as required by the care plan. Resident 288, who was admitted with a diagnosis of epilepsy, was observed on multiple occasions lying in bed with metal siderails that lacked the necessary padding. The resident's care plan, dated 3/6/2025, specifically indicated that padding should be applied to the siderails to prevent injury in the event of a seizure. Despite this, observations on 3/24/2025 and 3/25/2025 confirmed the absence of padding on the siderails. Interviews with RN 1 corroborated the oversight, as the nurse acknowledged the requirement for padding due to the resident's seizure disorder. During a concurrent observation and interview on 3/26/2025, RN 1 confirmed that Resident 288 was at risk for injury without the padding, especially if a seizure occurred. The facility's policy on Bed Safety and Bed Rails, revised in 8/2022, also indicated that additional safety measures should be implemented for residents with a higher risk of injury, which was not adhered to in this case.
Failure to Post Oxygen Signage for Resident Receiving Oxygen Therapy
Penalty
Summary
The facility failed to place an oxygen signage at the room door entrance for a resident receiving oxygen therapy, which was observed during a survey. The resident was receiving supplemental oxygen via nasal cannula at three liters per minute, but there was no sign indicating oxygen was in use outside the room. The resident had a history of acute respiratory failure with hypoxia, dependence on supplemental oxygen, pneumonia, congestive heart failure, and diabetes mellitus. The resident's cognitive abilities were severely impaired, and they were dependent on assistance for daily activities. During an interview, a Licensed Vocational Nurse acknowledged the absence of the oxygen sign and stated that it should have been posted for safety reasons. The Director of Nursing also confirmed that oxygen signage should have been placed on the doorway. The facility's policy and procedure for oxygen administration required an 'Oxygen in Use' sign to be placed on the outside of the room entrance door, which was not followed in this instance.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a rate of 18.75%. This was due to the actions of an LVN who did not administer medications to a resident in a timely manner as per the physician's orders. The resident, who had a history of Parkinson's Disease, type 2 diabetes mellitus, and convulsions, received six medications more than one hour after the scheduled administration time. Additionally, the LVN applied Lidocaine cream to the resident's right knee instead of the left knee as prescribed. The resident's medical records indicated that the medications were crucial for managing conditions such as Parkinson's disease, diabetes, and seizure disorders. The medications included benztropine, carbidopa-levodopa, docusate sodium, empagliflozin, Lidocaine cream, and primidone. The LVN acknowledged that the medications were administered late and that the Lidocaine cream was applied incorrectly, which could lead to adverse effects and symptoms that the medications were intended to treat. Interviews with the LVN and the Director of Nursing confirmed that the medications should have been administered within a specific time frame, which was not adhered to in this instance. The facility's policy required medications to be administered within one hour of their prescribed time, a guideline that was not followed, leading to the identified deficiency.
Failure to Provide Menu and Alternative Meal Options
Penalty
Summary
The facility failed to provide a daily menu and offer alternative menu options for a resident, identified as Resident 3, who was on a pureed diet. Resident 3, who was admitted with diagnoses including muscle wasting, dysphagia, and severe protein-calorie malnutrition, was cognitively intact and communicated through a digital device. Despite being on a pureed diet, Resident 3 reported that the meals were inedible and lacked variety, leading to dissatisfaction and reduced food intake. The resident had not received a menu since admission and was not offered alternative meal options despite expressing dissatisfaction and consuming less than 50% of the meals. Observations and interviews revealed that Resident 3's meals were not varied, and the resident was not provided with a menu to choose alternative options. The Certified Nursing Assistant (CNA) and Licensed Vocational Nurse (LVN) involved did not offer alternative meals, citing the resident's pureed diet as a reason. The LVN acknowledged that without a menu, Resident 3 could not see what was available and was unable to request preferred meals. The Dietary Services Supervisor and Director of Nursing (DON) had conflicting views on which department was responsible for providing menus, leading to a lack of clarity and failure to meet the resident's dietary needs. The facility's policies indicated that residents should be offered substitute food items for dislikes and that menus should be posted in accessible areas. However, these policies were not followed, resulting in Resident 3 not receiving a menu or alternative meal options. The failure to adhere to these policies and provide appropriate dietary care had the potential to impact Resident 3's nutritional status and quality of life, as the resident was consuming less than the recommended amount of food.
Failure to Protect Resident's Property and Ensure Staff Knowledge
Penalty
Summary
The facility failed to ensure staff were knowledgeable about the process for handling unlabeled resident clothes found in the laundry area and did not complete a resident belonging list upon readmission for one of the residents. This deficiency was identified during interviews and record reviews. A Licensed Vocational Nurse stated that dirty clothes during room transfers should be given to the laundry and returned to the resident once clean. However, a Laundry Services staff member indicated that unlabeled clothes were placed in the facility's donation box, while another staff member stated they should be kept in the laundry room. The Director of Nursing confirmed that unlabeled clothes should be kept in a designated area and compared to residents' belongings lists if clothes are reported missing. The report also highlighted that upon readmission, an inventory list of the resident's belongings was not created, as confirmed by the Medical Records review. The facility's policy and procedure on theft and loss, as well as the role of the nursing assistant during admission, require an inventory of all resident property, including clothing and valuables. The failure to adhere to these procedures had the potential to violate the resident's right to a safe and homelike environment, as it did not adequately protect the resident's property from loss or theft.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to implement its policies and procedures regarding comprehensive care planning and fall prevention for a resident who experienced a fall. After the resident's fall, the facility did not conduct an Interdisciplinary Team (IDT) meeting with the resident and their family representative to discuss and revise the care plan. The care plan was not updated to include safety interventions or measures to prevent future falls, despite the resident's fall being unwitnessed and resulting in a hospital transfer. The resident, who was cognitively intact and required partial assistance with activities of daily living, had a history of polyneuropathy and joint replacement surgery. The facility's policies required that care plans be reviewed and revised periodically and after changes in a resident's condition. However, the care plan did not include interventions such as providing a reacher to help the resident reach items, which was only added nine days after the fall. The Director of Nursing acknowledged the lack of documentation for an IDT meeting and the delay in updating the care plan.
Infection Control Deficiencies in Cohorting and PPE Use
Penalty
Summary
The facility failed to implement its infection prevention and control measures for five out of seven residents by not ensuring proper cohorting and signage for contact isolation and Enhanced Barrier Precautions (EBP). Residents 1 and 3 were cohorted with Resident 2, who had orders for contact isolation due to a methicillin-resistant Staphylococcus aureus (MRSA) infection. Despite Resident 2's need for contact precautions, Residents 1 and 3, who did not have such orders, were placed in the same room, contrary to the facility's policy. Additionally, the facility did not post clear signage to inform staff and visitors about the EBP required for Residents 6 and 7. Observations revealed that PPE supply drawers were present outside Resident 6's room without appropriate signage, and a PPE cart was observed across Resident 7's bed without EBP signage. Licensed Vocational Nurses (LVNs) and a Certified Nurse Assistant (CNA) acknowledged the absence of necessary signage, which is crucial for communicating the type of precautions and PPE required. Furthermore, staff failed to wear personal protective equipment (PPE) when entering a contact isolation room. A Physical Therapy Assistant (PTA) entered the room shared by Residents 1, 2, and 3 without donning PPE, despite a Contact Precaution sign on the door. The Infection Prevention Nurse (IPN) and Director of Nursing (DON) confirmed that staff should always wear PPE in such rooms, as the entire room is considered infected. The facility's policy indicated that residents with active infections should be placed in a private room or cohorted with residents with the same microorganism, which was not followed in this case.
Incomplete Documentation Delays Resident Transfer to Rehab
Penalty
Summary
The facility failed to ensure that all necessary documents were sent to the General Acute Care Hospital (GACH) Rehabilitation Center for a resident's evaluation and transfer. The resident, who was admitted with conditions such as hemiplegia, hemiparesis, muscle weakness, and gait disorders, required a transfer to the GACH Rehab for further physical therapy. However, the referral sent by the facility's Social Services (SS) was incomplete, lacking essential Physical Therapy (PT) notes. Despite attempts to send the missing documents, the SS could not provide confirmation of their transmission, leading to the GACH Rehab closing the resident's case due to incomplete documentation. Interviews with the SS and the Admissions Director (AD) at GACH Rehab revealed that the facility's failure to provide complete documentation resulted in the resident not being accepted for transfer. The AD confirmed that the missing PT notes were crucial for determining the resident's eligibility for admission. The facility's policy on discharge planning emphasized the importance of incorporating all relevant resident information to avoid delays, which was not adhered to in this case. This oversight delayed the resident's transfer and access to necessary therapies, impacting their potential for maintaining optimal physical, mental, and psychosocial well-being.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Lynwood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| California Post-acute Care | 0 mi | ★★★★★ | 63 | 0 |
| Lynwood Post Acute Care Center | 0 mi | ★★★★★ | 39 | 0 |
| Downey Post Acute | 1.4 mi | ★★★★★ | 20 | 0 |
| Briarcrest Nursing Center | 2.2 mi | ★★★★★ | 41 | 0 |
| Paramount Convalescent Hosp. | 2.5 mi | ★★★★★ | 24 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.