Average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Grand Park Convalescent Hospital during CMS and state inspections, most recent first.
The facility failed to submit required PBJ staffing data for one quarterly reporting period. The DON stated payroll and staffing information was gathered by Accounting and Payroll and sent to the Clinical Consultant for submission, but the deadline was missed due to technical issues and confusion between EST and PST. The DON also stated the facility had no PBJ policy or procedure, and CMS email correspondence confirmed the submission deadline had passed and late submission was not allowed.
A resident received Seroquel for psychosis/behavioral symptoms even though staff stated the resident was not a danger to self or others, behaviors were not interfering with ADLs, and no NPI were documented before administration; the chart also showed no GDR. Another resident had a PRN Xanax order for anxiety that lacked a stop date, and facility staff confirmed the order did not include an end date despite policy requiring a defined duration for PRN psychotropic meds.
Staff failed to follow menu, recipe, and tray line instructions during lunch service. Nine fortified trays were served without added fortified items because the DA did not communicate the orders to cooks, 16 regular and CCHO trays received larger starch and vegetable portions than ordered, and two minced and moist trays were served sticky rice that was not moist. The DS and RD confirmed the rice did not meet IDDSI Level 5 requirements, and the CCHO and fortified diet orders were not carried out as written.
Unsafe food handling and storage practices were observed in the kitchen and resident food refrigerator. A Dishwasher handled soiled dishes, trash, and clean dishes without washing hands, the ice machine had yellow residue inside the storage bin, and resident food brought in from outside was stored without dates or temperature monitoring. The dining room refrigerator also contained melted ice cream and was used for staff food as well as resident food.
Uncovered and overfilled trash dumpsters were observed in the kitchen trash area, with flies on and around the bins and trash on the ground, including gloves and paper. The DS stated the lids should have been covered and the area did not look clean, and facility policy and FDA Food Code required outside refuse receptacles to be kept covered and inaccessible to insects and rodents.
Failure to Maintain Privacy During Care for Two Residents: Staff exposed one resident’s abdomen and incontinence brief during a G-tube bolus feeding when the privacy curtain was left open, despite facility policy requiring privacy during procedures. Staff also failed to ensure another resident’s foley catheter bag had a privacy cover, and an LVN brought one to the room after the omission was observed. The DON and other staff acknowledged both situations did not follow the facility’s dignity and personal privacy policy.
Call lights were not kept within reach for two residents. One resident with dementia, CHF, DM 2, respiratory failure, HTN, and dependence with ADLs had her call light hanging over the head of the bed, while another resident with multiple medical conditions and dependence with ADLs had her call light on the floor. CNAs and the residents stated the call lights were not reachable and needed to be within reach so the residents could call for help.
Failure to complete pre-employment background check for the ADM. The DON stated there was no evidence of a background check before the ADM began working, even though facility policy required background and criminal checks to be initiated within two days of an offer of employment and completed prior to employment. The DON stated the DSD was responsible for initiating background checks for all employees, and a background report was not completed until years later, when the discrepancy was discovered.
Late Submission of Discharge MDS: The facility failed to timely transmit a resident’s Discharge Return Not Anticipated MDS to CMS after the resident was discharged home. The resident had multiple chronic conditions, including dementia, CKD, DM2, HTN, depression, psychosis, and metabolic encephalopathy, and was documented with severe cognitive impairment. The MDS was completed by the MDSC but not submitted until months later, despite the MDSC and DON acknowledging it should have been submitted within the required timeframe.
Failure to Develop Smoking-Specific Care Plan: A resident who was identified as a smoker and tobacco user did not have a person-centered care plan addressing smoking status, smoking-related needs, or individualized safety interventions after admission/readmission. The ADON, AD, and DON all confirmed the resident lacked a smoking-specific care plan, despite the resident's smoking being part of daily routine and the facility's expectation that care plans include resident-specific safety and supervision measures.
The facility failed to develop and implement resident-specific comprehensive care plans for two residents. One resident required supervised smoking but was allowed to smoke with her own lighter and without documented staff monitoring, and she sustained a burn to her hand while smoking in a dark patio area. Another resident with dementia and a high fall risk had a fall care plan that relied on call-light education and general safety reminders, which staff stated was not tailored to her cognitive impairment or need for supervision.
A resident at risk for PI/PU had a low air loss mattress ordered and monitored for skin management, but the mattress was observed set at 80 lbs. even though the resident weighed 99 lbs. and the machine label indicated a setting of 89-109 lbs. Staff confirmed the setting was incorrect, stated it could place the resident at risk for PI/PU, and identified licensed nurses as responsible for ensuring the mattress was monitored and adjusted to the correct setting.
A resident identified for supervised smoking sustained a burn while smoking in a dark patio without documented staff monitoring, with the DON confirming the facility could not prove supervision or follow its smoking policy. The facility also failed to place ordered floor mats on both sides of a high-fall-risk resident’s bed, and failed to complete a required smoking safety evaluation for another resident who smoked and had fluctuating capacity. The DON, ADON, and AD confirmed the missing evaluation and the lack of required safety measures.
Failure to Post Daily Staffing Information: The facility did not update and post DHPPD staffing information for several days, and the board still displayed older staffing data during observation. The ADON stated the information needed daily updates to reflect census and staffing changes, and the DON confirmed the DSD was responsible for posting projected and actual DHPPD but the postings were not updated in a timely manner.
Medication Administration Errors: An LVN did not follow a resident’s g-tube flush order while giving multiple meds, and another resident’s Lidoderm patches were not removed and were found on the wrong body sites instead of the ordered locations. Staff interviews and record review showed the g-tube flush volumes and patch placement/removal did not match the physician orders or facility policy.
Surveyors found multiple meds in a medication room refrigerator stored at 32.9 F, below the required range, including insulin products, eye drops, and other refrigerated meds. In Station 1 Medication Cart 1B, a resident’s Lantus Solostar pen was found without an open date and not refrigerated, and another resident’s opened budesonide foil pack had no open date. RN and DON interviews confirmed the storage and labeling issues and referenced the facility’s medication storage policy.
Elopement Risk Not Properly Assessed or Updated: A resident with dementia, altered mental status, and impaired decision-making had an elopement precaution care plan that called for monitoring whereabouts and a wander guard, but the ERE was inaccurate and was not repeated after multiple elopement events. The resident left the facility without staff supervision more than once, the care plan was not revised after the change in condition, and staff interviews confirmed the resident did not have the expected 1:1 supervision.
Failure to revise elopement care plan after repeated unsupervised exits. A resident with dementia, altered mental status, and impaired decision-making left the facility without staff knowledge on multiple occasions. The care plan included elopement precautions and monitoring, but after SBARs documented episodes of the resident going out without assistance, the DON confirmed no revision was made to the care plan. Staff interviews indicated the resident was not assigned a 1:1 sitter and was able to leave while staff were occupied with other duties.
Surveyors found that two staff members who transferred from dietary roles into Utility Nurse positions did not receive required competency and skills assessments for their new duties upon hire into the role or annually. Their files contained only dietary competency checklists, despite facility policy requiring Utility Nurses to receive orientation on call light response, resident safety and fall prevention, communication protocols, scope of practice, and emergency procedures, with competency to be assessed at hire and yearly. The DSD and DON both acknowledged the importance of these assessments to ensure staff can safely and competently perform Utility Nurse responsibilities.
Two residents with significant risk factors for pressure ulcers were found to have their low air loss mattresses set incorrectly, not matching their actual weights as required by physician orders and manufacturer guidelines. Nursing staff and the DON confirmed the settings were not appropriate, which could reduce the effectiveness of pressure ulcer prevention and treatment.
Two residents with severe cognitive and physical impairments were found without accessible call lights, despite care plans and facility policy requiring call lights to be within reach. In both cases, staff confirmed the call lights were not placed appropriately, leaving the residents unable to call for assistance when needed.
A resident with multiple medical conditions and missing teeth was admitted and assessed as able to participate in care planning and requiring significant ADL assistance. Despite documentation of dental issues and the facility's policy requiring comprehensive care plans, staff did not develop or implement a dental care plan for the resident. Interviews with the RN Supervisor, SSD, and DON confirmed the omission and the importance of including dental needs in the care plan.
A resident with major depressive disorder had a care plan that was not updated after a physician changed the Remeron dosage from 15 mg to 7.5 mg. The care plan continued to reference the outdated dosage, despite facility policy requiring updates after changes in physician orders. Both the MDSN and DON confirmed the care plan should have been revised to reflect the current medication order.
A resident with diabetes and multiple comorbidities received subcutaneous insulin injections in the same anatomical locations on consecutive days, despite facility policy and physician orders requiring site rotation. Nursing staff and the DON confirmed that injection sites should have been rotated, and the facility's EMR system displayed previous sites to assist with compliance, but this was not consistently followed, resulting in a deficiency.
A resident with multiple medical conditions and a history of smoking was not given a smoking risk assessment upon admission or after staff became aware of their smoking activity. Despite being observed smoking with staff assistance and without a protective apron, no updated assessment was completed, contrary to facility policy. This failure potentially placed the resident's safety at risk.
A medication cart was left unlocked and unattended in the hallway by an LVN who entered a resident's room to administer medication, in violation of facility policy requiring medication carts to be locked when not in use.
Nursing staff did not consistently follow EBP protocols during medication administration, with two nurses failing to don gowns as required when caring for two residents under EBP. Additionally, a resident with an indwelling urinary catheter did not have the required EBP identifier posted, despite care plan and policy requirements. These lapses were confirmed by staff interviews and policy reviews.
A room with three beds was found to be only 213.69 sq. ft., not meeting the federal requirement of at least 80 sq. ft. per resident in multiple occupancy rooms. The room was clean and accessible, and no immediate safety or privacy concerns were observed, but the facility's own policy and federal standards were not met.
A resident with dementia and a high fall risk was not provided with an individualized care plan or adequate supervision, leading to a fall and serious injury. The facility's staff failed to implement necessary safety measures, and the care plans lacked specific interventions for dementia care. The resident sustained a displaced right femur, requiring surgery and a blood transfusion.
A resident's medical records were incomplete and inaccurate due to the lack of documentation of their discharge plan. Despite the resident's expressed desire to be discharged to an apartment and the submission of an assisted living waiver application, the discharge plan was not recorded. The facility's policy mandates documentation of services and progress, which was not followed.
A resident with severe cognitive impairment was found with facial injuries of unknown origin, which the facility failed to report to the SSA within the required timeframe. Despite the facility's policies mandating prompt reporting to rule out abuse, the Administrator incorrectly assumed the injuries were reported as an unwitnessed fall, resulting in a delayed investigation.
The facility failed to ensure proper infection control measures for COVID-19. Two residents with cognitive impairments were observed without masks in common areas, contrary to the facility's policy during a COVID-19 outbreak. Additionally, an RN was found wearing an N95 respirator she was not fit-tested for, compromising its effectiveness. These deficiencies in mask usage and adherence to PPE protocols increased the risk of COVID-19 transmission among residents and staff.
A resident with cognitive impairment reported being physically mistreated by a CNA, but the facility failed to report the incident to the State Agency as required by their policies. Despite the facility's policy mandating the reporting of all possible abuse incidents, the Social Service Director and Director of Nursing did not report the incident, believing it did not occur. The Facility Administrator was also not informed, leading to a delay in an onsite inspection by the State Agency.
The facility failed to monitor and document pain levels for three residents during Restorative Nursing Assistant (RNA) services, despite physician orders. Residents with conditions like polyarthritis, osteoarthritis, and severe cognitive impairment were not assessed for pain, and care plans lacked directives for pain monitoring. Staff interviews revealed a misunderstanding of documentation requirements, leading to inadequate pain management.
The facility failed to label and discard food items according to professional standards, as observed by a Dietary Assistant. Several food items, including Aji-Mirin Sweet Cooking Rice seasoning, carrots, Salted Shrimp, ginger, and Dried [NAME], lacked open and use by dates. Additionally, items like Rice vinegar, Dried Seaweed-Sliced, garlic, and tofu were not discarded after their use by dates. Interviews with staff confirmed the facility's policy required labeling and discarding of food to prevent food-borne illnesses, but these practices were not followed.
Two residents with cognitive impairments were fed by staff standing over them, contrary to the facility's policy requiring staff to sit to maintain resident dignity. The DON confirmed the importance of sitting during meal assistance, but staff cited control as a reason for standing.
The facility failed to include advance directives in the medical charts of two residents, potentially compromising their end-of-life treatment decisions. One resident had fluctuating decision-making capacity, while another had mild cognitive impairment but was capable of making decisions. The facility's policy required documentation of advance directives, which was not followed.
The facility failed to report incidents involving two residents to the State Survey Agency within the required timeframe. A resident with cognitive impairments had an injury of unknown origin that was not reported, and another resident experienced a fall with a confirmed fracture that was also not reported. The facility's policies required timely reporting of such incidents, but staff interviews revealed non-compliance, leading to a delay in investigation.
A facility failed to develop a comprehensive care plan for a resident under hospice care, despite the resident's serious medical conditions and hospice orders. The absence of a hospice-specific care plan was confirmed by the RN and DON, highlighting a potential gap in providing necessary and personalized care.
A resident identified as a smoker did not receive a smoking risk assessment upon admission, contrary to facility policy. Despite being supervised while smoking, the lack of assessment meant safety measures were not formally evaluated or implemented, posing a risk of injury or burns.
A resident with end-stage renal disease and depression experienced weight loss due to the facility's failure to implement the RD's recommendation for snacks three times a day. Despite the RD's assessment, there was no order for snacks in the resident's chart or MAR. Interviews with staff revealed a lack of communication and documentation, increasing the risk of further weight loss.
A resident with a feeding tube was found to have tubing that was not changed as required by physician's orders and facility policy, leading to potential infection control issues. The resident, with conditions including Parkinson's Disease and dementia, had tubing dated two days prior still in use, despite a new feeding bottle being started. Both an LVN and the DON confirmed the tubing should have been changed every 24 hours to prevent contamination.
The facility failed to provide adequate staffing, resulting in delayed care for two residents. One resident, requiring assistance due to severe morbid obesity, reported waiting up to an hour for help. Another resident, with severe cognitive impairment, also faced long wait times. Staffing shortages were exacerbated by a no call, no show CNA, leaving eight CNAs to care for 147 residents during a night shift. The facility's reliance on overtime and extra staff calls was not always effective.
The facility's Arbitration Agreement failed to include verbiage allowing residents to choose a convenient venue for arbitration meetings. This deficiency was noted during a review of the agreement form, which did not provide residents the option to select a meeting place. Interviews with the Admissions Coordinator and Business Office Manager confirmed the absence of such verbiage, despite the facility's policy indicating hearings should be at a mutually agreed-upon location.
A deficiency was identified in a room that did not meet the required 80 square feet per resident, with a total of 203.3 square feet for three residents instead of the required 240 square feet. Despite this, residents and staff reported no issues with space or care provision, and privacy curtains were in place.
Missed PBJ Staffing Data Submission
Penalty
Summary
The facility failed to ensure its Payroll Based Journal (PBJ) staffing data was electronically submitted to CMS for the third quarter of 2025, covering 4/1/25 to 6/30/25. A review of the PBJ Staffing Data Report dated 7/21/26 showed the facility did not submit data for that quarter. During interview, the DON stated PBJ data had to be submitted quarterly and that Accounting and Payroll gathered payroll and staffing information, which was then sent to the Clinical Consultant for submission. The DON also stated the facility missed the deadline for the third quarter submission and that CMS used the information to monitor whether the facility had enough staff to provide resident care. The Accounting and Payroll Manager stated the facility had 45 days from the end of the quarter to submit PBJ data and that technical difficulties delayed submission until after the deadline. The DON later stated the facility did not have a policy or procedure for PBJ submission and relied on CMS guidelines. The Clinical Consultant stated she was responsible for submitting the quarterly PBJ data and reported confusion between EST and PST caused the deadline to be missed. Email correspondence with the CMS PBJ Staffing Team confirmed the facility was unable to meet the official submission deadline and that PBJ data could not be submitted or corrected after the deadline had passed.
Unnecessary Psychotropic Use and Missing PRN Stop Date
Penalty
Summary
The facility failed to ensure appropriate use of psychotropic medications for two residents. For one resident, quetiapine (Seroquel) was continued and administered for psychosis/behavioral symptoms despite documentation showing dementia, psychosis, depression, and Alzheimer’s disease, along with notes that the resident was calm at times, sometimes screamed for no reason, and was not combative or at risk of harming self or others. The record also showed the resident was dependent on staff for activities of daily living and had fluctuating capacity to understand and make decisions. The resident’s chart included care plan and psychiatric follow-up notes describing Seroquel use for recurrent outbursts of anger and psychosis, with no gradual dose reduction documented and no non-pharmacological interventions documented before administration. Facility staff stated the resident was not a risk of harm to self or others, that behaviors were not interfering with ADLs, and that there were no non-pharmacological interventions used before giving the antipsychotic. The psychiatrist’s notes stated the medication was continued and that the benefits outweighed the risks. For the second resident, Xanax 0.5 mg was ordered PRN for anxiety, but the order did not include a stop date. The resident’s psychiatric note documented fair insight and judgment, and the order summary showed the PRN Xanax order remained active without an end date. Facility staff, including QA, LVN, ADON, DON, and the NP, confirmed the order lacked a stop date and stated that PRN psychotropic orders typically require a limited duration and documentation of the rationale for extension. The facility’s policy reviewed by surveyors stated PRN psychotropic medication orders beyond 14 days require practitioner documentation of the rationale and that the duration should be indicated in the order.
Failure to Follow Diet Orders and Texture Standards During Lunch Service
Penalty
Summary
Staff failed to follow the standardized recipes, menu, and cook’s spreadsheet during lunch tray line service. On 7/20/2026 at 12:00 PM, nine trays requiring a fortified diet were served the same food as residents without fortified diet orders, and the Dietary Aide did not read the fortified diet orders aloud to the cooks. The tray cards on the meal carts showed fortified diet orders, but cook 2 and cook 3 did not add any additional food items, and no melted margarine was added during tray preparation because the fortified diet communication was not given. The same lunch service also showed that 16 regular and CCHO trays received 1/2 cup of diced fried potatoes and 1/2 cup of corn with green peppers, even though the menu and cook’s spreadsheet indicated the CCHO diet should have received 1/4 cup portions. During interview, the Dietary Aide stated the fortified and CCHO diets were not communicated to the cooks, and cook 3 stated the CCHO trays received more potato and corn than indicated on the menu. The Dietary Supervisor stated fortified diets should include extra calories such as melted margarine on starches or vegetables and gravy on meats, and that CCHO residents receive more starches, which could affect blood sugar levels. The kitchen also failed to prepare minced and moist rice correctly for two lunch trays. During observation, cook 1 served steamed white rice that looked sticky and not moist, and cook 2 stated the cooks should have added gravy to make the rice moist for the minced and moist diet. Cook 3 and the Dietary Supervisor agreed the rice was not moist and not appropriate for the minced and moist diet. The Registered Dietitian later stated minced and moist rice needed to be soft and moist with gravy and not sticky, and the facility’s recipe and IDDSI guidance required the food to be soft, moist, and minced to the proper size.
Unsafe Food Handling and Storage Practices
Penalty
Summary
Safe and sanitary food storage and preparation practices were not maintained in the kitchen and resident food storage area. During observation in the dishwashing area, a Dishwasher was seen handling soiled dishes, loading the dish machine, and then removing clean and sanitized dishes without washing hands. The same staff member was also observed taking out a garbage bag, going outside to the dumpster, returning to the kitchen, and replacing gloves without washing hands before handling clean dishes. In interview, the Dishwasher stated kitchen staff only changed gloves and did not wash hands after touching soiled dishes or after returning from the trash area, and the Dietary Supervisor stated gloves should not replace hand washing. The ice machine in the small dining room was not maintained in a sanitary manner. When the ice storage bin was swiped with a clean paper towel, yellow residue transferred onto the towel from the inner plastic board under the baffle. The Dietary Supervisor stated the outside vendor cleaned the ice machine monthly and that it was due for cleaning that month, and verified the residue on the towel. The Maintenance Supervisor stated the ice machine cleaning was due for the month and that ice machines should always be clean to avoid contaminating ice. Food brought in from outside for residents was stored in the dining room refrigerator without consistent dating or monitoring. Four bags of resident leftover food were observed with only room numbers and no dates, and two ice cream containers were found melted in the refrigerator. There was no refrigerator temperature log, and staff stated the refrigerator was also used for staff food. The DON stated the facility did not have a dedicated refrigerator only for residents, that residents' food was stored there for 48 hours, and that nurses were expected to monitor temperatures and expired food, but the temperature log could not be located.
Uncovered and Overfilled Trash Dumpsters
Penalty
Summary
The facility failed to ensure trash stored in two of five garbage dumpster areas was maintained in a sanitary manner. During a concurrent observation and interview with the Dietary Supervisor, one large dumpster for food and organics outside the kitchen back door was observed uncovered and overfilled with food trash, with flies on the trash bags inside the dumpster and around the bin. Trash was also observed on the ground around the dumpster, including disposable gloves and paper. In the same trash area, another trash bin was observed overfilled and not covered. During interview, the Dietary Supervisor stated the dumpster lids should have been covered and there should not have been trash on the floor, and stated the area did not look clean and there were flies everywhere. The Dietary Supervisor also stated a dietary staff member was assigned to clean the trash area every day. Review of the facility policy and the FDA Food Code indicated outside trash dumpsters were to be kept covered with tight-fitting lids or doors and stored so they were inaccessible to insects and rodents.
Failure to Maintain Resident Privacy During G-Tube Feeding and Foley Catheter Care
Penalty
Summary
The facility failed to respect the dignity and privacy of two residents during care and treatment. One resident, who had diagnoses including schizophrenia, adult failure to thrive, and hypertension, was assessed as rarely understanding others and lacking capacity to understand and make decisions. During a G-tube bolus feeding, the resident’s privacy curtain was open from the foot of the bed, exposing the abdomen and incontinence brief while the LVN accessed the G-tube and administered the feeding. The ADON later entered the room and closed the curtain fully, and the LVN stated the curtain had not been provided before the procedure to ensure privacy. Facility staff and records confirmed that privacy was required during procedures. RN 1 stated privacy needed to be provided before starting any procedure and was important to maintain dignity and respect for residents’ bodies. The ADON and DON both reviewed the facility’s Resident Dignity and Personal Privacy policy and stated that the use of a privacy curtain during treatments or procedures was required, that G-tube bolus administration was considered a procedure, and that the resident should not have been exposed more than necessary. The DON stated the facility failed to provide privacy for the resident and that this had the potential to cause embarrassment and violation. A second resident, who had diagnoses including type 2 DM, functional quadriplegia, muscle weakness, UTI, acute pyelonephritis, cystitis, ESRD, and dependence on renal dialysis, had a foley catheter in place and was documented as unable to make needs known and unable to make medical decisions in one record, while other records noted the resident could make needs known and was alert and oriented x3. During observation, the resident’s foley catheter bag was seen without a privacy cover, and an LVN brought a privacy bag cover to the room. The LVN stated the facility needed to provide the privacy cover to protect the resident’s privacy. Another LVN stated he did not check whether the resident had a privacy cover after returning from an outside procedure, and RN 3 stated the resident needed the cover to protect dignity. The DON stated the facility did not follow its policy when it failed to use a privacy cover for the resident’s foley catheter bag.
Call lights not kept within residents’ reach
Penalty
Summary
The facility failed to ensure call lights were within reach for two residents. One resident had diagnoses including heart failure, DM 2, respiratory failure, HTN, dementia, and needed assistance with personal care. Her H&P stated she did not have the capacity to understand and make decisions, and her MDS showed she was frequently incontinent, used a wheelchair, and needed assistance or was dependent with ADLs. During observation, her call light was hanging over the head of the bed, and a CNA stated it was not within her reach and should be on the side of the resident so she could reach it. The same resident’s care plan identified her as at risk for falls and directed staff to keep the call light within reach and answer promptly. The resident stated she knew what the call light was, would use it to ask for help, and needed it near her left hand because it was hard to reach when it was over the head of the bed. A CNA later stated that when she saw the call light hanging over the head of the bed, she put it back in a position so the resident could access it, and said that if the resident could not ask for help because the call light was not within reach, it would be difficult for her to call for help especially in an emergency. A second resident had diagnoses including hypo-osmolality, hyponatremia, right hip pain, atrial fibrillation, hyperlipidemia, HTN, DM 2, overactive bladder, gait and mobility abnormalities, muscle weakness, and needed assistance with personal care. Her H&P stated she had the capacity to understand and make decisions, and her MDS showed she needed assistance or was dependent on staff with ADLs. During observation, she was sitting on the bed and her call light was on the floor. A CNA picked it up and placed it on the bed within her reach, and another CNA stated she would not be able to reach it or call for help because it was on the floor. The resident stated she knew what the call light was, would use it when she needed something from the nurses, and could not reach it if it was on the floor.
Failure to Complete Pre-Employment Background Check for Administrator
Penalty
Summary
The facility failed to conduct a background check during the pre-employment screening for the Administrator, who was hired on 4/2/2012. During a concurrent interview and record review, the DON stated there was no evidence of a background check before the Administrator began working in the facility, and that all staff were required to complete a background check on hire. The DON also stated the DSD was responsible for initiating background checks for all employees during pre-employment screening. During a later interview, the DON stated a background check was completed for the Administrator in December 2017 after the facility discovered the discrepancy. Review of the Administrator’s Background Report dated 12/14/2017 showed no red flags or disqualifying records. Facility policy titled Background Screening Investigations stated background and criminal checks are initiated within two days of an offer of employment and completed prior to employment, and the Abuse Prevention Program policy stated the facility will conduct employee background checks as part of resident abuse prevention.
Late Submission of Discharge MDS
Penalty
Summary
The facility failed to ensure the MDS for Resident 109 was transmitted to CMS within the required timeframe after the resident was discharged home on 2/9/2026. Resident 109 was admitted on 9/12/2025 with diagnoses including metabolic encephalopathy, type 2 diabetes, hypertension, dementia, chronic kidney disease, depression, and psychosis. The Discharge Return Not Anticipated MDS indicated the resident had severe cognitive impairment and was discharged home from the facility. During interview and record review, the MDS Coordinator stated the Discharge Return Not Anticipated MDS was completed on 2/13/2026 but was not submitted to CMS until 7/23/2026. The MDS Coordinator stated the assessment should have been submitted earlier, within 14 days after the discharge, and the DON also stated the submission was too late and should have been completed within 14 days of the completion date. The facility policy stated resident assessments are to be conducted and submitted in accordance with current federal and state submission timeframes, and the RAI Manual requires the discharge assessment to be completed within 14 days after discharge and submitted within 14 days after the MDS completion date.
Failure to Develop Smoking-Specific Care Plan
Penalty
Summary
The facility failed to develop and implement a person-centered baseline care plan for Resident 15 within 48 hours of admission that addressed smoking status, smoking-related needs, and individualized safety interventions. Resident 15 was admitted on 8/18/2023 and later readmitted with diagnoses including schizophrenia, bipolar disorder, and essential hypertension. The Nursing Risk Evaluation dated 6/24/2026 identified Resident 15 as a smoker, and the MDS dated 6/28/2026 identified the resident as a tobacco user and cognitively intact. The Activities Initial Interview dated 6/29/2026 noted that Resident 15 enjoyed smoking on the facility patio. During the concurrent record review and interviews, the ADON stated the resident did not have a care plan for smoking and that the care plan needed to be specific to each resident, including safety and supervision. The Activities Director also stated that Resident 15 did not have a person-centered care plan addressing smoking and that such a plan was important to address burn risk, compliance with facility regulations, and prevention of smoking-related injuries. The DON stated that while care plans were developed upon admission in general, Resident 15's record did not include a smoking-specific care plan upon readmission, and smoking interventions were developed based on the facility's general Smoking Safety Evaluation.
Incomplete Care Planning for Smoking Safety and Fall Risk
Penalty
Summary
The facility failed to develop and implement a resident-specific comprehensive care plan for Resident 10 related to smoking safety. Resident 10 was admitted with diagnoses including anxiety disorder, bipolar disorder, rheumatoid arthritis, muscle weakness, and pain in the right wrist, and the assessment scoring report indicated she required supervised smoking. The record also showed she had a history of tobacco use, could make herself understood, and had fair insight and judgment. The care plan included a goal for her to be free from smoking-related injury and an intervention to store her smoking materials, but the record and staff interviews showed the facility did not document each time she refused to use a smoking apron, did not document who was monitoring her while she smoked, and did not document re-evaluation of her smoking privileges. Resident 10 sustained a burn to the right first knuckle while smoking a cigarette at night. The SBAR documented that the burn occurred during smoking, that the DON and Administrator were notified, and that Resident 10 was self-responsible. The physician later ordered topical treatment for the burn. During interview, Resident 10 stated she lit her own cigarette, had her own lighter, and there was no staff monitoring her outside when the burn occurred. She also stated the smoking patio was very dark at night and that she had previously told the DON it was too dark. Staff interviews confirmed the facility did not keep a log identifying who monitored residents in the smoking patio and could not provide documentation showing Resident 10 was monitored when the burn occurred. The facility also failed to develop a resident-specific comprehensive care plan for Resident 14, who had dementia, severe cognitive impairment, osteoporosis, gait and mobility abnormalities, and a prior right pubis fracture. The MDS showed Resident 14 required varying levels of assistance with activities of daily living, and the fall risk evaluation identified a high fall risk with intermittent confusion, balance problems, and the need for assistive devices. The care plan addressed fall risk with interventions such as keeping the call light within reach and educating the resident, family, and caregivers about safety reminders and what to do if a fall occurs. However, RN and ADON interviews stated those interventions were not tailored to Resident 14’s dementia and forgetfulness, and both stated the plan should have included supervision, monitoring, reorientation, and other dementia-appropriate interventions. The DON also stated the care plan needed to be specific to Resident 14’s needs, and that the existing interventions were not appropriate for a resident who could not reliably remember education about using the call light.
Incorrect Low Air Loss Mattress Setting for a Resident at Risk for Pressure Injury
Penalty
Summary
Failure to provide necessary treatment and services to minimize the risk of pressure injury development and worsening was identified for one resident who was admitted and later readmitted with diagnoses including pneumonia, sepsis, hypertension, dementia, and need for assistance with personal care. The resident’s care plan identified risk for pressure injury and directed staff to apply and monitor a low air loss mattress in bed for skin management, function, and effectiveness every shift. The resident’s MDS also indicated the resident was at risk for pressure injury and had a pressure-reducing device for the bed, and the order summary directed monitoring of the low air loss mattress every shift. During observation, the resident’s low air loss mattress machine was found set at 80 lbs., while the label on the machine indicated the setting should be 89-109 lbs. for a resident weighing 99 lbs. The resident’s weight record showed weights of 99 lbs. and 101 lbs. Staff interviews confirmed the setting was incorrect, that the wrong setting could place the resident at risk for pressure injury, and that licensed nurses were responsible for ensuring the mattress was monitored and adjusted to the correct setting. The DON stated the licensed nurses needed to ensure the correct setting was in place so the mattress could perform its therapeutic purpose and protect bony prominences.
Failure to supervise smoking, implement fall protection, and complete smoking safety evaluation
Penalty
Summary
The facility failed to provide direct supervision for a resident who was identified as requiring supervised smoking. The resident had diagnoses including anxiety disorder, bipolar disorder, rheumatoid arthritis, muscle weakness, and pain in the right wrist, and the record showed a smoking assessment score indicating supervised smoking was required. The resident later sustained a burn above the right index finger knuckle while smoking in the designated smoking patio at night. The resident stated there were no lights in the smoking patio, that she had her own lighter, and that no facility staff were monitoring her when the burn occurred. Record review and interviews showed the facility did not document who was responsible for monitoring residents in the smoking patio and could not provide documentation showing the resident was monitored when the injury occurred. The smoking log listed residents allowed to smoke but did not identify the staff assigned to monitor them. The DON stated the facility could not provide documented proof that staff were monitoring the resident when she burned her hand, and also stated the facility did not follow its smoking policy by allowing the resident to keep a lighter and by not providing proof of monitoring. The resident’s care plan included interventions related to smoking safety, including storing smoking materials, observing for unsafe smoking material from an outside source, and re-evaluating smoking privileges, but the DON stated the facility did not follow the care plan and did not document the re-evaluation of smoking privileges. The facility also failed to ensure a high-fall-risk resident had floor mats placed on both sides of the bed as ordered. The resident had diagnoses including dementia, osteoporosis, gait and mobility abnormalities, osteoarthritis, and a right pubis fracture. The fall risk evaluation identified the resident as high risk for falls with intermittent confusion, balance problems, and the need for assistive devices. A physician order directed floor mats on both sides of the bed to reduce injury risk if the resident tried to get up unassisted, and the care plan included the same intervention. During observation, the bed was found without floor mats on either side, and both CNA and ADON confirmed the mats were not present. The DON stated the mats should have been present per the physician order. The facility further failed to complete and document a smoking safety evaluation for another resident who was a smoker. That resident had diagnoses including schizophrenia, bipolar disorder, and hypertension, and the record showed fluctuating capacity to understand and make decisions. The admission nursing risk evaluation identified the resident as a smoker, but the medical record contained no smoking safety evaluation. The ADON, AD, and DON all confirmed the evaluation was missing, and the DON stated the facility failed to complete it on readmission. The facility’s smoking policy required an evaluation of physical and cognitive abilities to safely handle smoking materials upon admission and at other specified intervals, and the safety and supervision policy stated the facility aimed to keep the environment free from accident hazards and prioritize resident safety, supervision, and assistance to prevent accidents.
Failure to Post Daily Staffing Information
Penalty
Summary
The facility failed to update and post daily Direct Care Services Hours Per Patient Day (DHPPD) information for three of six sample days, specifically 7/18/2026, 7/19/2026, and 7/20/2026. During a concurrent observation and interview on 7/20/2026 at 9:02 AM with the ADON in front of Nursing Station 1, the DHPPD posted on the announcement board reflected 7/15/2026, 7/16/2026, and 7/17/2026. The ADON stated the posted DHPPD needed to be updated daily to reflect changes with census and staffing. During an interview on 7/22/2026 at 3:41 PM, the DON stated the DSD was responsible for posting the projected beginning-of-shift and actual end-of-day DHPPD, and that the DSD was unavailable due to a family emergency. The DON stated the facility did not update or post the DHPPD for 7/18/2026, 7/19/2026, and 7/20/2026 in a timely manner. Review of the facility policy titled, Posting Direct Care Daily Staffing Numbers, last reviewed January 2026, showed that within two hours of the beginning of each shift, the number of licensed nurses and unlicensed nursing personnel directly responsible for resident care are to be posted in a location accessible to residents and visitors.
Medication Administration Errors
Penalty
Summary
The facility failed to administer medications in accordance with physician orders and professional standards of practice for two residents. For one resident with gastrostomy status, gastrostomy malfunction, and dysphagia, the physician order required the g-tube to be flushed with 50 mL of water before and after medication administration. During a medication administration observation, an LVN prepared six medications for g-tube delivery and stated she would flush with 30 mL before and after medications and 5 mL between medications. She also stated the medications were not passing through the g-tube smoothly and that she needed to push on the syringe plunger for the medications to pass through. The resident’s record also showed a separate order to flush the g-tube with 10-15 mL of water between each medication, and staff later stated there was confusion because some g-tube orders had not been renewed when the resident was readmitted. For another resident with right knee and right thigh pain and osteoarthritis, the physician orders directed application of Lidoderm 5% patches to the right knee and right thigh, with application at 9 AM and removal at 9 PM. During observation, the resident was found with one patch on the right knee and one patch on the left knee, and no patch on the right thigh. The patches had no nurse initials and no date. The LVN stated another nurse had applied the patch the prior evening, that the patch on the resident did not have a date, and that the resident was only supposed to receive the patch on the right knee, but it was on both knees against physician orders. The record review and staff interviews showed that the patch was not removed as ordered and was relocated by the resident from the right thigh to the left knee. The LVN stated the physician later instructed staff to hold the patch for one day and then resume it on the right knee and right thigh, and to monitor the resident for vital signs and drowsiness. Facility policy required patch placement on the identified body location, removal of the old patch, and labeling the new patch with the date and nurse’s initials. Another facility policy stated medications shall be administered in a safe and timely manner, and as prescribed.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Medications and biologicals were not stored in accordance with manufacturer requirements and the facility’s Medication Storage in the Facility policy. In the Station 1 medication room refrigerator, surveyors found the temperature at 32.9 F, which was below the required 36 F to 46 F range. Stored in that refrigerator were multiple medications requiring refrigeration, including an unopened emergency medication kit containing Novolin R, Humalog Kwik Pen, and lorazepam, as well as acetaminophen suppositories, Humulin R vials, Novolin R vials, Rhopressa, latanoprost, Vyzulta, Lantus Solostar pens, insulin lispro, and Trulicity. RN 2 stated the refrigerator should have been maintained between 36 F and 46 F and that the out-of-range temperature could affect medication stability and effectiveness. The refrigerator temperature log also did not show a documented temperature reading for one of the scheduled checks. RN 2 stated the temperature had been documented at 12:00 AM but not at 12:00 PM. During interview, the DON stated the facility replaced the medications that were outside the required temperature range and ordered replacements from the pharmacy. In Station 1 Medication Cart 1B, Resident 155’s unopened prefilled Lantus Solostar pen was found without an open date and was not stored in a refrigerator. The resident had a diagnosis of Type 2 DM, and the order summary showed Lantus Solostar 30 units subcutaneously at bedtime. LVN 5 stated the pen had likely been delivered the day before, but it had not been dated or placed in the refrigerator. The DON stated that if insulin was removed from refrigeration and stored in the cart, it should be labeled with an open date. Also in Station 1 Medication Cart 1B, Resident 54’s opened foil pack containing budesonide inhalation suspension had no open date. The outside box showed a date, but the foil envelope had been opened and the ampules were required to be used within 2 weeks once opened. Resident 54 had diagnoses including COPD with acute exacerbation, acute respiratory failure with hypercapnia, and unspecified asthma with acute exacerbation. LVN 5 stated she was not sure why there was no open date on the foil pack, and the DON stated it was important to follow the manufacturer requirements for budesonide inhalation suspension because the medication could be administered beyond the manufacturer recommendations if not handled properly.
Elopement Risk Not Properly Assessed or Updated
Penalty
Summary
The facility failed to maintain a safe and functional environment for one resident by not consistently monitoring the resident’s whereabouts despite an elopement precaution care plan. The resident was admitted with metabolic encephalopathy, unspecified dementia, and altered mental status. The H&P stated the resident did not have the capacity to understand and make decisions, and the MDS showed moderately impaired cognitive skills for daily decisions with partial/moderate assistance needed for ADLs. The care plan for elopement, initiated on 6/4/2026, included monitoring the resident’s whereabouts in the facility and placing a wander guard on the right ankle. A separate care plan for impaired cognitive function/dementia included cueing, reorientation, and supervision as needed. The resident’s ERE dated 6/4/2026 scored 17, but it incorrectly indicated the resident had no diagnosis or history of Alzheimer’s disease or dementia. The record also showed SBAR documentation that the resident had gone out of the facility without assistance on 6/4/2026, had an episode of elopement on 6/22/2026, and left the facility without staff supervision on 7/15/2026, with the resident’s location unknown. Despite these events, there was no ERE completed after any of the elopements. The IDT meeting on 6/10/2026 documented that the resident consistently expressed a desire to return home, remained ambulatory without an assistive device, and was able to independently leave the facility. The resident’s care plan was not revised after the elopement events on 6/4/2026 and 6/22/2026. During interviews, the family member stated the facility did not provide the agreed-upon 1:1 supervision and that the resident had attempted to leave many times, including being missing throughout the night after the 7/15/2026 elopement. A CNA stated the resident did not have a 1:1 sitter assigned and that the resident was moving around the facility on his own. The LVN stated she was unaware the resident had left because she was busy with medication administration. The DON confirmed the ERE was not evaluated accurately, that no ERE was completed after the elopement incidents, and that the care plan was not revised after the resident’s change in condition related to elopement.
Failure to Revise Elopement Care Plan After Repeated Unsupervised Exit
Penalty
Summary
The facility failed to revise the care plan for a resident at risk for elopement after the resident left the facility without staff knowledge and assistance on 6/8/2026 and 6/22/2026. The resident was admitted with diagnoses including metabolic encephalopathy, unspecified dementia, and altered mental status. The history and physical dated 6/5/2026 stated the resident did not have the capacity to understand and make decisions, and the MDS dated 6/7/2026 indicated the resident’s cognitive skills for daily decisions were moderately impaired and that the resident required partial/moderate assistance with ADLs. The resident’s care plan, initiated on 6/4/2026 for elopement precaution, included a goal that the resident would have no episodes of leaving the facility without notice and interventions such as monitoring whereabouts in the facility and placing a wander guard on the resident’s right ankle. Another care plan, initiated on 6/3/2026 for impaired cognitive function/dementia and wandering, included cues, reorientation, and supervision as needed. SBAR documentation dated 6/4/2026 and 6/22/2026 documented episodes of the resident going out of the facility without assistance and elopement. During the IDT meeting on 6/10/2026, staff documented that the resident consistently expressed a desire to return home, remained ambulatory without an assistive device, and was able to independently leave the facility, with intermittent confusion noted. The DON reviewed the resident’s SBARs and care plan and confirmed that no revision had been made to the elopement care plan after the resident’s change in condition related to the elopement episodes. Facility staff interviews also reflected that the resident was not assigned a 1:1 sitter, and staff stated they were busy with other duties when the resident left the facility without staff knowledge.
Missing Initial and Annual Competency Assessments for Utility Nurses
Penalty
Summary
The facility failed to ensure that Utility Nurses had competency and skills assessments completed upon hire and annually, as required by facility policy, for two of six sampled employees working in that role. Interview and record review with the Director of Staff Development (DSD) showed that both Utility Nurse 1 and Utility Nurse 2 were initially hired in the dietary department and later began working as Utility Nurses on 2/25/25 and 8/19/25, respectively. Their personnel files contained competency checklists only for dietary duties and lacked any competency or skills checklists related to their Utility Nurse responsibilities, despite the DSD stating that such competencies should be completed upon hire and yearly to ensure correct resident care procedures. The Director of Nursing (DON) also stated it is important to have competency and skills assessments done upon hire and annually to ensure these staff can safely and competently perform their duties. Review of the facility’s “Utility Nurse” policy, revised on 1/25, indicated that Utility Nurses shall receive orientation on call light response, resident safety and fall prevention, communication protocols, scope of practice, and emergency procedures, and that competency shall be assessed upon hire and annually, which was not done for these two staff members. No specific residents, medical histories, or clinical conditions were described in the report in relation to this deficiency.
Incorrect Low Air Loss Mattress Settings for Pressure Ulcer Management
Penalty
Summary
The facility failed to ensure that low air loss mattresses (LALMs), which are specialized air mattresses designed to prevent and treat pressure ulcers, were set to the correct weight-based settings for two residents. For the first resident, who had a history of peripheral vascular disease, chronic ulcers, dementia, and was dependent on staff for all activities of daily living, the LALM was observed to be set at 80 pounds, while the resident's actual weight was 103 pounds. Both the LVN and the DON confirmed that the mattress was not set correctly, and that incorrect settings would reduce the effectiveness of the mattress in managing skin integrity as ordered by the physician. For the second resident, who had diagnoses including metabolic encephalopathy, severe protein calorie malnutrition, diabetes, and a Stage 3 pressure ulcer, the LALM was set at 150 pounds, despite the resident weighing 103 pounds. A sticker on the mattress indicated the appropriate setting should be between 89-109 pounds. The RN and DON both acknowledged that the mattress was not set according to the resident's weight, which could compromise the intended pressure redistribution for skin management as per the physician's order. In both cases, the operator's manual for the LALM specified that the pressure setting should be adjusted according to the patient's weight, with clear guides provided on the device. The failure to set the LALMs correctly was confirmed through observation, interviews with nursing staff and the DON, and review of medical records and physician orders. This deficiency was identified through direct observation and record review by surveyors.
Call Lights Not Accessible to Dependent Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach and easily accessible for two residents who required significant assistance with activities of daily living and had severely impaired cognition. For one resident with a history of falls, dementia, and limited mobility, the call light was observed on the floor out of reach while the resident was in bed. This was confirmed by a CNA, who acknowledged that the call light should have been placed next to the resident to allow her to call for help when needed. The resident's care plan specifically included an intervention to keep the call light within reach to provide a safe environment. For another resident with muscle weakness, upper mobility impairment, and a history of subarachnoid hemorrhage and encephalopathy, the touch pad call light was observed on the bed, out of reach, while the resident was lying in a geri-chair. The resident was seen attempting to reach the call light but was unable to do so. A CNA confirmed that the call light was not accessible and stated that the resident would not be able to call for assistance in an emergency. The care plan for this resident also required the call light to be within reach and answered promptly. Interviews with nursing staff and the DON confirmed that call lights should always be placed within reach of residents, as outlined in the facility's policy and procedures. The observations and staff interviews demonstrated that the facility did not follow its own policy, resulting in the call lights being inaccessible to residents who were dependent on staff for care and unable to independently summon assistance.
Failure to Develop Comprehensive Dental Care Plan
Penalty
Summary
A deficiency was identified when the facility failed to develop a comprehensive and resident-centered dental care plan for a resident who was admitted with multiple diagnoses, including encephalopathy, compression fractures, bipolar disorder, panic disorder, and malnutrition. The resident's admission record and Minimum Data Set (MDS) indicated that the resident was able to participate in assessments and goal setting, could be understood, and required substantial to maximal assistance with activities of daily living. The Social Services Evaluation noted the presence of missing teeth and indicated that a referral to dental consultation would be made as needed. However, upon review, it was found that no care plan addressing oral or dental health was created for the resident at the time of admission. Interviews with facility staff, including a Registered Nurse Supervisor, Social Services Director, and Director of Nursing, confirmed that the dental issue should have been included in the resident's care plan. Staff acknowledged the importance of initiating a care plan to set goals and provide proper care and treatment, as well as to facilitate communication between departments. The facility's policy requires that a comprehensive care plan, including measurable objectives and timetables, be developed for each resident within seven days of completing the comprehensive assessment, but this was not done for the resident's dental needs.
Failure to Update Care Plan Following Change in Antidepressant Dosage
Penalty
Summary
The facility failed to conduct a quarterly review and revise the care plan for a resident diagnosed with major depressive disorder (MDD) who was prescribed Remeron. The resident's care plan, last updated to reflect a 15 mg dosage of Remeron, was not revised after the physician changed the order to 7.5 mg. This discrepancy was identified during a review of the resident's records, which showed that the care plan interventions still referenced the outdated 15 mg dosage, despite the medication order having been changed months earlier. The Minimum Data Set Nurse (MDSN) and Director of Nursing (DON) both confirmed that the care plan should have been updated to reflect the new dosage and that the facility's policy requires care plans to be reviewed and revised quarterly or when there is a change in physician orders. The resident, who was admitted with diagnoses including MDD, muscle weakness, and a need for assistance with personal care, continued to be monitored for depressive symptoms. However, the care plan did not accurately reflect the current medication regimen, as it was not updated following the change in Remeron dosage. Both the MDSN and DON acknowledged that this oversight could lead to confusion regarding the correct dosage to be administered, as the care plan was not aligned with the physician's current orders.
Failure to Rotate Insulin Injection Sites as Ordered
Penalty
Summary
The facility failed to ensure proper rotation of insulin injection sites for one resident, as required by physician orders and facility policy. Record reviews showed that the resident, who had a history of type 2 diabetes mellitus, peripheral vascular disease, and bilateral above-knee amputations, received subcutaneous insulin injections in the same anatomical locations on consecutive days. Specifically, injections were administered to the right lower quadrant, left deltoid, and left upper quadrant on multiple consecutive days, contrary to best practices and the facility's own insulin administration policy. Interviews with nursing staff, including an LVN, RN, and the DON, confirmed that insulin injection sites should have been rotated and acknowledged that the electronic medical record system displayed previous injection sites to help prevent repeated use of the same site. Despite this, staff administered insulin in the same location on consecutive days. The staff interviewed were aware of the need for site rotation and the potential for tissue damage if not followed, but the practice was not consistently implemented for this resident. The facility's policy and procedure for insulin administration, dated January 2025, specified that injection sites should be rotated within the same general area to ensure safe administration. The failure to rotate injection sites as documented in the resident's Location of Administration Report was in direct violation of this policy and the physician's orders, resulting in a deficiency related to the administration of care according to orders and established guidelines.
Failure to Complete Smoking Risk Assessment for Resident
Penalty
Summary
The facility failed to complete a smoking risk assessment for a resident who was admitted with multiple diagnoses, including encephalopathy, type 2 diabetes, hypertension, and heart failure, and who required assistance with personal care. Upon admission, the resident's care plan identified a risk for injury due to smoking and included an intervention to re-evaluate smoking privileges per facility policy. However, the initial nursing risk assessment indicated that a smoking safety evaluation was not completed because the resident was believed not to smoke, and no further smoking safety evaluations were conducted after admission. Subsequent documentation showed that the resident had a past interest in smoking, and direct observation revealed the resident smoking on the facility's patio with assistance from activity staff, but without a protective smoking apron. Interviews with nursing staff and the DON confirmed that a smoking risk assessment should have been performed when it became known that the resident smoked, in accordance with facility policy, which requires such assessments on admission, quarterly, and as needed. The lack of an updated smoking risk assessment potentially placed the resident's safety at risk.
Unattended Unlocked Medication Cart by LVN
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to lock and secure a medication cart while it was left unattended in the hallway. The LVN was observed preparing medication at the doorway of a resident's room and subsequently entered the room, leaving the medication cart unlocked. Upon exiting the room, the LVN acknowledged that the cart had not been locked. Review of the facility's policy and procedures confirmed that medication carts are required to be locked when not in use and not left unattended while unlocked.
Failure to Adhere to Enhanced Barrier Precautions and Proper Resident Identification
Penalty
Summary
The facility failed to ensure that nursing staff adhered to its enhanced barrier precautions (EBP) policy during medication administration for two residents. Specifically, during medication passes, one nurse performed hand hygiene but did not don a gown before providing care to a resident with an EBP sign posted, while another nurse donned gloves but failed to wear a gown before measuring vital signs and administering medication to another resident under EBP. Both nurses acknowledged the requirement to use gloves and gowns as indicated by the EBP signage, with one nurse stating she forgot to put on the gown. Facility policies reviewed indicated that staff are required to follow established infection control procedures and receive education on proper techniques. Additionally, the facility did not provide a proper identifier for a resident on EBP due to an indwelling urinary catheter. The resident's care plan required appropriate infection control precaution signs to be placed next to the door entrance with the room number, but during observation, no such identifier was present. Both the nurse and the Infection Preventionist confirmed the absence of the EBP indicator, and the Director of Nursing acknowledged that signage should be placed above the resident's bed or outside the door as per the care plan intervention. Facility policy stated that the Infection Preventionist or designee is responsible for determining and implementing appropriate notification for EBP.
Resident Room Fails to Meet Minimum Space Requirements
Penalty
Summary
The facility failed to ensure that one of its resident rooms met the required minimum space of 80 square feet per resident for multiple occupancy rooms, as mandated by federal regulations. Specifically, room [ROOM NUMBER] was measured by the maintenance supervisor and found to be 213.69 square feet, yet it contained three beds, falling short of the required 240 square feet for three residents. This was confirmed through observation, staff interviews, and review of the Client Accommodations Analysis and a Room Variance Waiver Letter, both of which documented the room's insufficient size. Despite the room being clean, free from clutter, and no immediate safety or privacy concerns being observed during multiple visits, the facility's own policy also requires compliance with the square footage standards, which was not met in this instance.
Failure to Provide Adequate Dementia Care and Fall Prevention
Penalty
Summary
The facility failed to provide appropriate care and services to a resident diagnosed with dementia, who was also at high risk for falls. The resident, who had a history of falls and was diagnosed with dementia, syncope, psychosis, and gait abnormalities, was not provided with an individualized care plan through an Interdisciplinary Team (IDT) approach. The care plan lacked specific interventions to maximize the resident's safety and did not include supervision for bed mobility as required by the Activities of Daily Living (ADL) Self-Care Performance Deficit care plan. On multiple occasions, the resident was noted to have an unsteady gait and balance problems, yet the care plans did not adequately address these issues. Despite being identified as a high fall risk, the resident's care plan did not include measurable goals or interventions to address the diagnosis of dementia. The facility's staff, including the Registered Nurse (RN) and Certified Nursing Assistant (CNA), failed to provide the necessary supervision and safety measures, resulting in the resident falling and sustaining a serious injury. The resident was found on the floor in her room and later diagnosed with a displaced right femur, requiring surgery and a blood transfusion. Interviews with facility staff, including the Director of Nursing (DON) and Assistant Director of Nursing (ADON), revealed that the care plans lacked clear language and individualized interventions for dementia care. The facility's policies on dementia care and fall risk management were not effectively implemented, contributing to the resident's fall and subsequent injury.
Incomplete Documentation of Resident's Discharge Plan
Penalty
Summary
The facility failed to ensure that the medical records for a resident were complete and accurate, specifically regarding the resident's discharge plan. The resident, who was admitted with diagnoses including osteoarthritis and gait abnormalities, was cognitively intact and expressed a desire to be discharged to live in an apartment, having been homeless prior to admission. The Minimum Data Set indicated the resident's goal was to discharge to the community, but the discharge plan was not documented in the medical record. Interviews revealed that the social services department was searching for placement for the resident, and an application for an assisted living waiver was submitted but on hold. However, the Social Service Designee admitted to not documenting discussions about the discharge plan with the resident's next of kin. The Director of Nursing emphasized the importance of documenting the discharge plan to demonstrate the facility's efforts. The facility's policy requires documentation of services provided and progress toward care plan goals, which was not adhered to in this case.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to implement its abuse policy and procedures by not reporting an injury of unknown origin to the Survey State Agency (SSA) within 24 hours for a resident. The resident was found on the floor with discoloration to the left side of the face and a scratch on the nose. Despite the presence of these injuries, the facility did not report them to the SSA, resulting in a delayed investigation. The resident, who had severe cognitive impairment and required significant assistance with daily activities, was later observed to have extensive bruising and swelling on the left side of the face. The injuries were considered of unknown origin as no staff witnessed the incident, and the resident was unable to explain how they occurred. Interviews with facility staff, including a CNA, social worker, and the Director of Nursing, confirmed that the injuries should have been reported as per the facility's policy. The facility's policies required that injuries of unknown origin be reported to the SSA to rule out abuse. However, the Administrator mistakenly believed the injuries were reported as an unwitnessed fall, despite no staff observing the fall. The facility's policies clearly outlined the need for prompt reporting of such incidents, but these procedures were not followed, leading to the deficiency.
Inadequate Infection Control Measures for COVID-19
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically in preventing the transmission of COVID-19. Two residents, both with cognitive impairments and requiring substantial assistance for activities of daily living, were observed not wearing masks while interacting with others in common areas. Resident 1, with severe cognitive impairments, was seen walking around the unit without a mask and was unaware of the requirement to wear one. Similarly, Resident 3, with moderate cognitive impairment, was observed sitting in a wheelchair near the nurses' station without a mask, in close proximity to other residents. Additionally, a registered nurse (RN 1) was found not adhering to the facility's policy regarding the use of N95 respirators. The nurse was observed wearing a respirator that she had not been fit-tested for, which compromised the effectiveness of the protective equipment. The nurse admitted to wearing a different respirator than the one she was fitted for, acknowledging the importance of a proper fit to prevent the spread of COVID-19. The facility's policies and procedures require all staff to wear fit-tested N95 respirators in areas with residents in COVID-19 isolation or under investigation. Furthermore, during a COVID-19 outbreak, all residents are required to wear masks when leaving their rooms. The infection prevention nurse confirmed these requirements, emphasizing the necessity of proper mask usage to prevent transmission. The facility's failure to ensure compliance with these protocols placed both residents and staff at risk of infection.
Failure to Report Suspected Abuse
Penalty
Summary
The facility failed to implement its policies and procedures for reporting suspected abuse in accordance with state and federal law for a resident. The resident, who had chronic respiratory failure, congestive heart failure, and dysphagia, was cognitively impaired and dependent on staff for activities of daily living. The resident reported that a Certified Nursing Assistant (CNA) had physically mistreated her, which was documented in the progress notes. Despite this report, the Social Service Director (SSD) and the Director of Nursing (DON) decided not to report the incident to the State Agency (SA) because they believed the incident did not occur after their investigation. The facility's policy, titled 'Abuse Prevention Program,' requires the identification, assessment, investigation, and reporting of all possible incidents of abuse within the required timeframes. However, the SSD and DON did not adhere to this policy, as they did not report the incident to the SA, police, or ombudsman. The Facility Administrator was not informed of the incident, which further indicates a breakdown in communication and adherence to the facility's policies. This failure resulted in a delay of an onsite inspection by the SA and had the potential to result in unidentified abuse within the facility.
Failure to Monitor Pain During Restorative Nursing Services
Penalty
Summary
The facility failed to adequately monitor and document the pain levels of three residents before, during, and after Restorative Nursing Assistant (RNA) services, as required by physician orders. Resident 52, who has diagnoses including polyarthritis and neuralgia, was not assessed for pain during RNA services despite a physician's order to do so. The resident's care plan did not include instructions to monitor pain, and there was no documentation of pain assessment from June 1 to June 18, 2024. Similarly, Resident 92, with conditions such as osteoarthritis and fibromyalgia, was not monitored for pain during RNA services, as indicated by the absence of documentation for the same period. Although the resident reported experiencing pain and receiving medication, the care plan lacked directives for pain monitoring. The resident's fluctuating cognitive capacity further complicated the situation, as the facility did not consistently assess and document pain levels. Resident 129, who has severe cognitive impairment and requires significant assistance, also did not have pain levels documented during RNA services. Despite a physician's order to monitor pain, the care plan did not reflect this requirement, and no documentation was found for the specified period. Interviews with staff revealed a misunderstanding of documentation requirements, with the RNA only recording pain when it was present, contrary to the facility's policy and procedure guidelines.
Failure to Label and Discard Food Items
Penalty
Summary
The facility failed to adhere to professional standards for food service safety by not labeling several food items with open and use by dates. During an observation, a Dietary Assistant noted that a plastic container of Aji-Mirin Sweet Cooking Rice seasoning, a bag of carrots, a plastic container of Salted Shrimp, a plastic bag of ginger, and a plastic bag of Dried [NAME] were not labeled with open or use by dates. Additionally, several items, including a bottle of Rice vinegar, a bag of Dried Seaweed-Sliced, a container of garlic, and packs of tofu, were found with open and use by dates but were not discarded after their use by dates had passed. Interviews with the Dietary Supervisor, Dietary [NAME], and the Director of Nursing revealed that the facility's policy required all food to be labeled with open and use by dates and discarded after the use by date to prevent food-borne illnesses. The staff acknowledged the importance of these practices to ensure resident safety. The facility's undated policy on food storage indicated that all food should be covered, labeled, and dated, and checked to ensure consumption by their safe use by date. However, these practices were not followed, leading to the potential risk of food-borne illnesses.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to maintain or enhance the dignity and respect of two residents during meal assistance. Resident 87, who has Alzheimer's disease, bipolar disorder, and essential hypertension, was observed being fed by an Activity Assistant who stood over the resident instead of sitting at eye level. This practice was against the facility's policy, which requires staff to sit while assisting residents with meals to promote dignity. The Director of Nursing confirmed that staff are required to feed residents with attention to dignity by sitting down. Similarly, Resident 93, who has dementia and requires substantial assistance for eating, was fed by a Certified Nursing Assistant who also stood over the resident. The CNA stated that standing provided better control over the resident. However, this was contrary to the facility's policy and the expectations set by the Director of Nursing, who emphasized the importance of sitting while feeding residents to maintain their dignity. Both instances were observed and confirmed by a Licensed Vocational Nurse, highlighting a consistent failure to adhere to the facility's policy on meal assistance.
Failure to Document Advance Directives in Resident Charts
Penalty
Summary
The facility failed to ensure that a copy of the advance directive was included in the medical charts of two residents, which could potentially lead to the facility not honoring the residents' medical decisions regarding end-of-life treatment. Resident 92 was admitted with diagnoses including abnormalities in gait and mobility, osteoarthritis, and fibromyalgia. Despite having an advance directive and fluctuating capacity to make decisions, the document was not present in the resident's medical chart. Both the Director of Social Services and the Director of Nursing acknowledged the importance of having the advance directive in the chart to ensure the resident's wishes are respected. Resident 140 was admitted with diagnoses including hypotension and a need for assistance with personal care. The resident had mild cognitive impairment but was capable of making decisions. However, the Advance Directive Acknowledgment form was not completed upon admission, which could result in the resident not being informed about their rights to accept or refuse medical treatments. The Social Services Director admitted responsibility for completing the form and acknowledged the oversight. The facility's policy required that upon admission, residents be provided with information about their rights to accept or refuse treatment and to formulate an advance directive. The policy also stated that information about the existence of an advance directive should be prominently displayed in the medical record. The failure to adhere to this policy for Residents 92 and 140 indicates a lapse in ensuring that residents' medical decisions are documented and respected.
Failure to Report Incidents Timely
Penalty
Summary
The facility failed to report incidents involving two residents to the State Survey Agency within the required timeframe. For Resident 13, the facility did not report an injury of unknown origin, which included a bump on the forehead, discoloration on the hand, and an abrasion on the knee. Despite the resident's cognitive impairments and inability to recall the incident, the Director of Nursing (DON) did not report the incident based on advice from a consultant, which was later acknowledged as a mistake. For Resident 195, the facility failed to report a fall with injury. The resident, who had moderately impaired cognition and required assistance with personal care, reported a fall during a self-transfer from the toilet to a wheelchair, resulting in hip pain. Although initial assessments and x-rays did not reveal a fracture, a subsequent x-ray confirmed a left ischial ring fracture. Despite the resident's report of a fall and the confirmed fracture, the incident was not reported to the Department of Public Health or the ombudsman. The facility's policies required that incidents of unknown origin and falls with major injuries be reported within two hours. However, these incidents were not reported, leading to a delay in investigation by the California Department of Public Health. Interviews with staff, including the DON and Registered Nurses, revealed a lack of adherence to reporting protocols, which contributed to the deficiencies identified in the report.
Failure to Develop Comprehensive Hospice Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who was readmitted with serious medical conditions, including malignant neoplasm of the stomach, severe protein-calorie malnutrition, and sepsis. The resident was under hospice care, as indicated by the physician's order, but the care plan did not include hospice-specific interventions. This oversight was confirmed during interviews with the RN and the DON, who acknowledged the absence of a hospice care plan and the potential for the resident to not receive necessary and personalized care. The facility's policy requires a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's needs. The care plan should describe the services to be furnished to attain or maintain the resident's well-being and include the resident's stated goals and desired outcomes. However, the care plan for this resident did not reflect these requirements, particularly in relation to hospice care, which was a critical aspect of the resident's treatment plan.
Failure to Conduct Smoking Risk Assessment for Resident
Penalty
Summary
The facility failed to ensure safety measures were assessed and implemented for a resident who was a smoker. Despite the resident's admission records indicating they did not smoke, a subsequent social services evaluation identified the resident as a smoker who required supervision. However, the facility did not initiate a smoking risk assessment, which was a necessary step to evaluate and implement appropriate safety measures. This oversight was acknowledged by the Registered Nurse responsible for Quality Assurance and the Director of Nursing, who both confirmed that the assessment should have been conducted to prevent potential risks of injury or burns. The resident, who had intact cognition and required varying levels of assistance with daily activities, was observed smoking under supervision without a completed risk assessment. The facility's policy required an evaluation of smoking status upon admission and periodic re-evaluations, but this protocol was not followed. The failure to conduct a smoking risk assessment left the resident vulnerable to potential harm, as the necessary safety precautions were not formally assessed or implemented.
Failure to Implement Nutritional Recommendations for Resident
Penalty
Summary
The facility failed to provide adequate nutrition to a resident, identified as Resident 133, consistent with the weight loss assessment and the Registered Dietitian's (RD) recommendations. Resident 133, who was admitted with end-stage renal disease, dependence on renal dialysis, and depression, experienced a gradual weight loss of 3.8% over 30 days, which was concerning due to the resident's slightly underweight BMI. The RD recommended providing snacks three times a day to address this issue. However, there was no order for these snacks in the resident's chart, and the Medication Administration Record (MAR) did not reflect this intervention. Interviews with facility staff, including a Certified Nursing Assistant (CNA), Quality Assurance Nurse (QAN), Licensed Vocational Nurse (LVN), Dietary Supervisor (DS), and the Director of Nursing (DON), revealed a lack of communication and documentation regarding the RD's recommendations. The QAN and LVN confirmed the absence of an order for snacks, and the DS was unaware that the diet communication needed to be in the resident's order or MAR. The DON acknowledged that the missing order could increase the risk of further weight loss for the resident. The facility's policy required monitoring of nutritional status and response to interventions, which was not effectively implemented in this case.
Failure to Change Tube Feeding Set as Required
Penalty
Summary
The facility failed to ensure proper infection control practices were followed for a resident with a feeding tube. Resident 124, who was admitted with conditions including Parkinson's Disease, aftercare following digestive system surgery, gastrostomy, dysphagia, and dementia, was observed with tube feeding tubing that had not been changed as per the physician's order and facility policy. The physician's order specified that the tube feeding syringe and tubing set should be changed every night shift, but during an observation, it was found that the tubing dated 6/15/2024 was still in use on 6/17/2024, despite a new tube feeding bottle being started on 6/16/2024. Licensed Vocational Nurse (LVN) 5 confirmed the discrepancy and acknowledged the potential for infection control issues due to the reuse of the tube feeding tubing. The Director of Nursing (DON) also stated that the tubing should be changed every 24 hours along with the tube feeding bottle to prevent infection control issues. The facility's policy on enteral feedings and the Jevity 1.5 tube feeding bottle label both indicated that feeding sets are for single patient use and should be changed at least every 24 hours, or as specified by the manufacturer, to avoid contamination.
Staffing Shortages Lead to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of its residents, as evidenced by the experiences of two residents. On a specific date, the facility had eight CNAs working the night shift to care for 147 residents, resulting in each CNA being responsible for 17-19 residents. This situation arose when one CNA was a no call, no show, and her absence was not covered, leading to increased workloads for the remaining staff. Resident 99, who required assistance with personal care due to severe morbid obesity and other health conditions, reported having to wait for care, sometimes for an hour, which was frustrating and impacted their ability to use the bathroom in a timely manner. Similarly, Resident 28, who had severe cognitive impairment and was dependent on staff for various daily activities, also experienced delays in receiving care. A family member of Resident 28 noted that wait times during the night could be excessively long. Interviews with staff, including a CNA and the Director of Staff Development, highlighted the challenges faced due to staffing shortages, particularly during the night shift. The Director of Nursing acknowledged the issue but stated that the facility did not use registry staff and relied on offering overtime or calling in extra staff, which was not always successful.
Arbitration Agreement Lacks Venue Selection for Residents
Penalty
Summary
The facility failed to include specific verbiage in their Arbitration Agreement that allowed residents the freedom to choose a convenient venue for arbitration meetings. This deficiency was identified through a review of the facility's undated Arbitration Agreement form, which lacked provisions for residents to select a meeting place. During interviews, both the Admissions Coordinator and the Business Office Manager acknowledged the absence of such verbiage and agreed that it would be beneficial for residents to have a say in the meeting location. The facility's policy and procedure document, dated July 2023, indicated that hearings would be conducted at a mutually agreed-upon time and place, but this was not reflected in the actual agreement form.
Deficiency in Room Space Requirements
Penalty
Summary
The facility failed to meet the space requirements of 80 square feet per resident in room [ROOM NUMBER], which was identified as a deficiency. The room in question was observed to have a total of 203.3 square feet for three residents, falling short of the required 240 square feet for a three-bed capacity room. Despite the deficiency, observations during the survey period indicated that nursing staff were able to provide adequate care, and privacy curtains were in place for residents. Interviews with residents and staff revealed that there were no complaints regarding space or the ability to provide care. Residents expressed satisfaction with the room's space, and staff, including a CNA and an LVN, confirmed that there was enough room to provide care. A Room Waiver letter from the Administrator suggested that the space issue would not adversely affect the health and safety of the residents, but the deficiency was noted due to the room not meeting the specified square footage requirements.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 8,322 citations issued within 25 miles in the last 12 months — including the 27 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Los Angeles
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Alta View Post Acute | 0.1 mi | ★★★★★ | 5 | 0 |
| California Post Acute | 0.2 mi | ★★★★★ | 8 | 0 |
| Olympia Convalescent Hospital | 0.4 mi | ★★★★★ | 13 | 1 |
| Alvarado Care Center | 0.4 mi | ★★★★★ | 25 | 0 |
| Alden Terrace Convalescent Hospital | 0.5 mi | ★★★★★ | 14 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.