Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Grand Valley Health Care Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, extensive ADL dependence, multiple comorbidities, and a history of repeated falls experienced two documented falls, including an unwitnessed fall with a head laceration. Fall Risk Evaluations completed by the DON after each fall failed to accurately record the recent fall history and left key gait and balance items (such as decreased muscular coordination, change in gait pattern, and gait problems) unmarked, even while scoring balance problems and use of assistive devices. These actions did not align with the facility’s fall risk policy, which required comprehensive fall risk assessments after each fall to guide individualized care planning.
Licensed nurses completed dehydration risk assessments for a resident with severe cognitive impairment and multiple diagnoses, including dehydration, stroke, CKD, DM, and dementia, using unverified and incomplete information. On admission, an RN scored the resident’s oral intake as 75–50% and moderate risk based only on one observed meal, without reviewing hospital records or obtaining history from the resident or family. On readmission, another RN documented oral intake as 100–75% and low risk without confirming actual intake, without hospital record review, and with no reliable input from family or the resident, despite an active dehydration diagnosis, resulting in inaccurate hydration risk assessments contrary to facility policies.
A resident with dysphagia, CVA history, and aspiration precautions was served thin coffee with a straw instead of the ordered mildly thick liquid, and coughed after drinking it. Staff confirmed the resident should not have received thin liquids or a straw. The facility also served puree items that were too watery and did not hold shape or pass the spoon tilt test, including puree chili and puree tossed green salad.
Failure to Protect Confidential Diet Ticket Information: A Dietary Aide was observed sorting soiled tray items and placing diet tickets in the trash instead of shredding them. The DS stated the tickets contained resident names, diets, room numbers, and food preferences, and acknowledged this information was protected PHI. Facility policy stated resident health information must be kept secure and confidential.
Medication administration errors caused the facility’s error rate to exceed the allowed threshold. An LVN applied a topical analgesic to the wrong site for one resident and failed to follow the ordered site-specific directions for another topical medication, while another resident’s metformin was given late and not with a meal as ordered. The DON confirmed the orders were not followed as prescribed.
Failure to follow the standardized puree chili recipe led staff to add unmeasured water, butter, chicken base, and thickener to puree 3 bean chili for residents on puree/IDDSI Level 4 and puree CCHO diets. The DS stated the chili was too thin, staff kept adjusting the texture, and the recipe did not include chicken base or butter.
Food Texture and Temperature Deficiencies During Meal Service: A resident with dysphagia and other chronic conditions reported cold meals, while trayline and test tray observations found puree chili that was flat and too thin and salads, Jello, and dessert items served at temperatures ranging from 51 F to 61 F. The DS stated staff added liquid and thickener to puree foods without measuring and that the puree salad was too watery, despite facility guidance requiring IDDSI Level 4 foods to be smooth, hold shape, and pass spoon tilt, fork drip, and appearance checks.
A resident with malnutrition, DM2, and HTN was ordered a NAS, CCHO, soft bite sized diet with regular thin liquids, but the tray ticket showed a small portion diet and an extra plate of chopped food was prepared. The RD stated the menu ticket must match the physician diet order to ensure the correct therapeutic diet is served, and the facility policy required residents to receive food in the nutritive content prescribed by the physician.
Unsafe food storage and prep practices were observed in the kitchen. Multiple reach-in refrigerators and freezers had dirt, food debris, and buildup on shelves and gaskets, a toaster contained breadcrumbs and burnt bread, and the ice machine had dirt residue. Milk in cups was held at 43 F to 44 F in a reach-in refrigerator, one refrigerator gasket was torn, and a trayline refrigerator had no internal thermometer. The dry storage floor had debris, dented cans were mixed with undented cans, chopping boards were stored near sanitizer buckets, and many resident meal trays were cracked and chipped.
Improper garbage and refuse disposal was observed when two black dumpsters were left partially open, trash and soiled PPE were found on the floor around the dumpster area, and the food waste dumpster had liquid drippings on its base. The DS stated trash must stay inside the dumpster, lids should remain closed, and the area must be kept clean for infection control and to avoid pests and animals.
Expired lancets were found in the medication storage room, and RN and DON stated they should not be used because they could be unsterile. In a separate observation, an LVN attached a needle to a resident’s Lantus SoloStar pen without first wiping the pen tip with alcohol, despite the resident’s DM, impaired cognition, and care plan for infection precautions; the DON and manufacturer instructions both indicated the pen tip should be cleaned before needle attachment.
A dead cockroach was observed inside the residents' refrigerator in the staff break room while resident food was stored inside. The DS confirmed the insect appeared to be a dead cockroach, and the HKS stated there had been dead cockroaches in the refrigerator and that the door would not fully open because it was blocked by a bench chair and another refrigerator. The IPN stated pests in the refrigerator could spread infection to residents, and records showed recent pest activity in the breakroom area.
Failure to Knock Before Entering a Resident’s Room: An LVN entered a resident’s room multiple times without knocking or asking permission while delivering meds and checking BP. The resident had intact cognitive skills for daily decision making and required assistance with ADLs. The facility policy stated staff will knock and request permission before entering a resident’s room.
Care plan did not specify transfer assistance level. A resident with muscle weakness and an artificial knee joint was assessed as needing assistance from two or more helpers for ADLs and total dependence for bed-to-chair transfers, but the care plan only stated that staff should assist with transfers and use an appropriate device as needed. The MDS nurse assistant confirmed the plan did not identify the required number of staff for safe transfers, and a CNA stated that transfer assistance levels are documented in the care plan.
Missing Communication Board for Non-English-Speaking Resident: A resident with muscle weakness, dysphagia, severely impaired cognition, and a non-English preferred language did not have a communication board at the bedside. The MDS showed the resident needed an interpreter to communicate with HCPs and required substantial to maximal assistance with several ADLs. Staff from SS and IPN confirmed the communication need, and the care plan called for daily use of a translator, gestures, and a communication board, but none was observed in the room.
A resident with anemia and severe cognitive impairment had an order for Hgb and Hct labs every two weeks and epoetin alfa-EPBX for anemia. Record review showed the labs were obtained on several Fridays, but two scheduled draws were missing, and the MDS nurse, ADON, and DON confirmed the ordered monitoring was not completed and the physician was not contacted to clarify the ongoing need for the tests.
Medications Left Unattended at Bedside: An LVN brought a resident's medications into the room and left them on the bedside table unattended while returning to the cart for another medication. The resident had dementia, impaired cognition, and required substantial assistance with ADLs; the DON stated the resident could not safely self-administer medications and that medications should not be left out of eyesight.
A resident with a Foley catheter for wound management had catheter tubing observed looped so urine could not flow freely into the drainage bag. CNA and LPN staff stated the tubing should not be looped because urine could back up into the bladder and cause a UTI, and the facility's catheter instructions and CAUTI policy required unrestricted urine flow.
Missing Post-Dialysis Dialysis Documentation A resident with ESRD and dependence on dialysis had repeated gaps in the dialysis communication record, including missing post-dialysis weights and, on several occasions, missing post-dialysis vital signs. The MDSN and DON confirmed the omissions and confirmed the facility’s LPNs did not contact the dialysis center to obtain the missing information, despite the facility’s dialysis care policy requiring documentation of pre- and post-dialysis weights and vital signs for each treatment.
A resident admitted with sepsis and UTI was prescribed Macrobid for UTI, but the facility did not complete the required infection surveillance form before the antibiotic was initiated. The IPN reviewed the record and confirmed the missing antibiotic surveillance, and the DON stated that all antibiotics should be monitored for appropriate use using the surveillance form and documentation when criteria are not met.
Insufficient Square Footage in Multiple Resident Rooms: The facility failed to provide at least 80 sq. ft. per resident in four double-occupancy rooms. A waiver letter and room analysis showed Rooms 1, 3, 9, and 11 had only 73, 77.5, 71.5, and 75.5 sq. ft. per resident, respectively. Resident council raised no concerns, and later observations noted adequate space for care, privacy, and movement.
A resident with multiple medical conditions and intact decision-making capacity requested that a specific CNA not provide care or be present in her room. Despite this request being acknowledged by facility staff, the CNA was initially assigned to the room and later entered the room to interact with the resident, causing discomfort and anxiety. This action was contrary to the facility's policy on resident dignity and privacy.
Late Transfer/Discharge Notices for Three Residents: The facility did not provide the Notice of Proposed Transfer/Discharge to three residents and/or their representatives at least 30 days before discharge or as soon as practicable. One resident had chronic venous hypertension with ulcer and MRSA, another had UTI and bilateral LE cellulitis, and a third had pneumonia; all had capacity and were being discharged to a board and care or ALF after rehab. Staff stated the notices were given on the day of discharge, rather than when discharge planning or NOMNC timing indicated.
A resident was not adequately prepared for a safe transfer or discharge, and the facility did not ensure that the process met the resident's needs and preferences, resulting in a deficiency related to transfer/discharge planning.
A resident with paraplegia, morbid obesity, and diabetes was found to have a low air loss mattress set for a much higher weight than their actual weight, contrary to physician orders and facility policy. Both an LVN and the DON confirmed the mattress setting was incorrect, which was identified during observation and record review.
A resident with multiple complex medical conditions received Oxycodone Hydrochloride, a controlled substance, which was signed out and administered by two LVNs but not documented on the MAR as required. The DON confirmed that facility policy mandates immediate documentation of medication administration on the MAR and that the MAR should match the Controlled Drug Record. This failure to document the administration of a narcotic medication resulted in a deficiency.
Two residents were not provided necessary assistance with mobility and getting out of bed, despite being dependent or requiring moderate help for these activities. One resident remained in bed throughout the day, with the assigned CNA admitting to forgetting to offer assistance, while another reported that only the physical therapist, not nursing staff, helped her get out of bed. Facility policy required staff to assist with ADLs, but this was not followed, resulting in prolonged bed rest for both residents.
A resident who was fully dependent on staff for activities of daily living did not receive required oral care, resulting in dry, cracked lips and an unclean tongue with a thick coating. The CNA assigned to the resident did not provide oral care, failed to promptly report the resident's oral condition to nursing staff, and only disclosed the issue after being questioned by a surveyor. Facility staff confirmed that oral care was not provided as required and that the resident's condition was not reported in a timely manner.
The facility did not complete required 72-hour follow-up assessments for two residents with bowel and bladder incontinence issues, resulting in missed opportunities to evaluate their candidacy for retraining programs and to implement appropriate care interventions, as required by facility policy.
Two residents were not informed in advance about the deep cleaning of their rooms, violating their rights to a dignified existence and self-determination. Both residents were informed on the day of cleaning, causing inconvenience and lack of preparation time. The facility's housekeeping schedule was not communicated to nursing staff or residents in advance.
A resident was physically assaulted by another resident, resulting in injuries requiring treatment. The incident occurred while the resident was sleeping, and the aggressor, who had severely impaired cognition and auditory hallucinations, punched the victim multiple times. The facility failed to prevent this altercation, leading to a deficiency in protecting residents from abuse.
A resident with a left hip fracture and dementia did not receive proper follow-up care for their surgical wound. The facility failed to obtain a physician's order to continue monitoring the wound after the initial 14-day period, and licensed nurses stopped documenting the wound's condition. The Treatment Nurse admitted to monitoring the wound without documentation, which is considered as not having been done. The facility's policy requires documentation of wound care, but this was not followed, resulting in a deficiency.
A resident with glaucoma did not receive their prescribed Latanoprost eye drops on the day of admission, yet the MAR inaccurately documented the administration. The LVN admitted to the error, and the DON highlighted the need for accurate documentation and physician notification when medications are unavailable.
The facility failed to ensure proper infection control practices, as a nurse did not perform hand hygiene after checking a resident's blood pressure, and another nurse did not perform hand hygiene between glove changes during wound treatment. Both incidents involved residents requiring assistance with daily activities, and the staff acknowledged the oversight, which was confirmed by the Infection Control Preventionist.
The facility failed to set low air loss mattresses (LALM) correctly for three residents, as per physician orders and guidelines. One resident's LALM was set to 210 lbs instead of their weight of 140 lbs, another's was set to firm despite weighing 132 lbs, and a third's was set to 280 lbs instead of 133 lbs. This non-compliance with LALM settings increased the risk of skin breakdown and pressure ulcers.
The facility failed to label leftover food brought by families with resident identifiers and use-by dates, as observed in three residents' cases. Various food containers in the residents' refrigerator were found without proper labeling, which the Dietary Manager confirmed should be done to prevent foodborne illness. The facility's policy requires perishable food to be labeled and disposed of within two days.
The facility failed to ensure proper infection control practices, including a nurse not wearing a gown while administering medications to a resident on enhanced barrier precautions, a CNA not performing hand hygiene after handling a dirty towel before assisting a resident with lunch, and unlabeled urinals in a resident's room, all of which could increase infection risk.
The facility failed to ensure accessible call lights for two residents, leading to potential delays in care. One resident's call light was out of reach, while another required an adaptive call light due to upper extremity impairments. Both situations were confirmed by staff, highlighting a breach in the facility's call light policy.
A facility failed to inform a resident of their right to formulate an advance directive, as required by the Patient Self-Determination Act of 1990. The resident, who was capable of making and understanding decisions, did not have a signed form acknowledging receipt of this information. This oversight violated the resident's rights and could lead to conflicts with their healthcare wishes.
A resident with severe cognitive impairment and multiple health conditions was found in a room with a temperature of 68°F, below the facility's policy of 70-75°F. The resident expressed feeling cold, and an open window was identified as the cause. The facility's policy requires maintaining a comfortable temperature range for residents.
The facility failed to create person-centered care plans for two residents, one with range of motion limitations and another with bowel and bladder incontinence. Despite documented needs, no care plans were developed, leading to potential gaps in care. The facility's policy on comprehensive care planning was not followed, resulting in deficiencies in addressing the residents' specific needs.
A facility failed to involve a cognitively intact resident in IDT Care Conferences, depriving them of the right to participate in their care plan development. Additionally, the facility did not update another resident's care plan after symptoms of a burning sensation during urination resolved, potentially leading to inappropriate care. These actions were contrary to the facility's policies, resulting in deficiencies in care planning.
A facility failed to assess and provide appropriate equipment for a resident with limited ROM upon readmission. The resident, with conditions like osteomyelitis and diabetic neuropathy, was unable to use the standard call light due to impairments in both upper extremities. The initial nursing assessment and Occupational Therapy Evaluation missed these limitations, leading to the resident's inability to call for assistance, potentially delaying care.
A facility failed to conduct a timely fall risk evaluation for a resident with a history of falls and severely impaired cognition, potentially impacting their care plan. Additionally, an LVN left medications unattended at a resident's bedside, risking unauthorized access. These actions violated the facility's policies on fall risk prevention and medication administration.
An LVN failed to provide adequate respiratory care to a resident by not administering oxygen as ordered, not covering the suction catheter, and not labeling the suction tubing. The resident, with serious health conditions, was found with an oxygen saturation below the prescribed level due to these oversights.
A resident was inappropriately administered hydrocodone-acetaminophen (Norco) despite having a pain level of zero, contrary to the physician's orders which specified its use for severe pain. This occurred on two occasions, as confirmed by a nurse during a review of the Medication Administration Record (MAR). The nurse acknowledged the potential adverse consequences of unnecessary medication use.
A facility failed to complete a post-dialysis assessment for a resident with end-stage renal disease, missing vital signs and access site evaluation. The oversight was confirmed by an LVN and the ADON, who stated that licensed nurses are responsible for these assessments. The facility's policy requires documentation of vital signs, access site condition, and additional instructions, which was not followed, placing the resident at risk for complications.
The facility did not meet the federal regulation of providing at least 80 square feet per resident in multiple resident bedrooms, affecting four rooms. Despite this, residents did not express concerns, and observations showed adequate space for movement and care.
A facility failed to implement its policy for an allegation of financial abuse involving a resident with Alzheimer's Disease. The Business Office Manager reported the abuse, but the Administrator did not conduct a formal investigation or document findings. The Director of Nursing was not informed, resulting in no SBAR form completion or monitoring for emotional distress. This failure placed the resident at risk for further abuse.
A facility failed to report the results of a financial abuse investigation involving a resident with Alzheimer's and hydrocephalus. The resident's son, who was the financial POA, used the resident's Social Security checks for personal expenses instead of medical costs. The BOM reported the abuse, but the ADM did not conduct a formal investigation or document findings, violating the facility's abuse reporting policy.
Inaccurate Fall Risk Assessments Following Multiple Falls
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure accurate fall risk assessments and evaluations for a resident with significant medical and functional impairments. The resident was originally admitted with multiple diagnoses, including metabolic encephalopathy, dehydration, diabetes mellitus, anemia, dementia, hemiplegia and hemiparesis following a stroke, chronic kidney disease, and a history of repeated falls. An MDS dated 3/24/2026 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for toileting hygiene, showering/bathing, and lower body dressing, and required maximal assistance for eating, hygiene, dressing, bed mobility, and transfers. On 4/6/2026, an SBAR form documented that the resident had an unwitnessed fall in the room, sustained a laceration to the back right side of the head, and was transferred to the hospital. A Fall Risk Evaluation completed on the same date instructed staff to evaluate eight clinical condition parameters, including history of falls and gait/balance, and to consider a total score of 10 or greater as high risk requiring immediate prevention protocols and care plan documentation. However, in the history of falls section for the past three months, the evaluation indicated that the resident had no falls, despite the SBAR documenting a fall on that date. In the gait and balance section, the evaluation did not indicate decreased muscular coordination, changes in gait pattern, or gait problems, although it was scored for balance problems while standing, balance problems while walking, and use of assistive devices. On 4/9/2026, another SBAR documented an additional fall, and nursing progress notes indicated the resident was found lying on the left lateral side next to the bed. A Fall Risk Evaluation dated 4/9/2026 again left the items for decreased muscular coordination, change in gait pattern, and gait problems unmarked, while still scoring balance problems and use of assistive devices. During interview and record review, the DON acknowledged completing the Fall Risk Evaluations after the falls occurred, confirmed that the 4/6/2026 fall was not reflected in the history of falls section, and stated that gait and balance items were left blank on 4/6/2026 because the resident had been transferred to the hospital and could not be personally assessed. The DON further stated that for the 4/9/2026 evaluation, information from rehabilitation therapy staff indicated no issues with decreased muscular coordination, change in gait pattern, or gait problems, so those items were left blank. Facility policy required completion of a Fall Risk Assessment upon admission, quarterly, and after each fall, with review by the interdisciplinary team and recommendations for additional approaches to prevent further falls.
Inaccurate Dehydration Risk Assessments for High-Risk Resident
Penalty
Summary
Licensed nurses failed to accurately assess and complete dehydration risk assessments for a resident with multiple complex medical conditions. The resident had diagnoses including metabolic encephalopathy, dehydration, DM, anemia, dementia, hemiplegia/hemiparesis following stroke, chronic kidney disease, and repeated falls, and was documented on the MDS as having severely impaired cognition and requiring extensive to total assistance with ADLs, including eating. On an admission dehydration risk assessment, the nurse marked the oral intake section as 75% to 50% and recorded a total score of 6, indicating moderate dehydration risk. During interview, the RN who completed this assessment stated that the intake percentage was based solely on observation of one meal on the day of admission, without obtaining additional information from hospital records, the resident, or family, and acknowledged that this did not represent the resident’s usual intake and was therefore not accurate. On a subsequent dehydration risk assessment completed at readmission, the oral intake section was marked as 100% to 75%, with a total score of 2, indicating low dehydration risk, despite the resident carrying a diagnosis of dehydration at that time. The RN who completed this assessment stated that the intake range was documented without verification of the resident’s actual intake, that hospital records were not reviewed, family could not provide intake details, and the resident was unable to report intake amounts, so the accuracy of the documented oral intake could not be confirmed. Facility policies on Dehydration Risk Assessment and Hydration Management required that residents be assessed on admission, within the assessment period, and at least quarterly, and that residents identified with potential or actual dehydration be assessed for risk factors with appropriate recommendations documented on the care plan, but the assessments for this resident were not based on accurate or complete information.
Failure to Provide Ordered Liquid Consistency and Proper Puree Food Texture
Penalty
Summary
The facility failed to provide food and liquids in the form ordered for a resident with dysphagia and aspiration precautions. The resident was admitted with diagnoses including dysphagia following a CVA, aphasia, and GERD. The physician ordered a no added salt, pureed diet with nectar/mildly thick liquids. The resident’s care plans identified aspiration risk and included interventions to provide the diet as ordered and to avoid straws when consuming fluids. During lunch in the activity/dining room, the resident was observed drinking coffee that was light brown and thin, water-like in consistency, through a straw. The resident coughed after drinking from the cup. The resident’s meal tray contained other liquids labeled as mildly thickened, and the meal ticket indicated a pureed diet with mildly thickened liquids. Staff interviews confirmed the resident should not have been given thin coffee or a straw, and that the resident’s ordered liquid consistency was mildly thick. The report also documented that the facility failed to prepare puree foods in the proper form for residents on puree diets. On trayline, puree three bean chili was observed being thinned with added liquid, including water, butter, chicken base, and later slurry, and was seen flat on the plate. A puree tossed green salad was observed to be watery and fell off the spoon quickly during the spoon tilt test. The facility’s diet manual stated puree foods must be smooth, hold their shape, and pass IDDSI Level 4 testing requirements, but the observed foods did not meet those standards.
Failure to Protect Confidential Diet Ticket Information
Penalty
Summary
The facility failed to ensure confidential personal information was protected when diet tickets containing protected health information were not shredded before being placed in waste containers. During observation of the dishwashing process, a Dietary Aide was seen sorting food and diet tickets from soiled resident trays into different trash containers and throwing the menu tickets in the trash. In interview, the Dietary Aide stated he separated food from diet tickets and napkins because they go into separate dumpster containers, and stated he throws the diet tickets in the trash dumpster after washing dishes. The Dietary Supervisor stated the facility has different dumpsters outside, including one for organic waste and another for plastic and paper, and that diet tickets were thrown into the dumpster designated for paper and plastic. The Dietary Supervisor also stated the diet ticket contains resident name, menu, diet, diet consistency, room number, food likes and dislikes, and that this information is protected. Review of the facility policy titled Health Information Record dated 8/25/2025 indicated the facility will maintain systems/platforms that are secure, encrypted, and minimize the risk to resident privacy and confidentiality as per HIPPA/HITECH regulations and the Condition of Participation or Conditions of Coverage.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to keep its medication error rate below 5 percent. Surveyors identified 3 medication errors out of 34 total opportunities, resulting in an overall error rate of 8.82% and affecting two residents observed during medication administration. The errors involved topical pain medications for one resident and the timing and administration of metformin for another resident. For one resident with diagnoses including UTI, type 2 DM, and unspecified dementia, the order summary showed diclofenac sodium 1% gel was to be applied to both knees for pain and lidocaine 4% gel was to be applied to the left shoulder and left arm for pain. During observation, an LVN applied diclofenac sodium to the resident's bilateral knees and left shoulder. During interview, the LVN stated she believed diclofenac sodium was ordered for the knees and left shoulder, but after reviewing the orders acknowledged that diclofenac sodium should have been applied to the knees only and lidocaine to the left shoulder. The DON stated the doctor's orders should have been followed and that diclofenac sodium should not have been applied to the shoulder. For another resident with diagnoses including sepsis and DM, the order summary showed metformin ER 500 mg was ordered by mouth twice daily with meals. The administration history showed the medication was scheduled for 7:15 a.m. and 5:15 p.m., but it was administered at 8:44 a.m. During observation, the LVN confirmed metformin was supposed to be given with meals at 7:15 a.m. and stated that giving it late and without a meal could affect how the medication works and alter absorption. The DON stated it was important to provide metformin at the right time and with meals as prescribed because taking it at a different time or without food can affect absorption and cause significant changes in blood sugar levels.
Failure to Follow Standardized Puree Chili Recipe
Penalty
Summary
The facility failed to follow the menu and meet the nutritional needs of residents when the puree 3 bean chili was not prepared according to the standardized recipe. The menu spreadsheet for the winter menu showed that residents on puree/IDDSI Level 4 and puree consistent carbohydrate diets were to receive puree three bean chili, puree tossed green salad, puree cornbread with green chili, margarine with puree bread, pudding, and milk. During trayline observation, staff were seen pouring liquid into the puree three bean chili without measuring it, and a staff member stated a mixture of water, butter, and chicken base had been added. The staff member also stated the puree food was checked every 15 minutes and more liquid was added because it was too thick, and a total of 4 3/4 cups of liquid was added to the chili. During further observation, the puree three bean chili was seen flat on the plate, and more liquid was added after a spoon tilt test. Later, five puree diet trays were observed with puree chili and puree seasoned green beans that were flat and had a thin texture. The Dietary Supervisor stated the puree three bean chili was too thin when served and that slurry was being added to correct the consistency. In interview, the Dietary Supervisor stated cooks kept adding extra thickener and chicken base with butter, that the CCHO diet was not followed, and that residents were not compliant with the diet orders. Review of the facility's food preparation policy and standardized recipes showed approved recipes were to be used, and the recipe for 3 bean chili did not include chicken base or butter; the pureed IDDSI Level 4 recipe listed only approved thickening ingredients.
Food Texture and Temperature Deficiencies During Meal Service
Penalty
Summary
The facility failed to prepare puree and regular diet foods so they remained palatable, attractive, and at safe serving temperatures. During trayline and test tray observations, puree three-bean chili was repeatedly observed as flat on the plate and too thin, with staff adding water, butter, chicken base, thickener, and slurry without measuring the additions. The Dietary Supervisor stated the puree chili was too thin when served and that staff were supposed to follow the standardized recipe rather than add liquid and thickener without measuring it. On the same meal service, the puree tossed green salad was observed at 61 F and the puree Jello at 51 F. On the regular tray, tossed green salad was observed at 61 F and citrus chiffon delight at 55 F. During the test tray, the Dietary Supervisor stated the puree tossed green salad was too watery and too thin. The facility’s IDDSI Level 4 guidance stated pureed foods must be smooth, hold their shape, and not weep, and the finished items must pass appearance, fork drip, and spoon tilt testing. Resident 42 had dysphagia, type 2 diabetes, and essential hypertension, and required set-up and clean-up assistance with eating. In interview, Resident 42 stated eggs and toast were cold at breakfast and that lunch and dinner also came cold at times. The Dietary Supervisor stated cold food should stay at 41 F or below before serving and that unacceptable temperatures could affect whether residents ate the food, with decreased intake and weight loss. The facility’s policies stated food and drink should be palatable, attractive, and at safe and appetizing temperatures and prepared by methods that conserve nutritive value, flavor, and appearance.
Therapeutic Diet Order Mismatch for a Resident
Penalty
Summary
The facility failed to ensure Resident 20 received food in the appropriate nutritive content as prescribed by the physician. Resident 20 was admitted and later readmitted with diagnoses including moderate protein-calorie malnutrition, type 2 diabetes, and essential hypertension. The MDS dated 11/15/2025 indicated the resident usually understood others and rarely or never made self-understood, and required supervision and touching assistance when eating. The physician order summary dated 11/18/2025 showed the resident was ordered a NAS, CCHO, soft and bite sized, thin liquid diet. During trayline observation on 12/29/2025 at 12:15 p.m., Resident 20's diet ticket indicated CCHO, NAS, soft bite sized, small portion, and an extra plate of chopped quesadilla had been prepared for the resident. The Dietary Supervisor stated small portion diets receive less food than regular portions and are used for residents transitioning from tube feeding or needing to lose weight. The supervisor also stated that if a resident on a small portion diet got additional food on the plate, it could result in unplanned weight gain. On 12/30/2025, the physician diet order was reviewed and showed Resident 20 was ordered NAS, CCHO, soft bite sized, regular thin liquid diet. The Registered Dietitian stated diet orders are entered by nursing and printed on the menu ticket each meal, and that the diet order must match the menu ticket to avoid serving the wrong food and to ensure therapeutic diets are provided as ordered. The RD stated she changed Resident 20's meal ticket to match the diet order because the right portion was regular portion. Facility policies stated each resident will receive food in the appropriate form and nutritive content as prescribed by the physician, and that diet orders and tray cards are to be adjusted as prescribed.
Unsafe Food Storage and Preparation Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen. During observations, multiple reach-in refrigerators and freezers had dirt, food debris, dust buildup, and spills on shelves and gaskets. The Dietary Supervisor stated the refrigerators were cleaned on a schedule, but also acknowledged that food debris in the refrigerators was not okay because of cross-contamination. The toaster also contained breadcrumbs and a burnt piece of bread, and the Dietary Supervisor stated it should be cleaned after each use and that the toaster’s condition could allow contamination. The milk stored in cups inside Reach-in refrigerator 2 was observed at 44 F, and later at 43 F and 44 F. The Dietary Supervisor stated the milk had been poured earlier that morning and would not be acceptable to serve because it was in the danger zone and had not cooled to 40 F or below within 2 hours. Reach-in refrigerator 2 also had a torn gasket, and the Dietary Supervisor stated the gasket needed replacement to maintain proper refrigerator temperature. The reach-in refrigerator by the trayline had no internal thermometer, although the Dietary Supervisor stated thermometers should be present in all refrigerators to verify temperature maintenance. Additional observations showed dirt, food, and dust debris on the dry storage floor under the shelves, four dented cans stored with non-dented cans, chopping boards stored alongside red and green buckets containing sanitizer without a physical barrier, and 50 of 80 resident trays for dinner service that had no glaze and were cracked and chipped. The Dietary Supervisor stated dented cans should be separated, the chemical buckets should not be near clean chopping boards because of cross-contamination, and chipped trays needed replacement because they were not smooth and could harbor bacteria. The report stated these failures had the potential to result in harmful bacterial growth and cross contamination in medically compromised residents who received food and ice from the kitchen.
Improper Dumpster Closure and Waste Disposal
Penalty
Summary
Improper disposal of garbage and refuse was identified in the facility’s dumpster area when two black dumpsters were observed not completely closed while not actively being used. During the same observation, a bag of trash, soiled gloves, a mask, plastic, and paper were seen on the floor and surrounding area of the dumpsters. The dumpster designated for food waste was also observed with liquid drippings on its base. The Dietary Supervisor stated that trash must be kept inside the dumpster, trash bags cannot be left on the floor, and dumpster lids should always be closed. The supervisor also stated the dumpster surroundings must be kept clean and free of trash for infection control and to avoid animals and pests getting into the trash, and stated it was not acceptable that the lids were open, trash was around the area, and fluid was leaking from the food dumpster. Review of the facility policy and Food Code 2022 showed requirements for outside receptacles to have tight-fitting lids or covers and for proper cleaning and storage of garbage and refuse.
Expired Lancets and Improper Insulin Pen Preparation
Penalty
Summary
An unopened box of expired ACCU-CHEK Softclix lancets was found on a shelf in the medication storage room during a concurrent observation and interview with RN 1. The box had an expiration date that had passed, and RN 1 stated the lancets needed to be disposed of because they could cause infection if not used before the expiration date. The DON later stated the expired box could cause infection because there is no way of verifying if the lancets are still sterile and safe to use. The facility’s insert for the lancets stated that if the use-by date has expired, the lancet can be unsterile and that only lancets within the use-by date should be inserted. Resident 21 had diagnoses including UTI, type 2 DM, and unspecified dementia, and the MDS indicated moderately impaired cognition and need for moderate to substantial assistance with most ADLs. The resident’s care plan included infection/universal precautions while administering skin punctures, and the order summary showed Lantus 9 units subcutaneously twice daily. During a medication administration observation with LVN 3, the LVN attached a needle to the resident’s Lantus SoloStar pen without first scrubbing the pen tip with alcohol. LVN 3 stated she cleans insulin vials with alcohol before drawing up insulin but did not clean the insulin pen, and stated she should have cleaned the pen tip first because germs could get to the patient and cause an infection. The DON stated insulin pen tips should be wiped with alcohol before putting on the needle, and the manufacturer’s instructions indicated to wipe the pen tip with an alcohol swab before screwing on a new needle.
Pest Control Failure in Residents' Refrigerator
Penalty
Summary
The facility failed to maintain sanitary conditions in the food services department when a dead cockroach was observed inside the residents' refrigerator in the staff break room. During a concurrent observation and interview, the Dietary Supervisor confirmed that the brown insect appeared to be a dead cockroach, and resident food was stored in the refrigerator at the time. The refrigerator's vegetable bin was difficult to remove because a bench chair and another refrigerator were blocking the door from fully opening. During a concurrent observation and interview, the Housekeeping Supervisor stated she had cleaned the refrigerator that morning and reported that there were dead cockroaches in the refrigerator, adding that she could not clean it properly because the door would not completely open. She stated it was not acceptable to have dead cockroaches in the residents' refrigerator because resident food was stored there. The Infection Prevention Nurse stated that pests in the refrigerator could lead to infection spread to residents. Record review showed the facility had a pest control policy and recent pest control reports documenting German roach activity in the employee break room and high activity of fungus gnats in the breakroom area.
Failure to Knock and Ask Permission Before Entering Resident Room
Penalty
Summary
The facility failed to ensure that an LVN knocked on a resident’s door and requested permission before entering the room for Resident 114. Resident 114 was admitted on 12/17/2025 with diagnoses including muscle weakness and type 2 diabetes mellitus. The MDS dated 12/23/2025 indicated the resident’s cognitive skills for daily decision making were intact and that the resident required assistance with activities of daily living. During a concurrent observation and interview on 12/29/2025 at 9:51 a.m., LVN 5 wheeled the medication cart outside the resident’s room and entered without knocking or asking permission. LVN 5 then exited the room, placed a blood pressure machine on the medication cart, re-entered the room without knocking or asking permission, exited again to pour medications into a medicine cup, and entered the room a third time with the medications without knocking or asking permission. When asked about the practice, LVN 5 stated he should have knocked, introduced himself, and asked permission before entering, and said knocking helps prevent the resident from being startled and shows respect for personal space. The facility’s policy on Resident’s Right to Dignity and Privacy stated that staff will knock and request permission before entering a resident’s room.
Care plan did not specify transfer assistance level
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for one resident with impaired physical mobility and self-care deficit. The care plan titled, "Impaired Physical Mobility and Self-Care Deficit," dated 1/08/2025, included an intervention to assist with ADLs as necessary and to provide assistance during transfers in and out of bed, wheelchair, toilet, and vice versa using an appropriate device as needed, but it did not specify the required number of staff needed to safely transfer the resident from the bed to the wheelchair and from the wheelchair back to the bed. Resident 11 was initially admitted on 6/21/2024 and readmitted on 4/28/2025 with diagnoses including muscle weakness and presence of artificial knee joint. The MDS dated 9/25/2025 indicated the resident's cognitive skills for daily decision making were intact, that the resident was dependent on assistance of two or more helpers for ADLs, and totally dependent on staff for chair/bed-to-chair transfer. During interview and record review, the MDS Nurse Assistant stated the care plan did not specify the required number of staff for safe transfers and stated the resident required two-person assistance based on the MDS assessment. A CNA also stated that the level of assistance needed for transfers is indicated in the resident's care plan.
Missing Communication Board for Non-English-Speaking Resident
Penalty
Summary
The facility failed to implement its policy and procedure titled Residents Who Present with Communication Barriers by not providing a communication device or board in the preferred language for Resident 55. Resident 55 was admitted with diagnoses including muscle weakness and dysphagia, had a preferred language that was not English, required an interpreter to communicate with health care staff, and had severely impaired cognition. The Minimum Data Set also showed the resident required substantial to maximal assistance with toileting hygiene, showering, lower body dressing, and putting on and taking off footwear. During a concurrent observation and interview, no communication board was seen at Resident 55's bedside. The IPN stated that social services was responsible for assisting residents with communication needs when the primary language was not English. The SSD stated that her department was responsible for assessing the communication needs of residents who were non-English speakers and that communication boards were very important for residents with a language barrier to communicate their needs. The resident's care plan identified impaired communication secondary to language barrier and included use of a translator, gestures, and a communication board daily, while the facility policy stated that communication boards would be provided at no charge to non-English speakers or aphasic residents so they could use pictograms to communicate needs and desires.
Missed Ordered Hgb and Hct Monitoring for Resident With Anemia
Penalty
Summary
The facility failed to obtain hemoglobin (Hgb) and hematocrit (Hct) laboratory tests as ordered for one resident with anemia. The resident was admitted and later re-admitted to the facility with a diagnosis of anemia, and the MDS showed severe cognitive impairment with substantial to maximal assistance needed for eating, oral hygiene, and upper body dressing. The physician ordered Hgb and Hct levels to be drawn every two weeks on Fridays, and the resident also had an order for epoetin alfa-EPBX for anemia with instructions to hold the dose if Hgb was greater than 11 g/dL. Record review showed Hgb and Hct labs were drawn on 10/31/2025, 11/14/2025, 11/28/2025, and 12/05/2025, but there was no documentation that the labs were drawn on 12/12/2025 or 12/26/2025. The anemia care plan, initiated on 10/25/2025, included a goal for Hgb and Hct to be within normal limits when checked and an intervention to draw the labs every two weeks. During interview, the MDS nurse, ADON, and DON all confirmed the missing labs should have been drawn and stated the physician should have been contacted to clarify whether the tests were still needed.
Medications Left Unattended at Resident Bedside
Penalty
Summary
The facility failed to maintain an environment free from potential accident hazards when medications for one resident were left unattended at the bedside during medication administration. The resident had diagnoses including UTI, type 2 DM, and unspecified dementia, and the MDS indicated moderately impaired cognition and a need for moderate to substantial assistance with most ADLs. The resident's medication regimen included multiple scheduled medications, including insulin, blood pressure medications, a blood thinner, and medications for pain, anxiety, dementia, and bowel management. During observation on 12/30/2025, an LVN brought the resident's medications into the room and placed them on the bedside table, then left them unattended and out of eyesight while returning to the medication cart to retrieve the resident's Colace capsule. The LVN stated the medications should not have been left unattended because the resident could knock them over, take some without the nurse knowing exactly what was taken, or someone else could come in and take them. The DON stated the resident was not able to safely self-administer medications and that the best practice is for a licensed nurse not to leave medications out of eyesight due to safety issues.
Looped Foley Tubing Prevented Free Urine Flow
Penalty
Summary
The facility failed to ensure appropriate catheter care and services to prevent urinary tract infections for a resident with an indwelling Foley catheter. Resident 79 was admitted and later readmitted with diagnoses including unstageable pressure injuries to the sacral region and left heel, Parkinson's disease, and diabetes mellitus. The resident's MDS indicated moderately impaired cognition and use of an indwelling urinary catheter. The care plan identified the Foley catheter as being used for wound management and included interventions to monitor tubing patency and keep it below the level of the bladder, with a goal of being free from signs and symptoms of UTI. During observation, the resident's urinary catheter tubing was seen looped, which prevented urine from flowing freely into the collection bag. CNA 1 stated the tubing should not be looped because urine building up in the tubing could cause infection. LVN 1 also observed the looped tubing, stated it should not be looped because urine could back up into the bladder and cause a UTI, and then repositioned the tubing to allow drainage. RN 1 later stated indwelling catheter tubing should never be looped because it could cause urine to back up and cause infection. The facility's Foley catheter insert and policy both stated the drainage system should allow unimpeded or unrestricted urine flow.
Missing Post-Dialysis Weights and Vital Signs
Penalty
Summary
The facility failed to ensure safe, appropriate dialysis services for a resident who required hemodialysis. Resident 34 was admitted and later re-admitted with diagnoses including end stage renal failure and dependence on dialysis. The resident’s MDS dated 10/11/2025 indicated the resident was cognitively intact, required setup assistance with eating and personal hygiene, and received dialysis treatments. Physician’s orders dated 12/05/2025 directed dialysis treatments on Tuesdays, Thursdays, and Saturdays at a dialysis facility. Review of Resident 34’s Dialysis Communication Records showed blank spaces for post-dialysis weights on 9/04/2025, 10/14/2025, 10/16/2025, 10/25/2025, 11/06/2025, 11/18/2025, 12/11/2025, and 12/18/2025. The records also showed blank spaces for post-dialysis vital signs on 10/14/2025, 10/16/2025, 10/25/2025, 12/11/2025, and 12/18/2025. During interview and record review, the MDSN and DON confirmed the missing post-dialysis weights and vital signs and confirmed licensed nurses had not contacted the dialysis center to obtain the missing information. The DON stated the facility’s process was for licensed nurses to check the dialysis communication record and call the dialysis center if entries were missing. The facility policy titled Dialysis Care, last reviewed 8/28/2025, indicated documentation should include pre-dialysis and post-dialysis weights and vital signs for each dialysis treatment.
Missing Antibiotic Surveillance Before Macrobid Was Started
Penalty
Summary
The facility failed to implement its antibiotic stewardship program when it did not conduct and complete an infection surveillance form before Macrobid was started for Resident 15. Resident 15 was admitted on 12/4/2025 with diagnoses including sepsis and UTI, and the MDS dated 12/10/2025 indicated intact cognition for daily decision-making and maximal assistance from staff for ADLs. A physician order dated 12/23/2025 prescribed Macrobid 100 mg by mouth twice a day for UTI for one week. During a concurrent interview and record review on 12/31/2025, the IPN reviewed the resident’s medical record and the facility’s surveillance data collection form and found missing antibiotic surveillance for the Macrobid order. The IPN validated the missing surveillance and stated that antibiotic surveillance should be completed for all antibiotic orders using the facility’s surveillance data collection form, with physician notification and documentation if criteria were not met. The DON also stated that the facility should monitor all antibiotics for appropriate use and use the surveillance form and documentation when criteria were not met. The facility policy titled Infection Control-Antibiotic Stewardship stated that the facility establishes antibiotic stewardship to promote appropriate antibiotic use and a system of monitoring to improve resident outcomes and reduce antibiotic resistance.
Insufficient Square Footage in Multiple Resident Rooms
Penalty
Summary
The facility failed to provide at least 80 square feet per resident in multiple resident bedrooms for four of 38 rooms: Rooms 1, 3, 9, and 11. Each of these rooms had two beds, and a review of the facility’s Request for Room Size Waiver letter dated 11/1/2025 confirmed that these rooms did not meet the federal square footage requirement per resident. A review of the Client Accommodations Analysis dated 11/7/2025 showed the following room sizes and per-resident space: Room 1, 146 square feet/73 per resident; Room 3, 155 square feet/77.5 per resident; Room 9, 143 square feet/71.5 per resident; and Room 11, 151 square feet/75.5 per resident. During the resident council meeting on 12/29/2025, no concerns were raised about room size, and during observations of Rooms 1, 3, 9, and 11 on 12/29/2025, 12/30/2025, 12/31/2025, and 1/2/2026, the rooms were not occupied by more than three residents and were observed to provide enough space for care, dignity, privacy, and free movement.
Failure to Honor Resident's Request Regarding Caregiver Assignment
Penalty
Summary
The facility failed to honor a resident's explicit request to not have a specific Certified Nursing Assistant (CNA) provide care or be present in her room upon readmission. The resident, who had diagnoses including a left femur fracture, osteoporosis, rheumatoid arthritis, morbid obesity, and generalized anxiety disorder, had intact cognition and decision-making capacity. Upon readmission, the resident communicated her request to the case manager, who acknowledged it and assured her that the CNA would not be assigned to her care or be present. Despite this, the CNA was initially assigned to the resident's room and, after being informed of the restriction, was reassigned to the roommate but still entered the room and interacted with the resident, including responding to a call light and providing ice water. Interviews with facility staff, including the Assistant Director of Staff Development (ADSD), the case manager, and the Director of Nursing (DON), confirmed that the resident's request was known and that the CNA should not have entered the room or interacted with the resident. The facility's policy on dignity and privacy requires that residents be treated with respect and that their rights and preferences be honored. The DON acknowledged that the CNA's presence in the room had the potential to cause the resident increased anxiety, fear, and discomfort, which was contrary to the facility's stated policy and the resident's expressed wishes.
Late Transfer/Discharge Notices
Penalty
Summary
The facility failed to ensure that Notice of Proposed Transfer and Discharge documents were provided to residents and/or their representatives at least 30 days before discharge or as soon as practicable for three sampled residents. The deficiency involved Resident 1, Resident 2, and Resident 3, all of whom had documentation showing they had capacity to make decisions and were being discharged from the facility to another setting after short-term stays or rehabilitation services. Resident 1 was admitted with chronic venous hypertension with ulcer of the left lower extremity and MRSA infection. The record showed a social work progress note dated 7/31/2025 indicating the resident agreed to be discharged on 8/2/2025, and a physician order dated 8/1/2025 directing discharge to a board and care with home health. The Notice of Transfer/Discharge was dated 8/2/2025 and indicated it was given to Resident 1 on 8/2/2025. During interview, the ADON stated that once the facility is aware of a resident's discharge, licensed nurses and social services should give the notice to the resident and/or responsible party, and stated Resident 1 should have been given the notice when social services became aware of the upcoming discharge. Resident 2 was readmitted with UTI and cellulitis of both lower limbs, and the care plan indicated a plan to return to an ALF after rehabilitation. A physician order dated 8/1/2025 directed discharge back to the ALF on 8/2/2025, and the Notice of Proposed Transfer/Discharge was dated 8/2/2025 and documented as given that same day. The CM stated the resident was admitted for a short-term rehab stay and that the notice should have been given on 7/30/2025 when the NOMNC was issued. Resident 3 was admitted with pneumonia, had a care plan to return to an ALF after rehabilitation, and had a physician order dated 7/28/2025 directing discharge to the ALF that same day. The Notice of Proposed Transfer/Discharge was dated and documented as given on 7/28/2025, and the CM stated it should have been given on 7/25/2025 when the NOMNC was issued so the resident and family would have time to appeal.
Failure to Ensure Resident-Centered and Safe Transfer/Discharge
Penalty
Summary
The facility failed to ensure that the transfer or discharge process met the resident's needs and preferences, and did not adequately prepare the resident for a safe transfer or discharge. The report identifies that the necessary steps to assess and address the resident's individual requirements and preferences during the transfer or discharge process were not completed, resulting in a deficiency related to resident-centered care and safe transition planning.
Incorrect Low Air Loss Mattress Setting for Resident
Penalty
Summary
A resident with multiple medical conditions, including paraplegia, morbid obesity, type 2 diabetes, and a history of poor wound healing, was admitted to the facility and required a low air loss mattress for skin management as per physician orders. Upon review, it was found that the mattress was set for a weight range of 600 to 1000 pounds, while the resident's actual weight was 246 pounds. This incorrect setting was confirmed by both a Licensed Vocational Nurse and the Director of Nursing, who acknowledged that the mattress should have been set according to the resident's current weight. The facility's policy on the prevention of pressure injuries specifies the use of specialized mattresses as an intervention to prevent skin breakdown. However, the failure to set the mattress correctly for the resident's weight constituted a lapse in following this policy. The deficiency was identified through observation, interview, and record review, and it was confirmed that the mattress setting was not appropriate for the resident's needs at the time of the survey.
Failure to Accurately Document Narcotic Administration on MAR
Penalty
Summary
The facility failed to maintain accurate clinical records for one resident by not properly documenting the administration of Oxycodone Hydrochloride on the Medication Administration Record (MAR). Specifically, the Controlled Drug Record showed that Oxycodone was signed out and administered by two different Licensed Vocational Nurses on two occasions, but these administrations were not recorded on the MAR. The Director of Nursing confirmed that medication administration should be documented on the MAR immediately after the medication is given and that the MAR entries should align with the Controlled Drug Record. The resident involved had multiple diagnoses, including a right femur fracture, type 2 diabetes, end stage renal disease, and muscle weakness, and was assessed as having intact cognition and decision-making capacity. Facility policy required that all administered medications be documented on the MAR by the person administering them, and that the MAR be reviewed at the end of each medication pass to ensure accuracy. The failure to document the administration of a controlled substance as required by policy and professional standards constituted the deficiency.
Failure to Assist Residents with Mobility and Getting Out of Bed
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs), specifically mobility and getting out of bed, for two residents. One resident, who had diagnoses including traumatic subdural hemorrhage, pneumonia, and epilepsy, was assessed as cognitively moderately impaired and fully dependent on staff for mobility and other ADLs. Observations throughout the day showed this resident remained in bed with the call light within reach, and the gastrostomy tube feeding was alternately on and off. The assigned CNA admitted not offering to get the resident out of bed, citing forgetfulness and the presence of a g-tube, despite acknowledging the importance of mobility for preventing bed sores and maintaining function. The Director of Staff Development confirmed that getting residents out of bed is part of morning care and does not require a physician's order, but stated the facility preferred to keep the resident in bed during feeding times. Another resident, with diagnoses including pneumonia, COPD, and low back pain, was cognitively intact and required partial or moderate assistance for mobility. Observations showed this resident remained in bed throughout the morning and early afternoon, with staff assisting only with lunch. The resident reported that only the physical therapist, not nursing staff, assisted her with getting out of bed, and that nursing staff had not offered to help her transfer to a chair. The Director of Staff Development stated that CNAs are expected to offer and assist all residents with getting out of bed and to report refusals to the charge nurse, emphasizing that this is a standard part of daily responsibilities. A review of facility policies confirmed that staff are required to monitor, assist with, and provide ADLs, including transferring from bed to chair, to ensure residents attain or maintain their highest practicable well-being. Despite these policies, the facility did not ensure that the two residents were offered or provided necessary assistance with mobility and getting out of bed, resulting in prolonged periods spent in bed and potential compromise of dignity, preferences, and functional well-being.
Failure to Provide Oral Care and Timely Reporting for Dependent Resident
Penalty
Summary
The facility failed to provide oral care for a resident who was dependent on staff for all activities of daily living, including oral hygiene. The resident had a history of traumatic subdural hemorrhage, pneumonia, and epilepsy, and was assessed as having moderately impaired cognition and being fully dependent on staff for personal care. The resident's care plan specifically required staff to assist with personal hygiene and provide oral care. On the day in question, the resident was observed in bed with dry, cracked lips. A CNA assigned to the resident that day initially stated that oral care had been provided, but upon further questioning, admitted that oral care was not given. The CNA described the resident's tongue as unclean, with a thick white and yellow coating, and stated that this condition had persisted for a long time. The CNA also admitted to not reporting the condition to the nurse until prompted by the surveyor and did not provide oral care because the resident began to scream. Interviews with facility staff, including the LVN, Assistant Director of Nursing, and Director of Staff Development, confirmed that oral care was not provided as required and that the condition of the resident's tongue was not reported in a timely manner. Review of facility policies indicated that oral care should be provided at least once per shift and that staff are responsible for monitoring and assisting with activities of daily living, including mouth care, and reporting any changes in resident condition.
Failure to Timely Reassess Bowel and Bladder Function for Two Residents
Penalty
Summary
The facility failed to implement an effective bowel and bladder retraining program for two residents by not ensuring timely reassessment of their bowel and bladder status. For one resident, the initial bowel and bladder assessment indicated functional incontinence and occasional episodes of both bladder and bowel incontinence. The facility's protocol required a follow-up evaluation 72 hours after admission, but this evaluation was not completed until ten days later. The delay was acknowledged by the registered nurse, who confirmed that the late assessment prevented the facility from providing appropriate interventions based on the resident's needs. For another resident, the admission record showed a history of traumatic subdural hemorrhage, pneumonia, and epilepsy, with the resident being dependent on staff for most activities of daily living. The initial bowel and bladder assessment indicated the resident was always continent of bladder but always incontinent of bowel. However, the required 72-hour follow-up evaluation was left blank and not completed. The registered nurse confirmed that the assessment was missing and emphasized the importance of timely completion to ensure proper care planning and interventions. The facility's policy on bowel and bladder retraining, last reviewed in August 2024, specifies that the purpose of the program is to assist incontinent residents in regaining control over excretory functions. The failure to complete timely reassessments as outlined in the policy resulted in missed opportunities to accurately assess residents as candidates for retraining programs and to implement appropriate care interventions.
Failure to Inform Residents of Room Cleaning Schedule
Penalty
Summary
The facility failed to inform two residents, Resident 2 and Resident 3, in advance about the deep cleaning of their rooms, which is a violation of their rights to a dignified existence and self-determination. Resident 2, who was admitted with right knee and ankle fractures and hypothyroidism, was informed on the morning of the cleaning and was not given details about the duration or reason for the cleaning. Resident 2 expressed a desire to be informed at least one or two days in advance to prepare for the inconvenience. Similarly, Resident 3, who was admitted with Guillain-Barre syndrome, was also informed on the day of the cleaning and was not given adequate time to arrange personal belongings. Resident 3 expressed a preference for being informed three days in advance. Both residents were left waiting outside their rooms without clear communication about when they could return. The facility's housekeeping department had a monthly cleaning schedule, but it was not communicated to the nursing staff or residents in advance. The Director of Nursing acknowledged the need for a better system to inform residents about cleaning schedules. The facility's policy on resident rights emphasizes the importance of providing residents with information material to their decisions, which was not adhered to in this case.
Resident-to-Resident Physical Abuse Incident
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, resulting in a deficiency. On January 8, 2025, Resident 2 physically assaulted Resident 1 by punching him in the face multiple times. This incident occurred while Resident 1 was trying to sleep, leading to injuries including a left periorbital discoloration, an abrasion on the left eyebrow, and skin tears on the left forearm and dorsal hand. These injuries required first aid and daily wound treatments. Resident 1 was admitted to the facility on December 5, 2024, with diagnoses including cauda equina syndrome, osteomyelitis of the left ankle and foot, and cellulitis of the left lower limb. The Minimum Data Set (MDS) indicated that Resident 1 had intact cognition. In contrast, Resident 2, admitted on December 12, 2024, had diagnoses including chronic obstructive pulmonary disease, unspecified dementia, opioid dependence, and nicotine dependence, with the MDS indicating severely impaired cognition. On the day of the incident, Resident 2 reported hearing voices instructing him to punch his roommate, Resident 1, and was noted to be agitated and experiencing auditory hallucinations. The facility's policy on abuse reporting and prevention mandates the protection of residents' rights and the prevention of resident-to-resident altercations. However, the facility failed to prevent the altercation between Resident 1 and Resident 2, resulting in physical abuse. The incident was confirmed through interviews with staff and residents, and the facility's investigative report corroborated the occurrence of the physical assault. Despite the facility's policy, the actions and inactions leading to this deficiency highlight a failure to adequately protect Resident 1 from harm.
Failure to Monitor and Document Surgical Wound Care
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice by not following up with the physician to obtain an order to continue monitoring the resident's surgical wound. The resident, who was admitted with a left hip fracture and dementia, had an order to monitor the surgical wound for signs of infection for 14 days. However, after the 14-day period, the licensed nurses stopped documenting the monitoring of the wound, and no follow-up order was obtained from the physician. During an interview, the Treatment Nurse admitted to monitoring the wound but not documenting it, which is considered as not having been done according to the Assistant Director of Nursing. The resident's surgical wound was partially covered with a non-removable dressing and had visible staples, which were not observed the previous day. The facility's policy requires documentation of wound care, but this was not adhered to, leading to a deficiency in the care provided to the resident.
Inaccurate Documentation of Medication Administration
Penalty
Summary
The facility failed to accurately document the administration of a physician-ordered eye drop medication in the Medication Administration Record (MAR) for a resident diagnosed with glaucoma. The resident was admitted with a physician's order to receive Latanoprost eye drops at bedtime. However, the MAR inaccurately indicated that the medication was administered on the day of admission, despite the medication not being delivered to the facility until the following day. This discrepancy was confirmed during interviews with the resident, the Assistant Director of Nursing (ADON), and the Licensed Vocational Nurse (LVN) responsible for the documentation. The resident, who had intact cognitive skills and required varying levels of assistance with daily activities, reported not receiving the eye drops on the evening of admission. The LVN admitted to incorrectly documenting the administration of the medication in the MAR, acknowledging the importance of accurate documentation to ensure continuity of care. The Director of Nursing (DON) stated that the licensed nurses should have notified the physician about the unavailability of the medication and documented the situation accurately in the MAR. The facility's policy on medication administration emphasizes the need for accurate documentation and appropriate actions when medications are not administered as scheduled.
Infection Control Lapses in Hand Hygiene
Penalty
Summary
The facility failed to implement proper infection control practices, as evidenced by two separate incidents involving staff members. In the first incident, a Licensed Vocational Nurse (LVN) did not perform hand hygiene after checking a resident's blood pressure with bare hands. The resident, who was admitted with diagnoses including glaucoma, required various levels of assistance for daily activities. The LVN admitted to forgetting to wear gloves and perform hand hygiene, acknowledging the risk of cross-contamination. In the second incident, a Treatment Nurse (TN) failed to perform hand hygiene between glove changes while providing wound treatment to another resident. This resident, who had been readmitted with lymphedema, required maximum assistance with dressing and transfer. The TN initially performed hand hygiene and wore gloves but neglected to do so between glove changes during the treatment process. The Infection Control Preventionist confirmed that hand hygiene should be performed before and after wearing gloves and between glove changes to prevent cross-contamination. The facility's policy on infection control and hand hygiene supports these practices.
Incorrect LALM Settings for Residents
Penalty
Summary
The facility failed to ensure that the low air loss mattresses (LALM) for three residents were set at the correct settings, as per physician orders and the LALM operator's manual. Resident 88, who was admitted with multiple fractures and diabetes, had a care plan indicating high risk for skin breakdown and required a LALM set to their weight of approximately 140 lbs. However, during an observation, the LALM was set to 210 lbs, which was not in accordance with the physician's order or the manual's guidelines. Similarly, Resident 11, admitted with a fracture and requiring maximal assistance for activities of daily living, had a physician's order for a LALM for wound management. Despite weighing 132 lbs, the LALM was observed to be set to firm, or greater than 350 lbs. This setting was inconsistent with the facility's practice of setting the LALM according to the resident's weight to prevent wound development. Resident 196, admitted with osteomyelitis and stage III pressure ulcers, also had a physician's order for a LALM. The mattress was observed to be set at 280 lbs, while the resident's weight was 133 lbs. The Assistant Director of Nursing confirmed that the LALM should be set according to the resident's weight to effectively manage and prevent wounds. The facility's policy and procedure for wound care emphasized the importance of following guidelines to promote healing, which was not adhered to in these cases.
Improper Labeling of Leftover Food Brought by Families
Penalty
Summary
The facility failed to ensure that leftover food brought in by residents' families and visitors was properly labeled with a resident identifier and use-by date. This deficiency was observed in the cases of three residents. During a kitchen observation, various food containers were found in the residents' refrigerator without proper labeling. A red container belonging to one resident had no use-by date, an orange container with food items had no resident name or use-by date, a plastic container belonging to another resident had no use-by date, and a clear plastic container belonging to a third resident also lacked a use-by date. The Dietary Manager confirmed that leftover food from outside should be labeled with a resident identifier and dated to ensure it is discarded by the use-by date. The facility's policy on food brought from outside sources requires that perishable food be stored properly and labeled with the date opened, to be disposed of within two days. The failure to adhere to these procedures had the potential to result in foodborne illness for the residents.
Infection Control Deficiencies in PPE Use, Hand Hygiene, and Labeling
Penalty
Summary
The facility failed to ensure that a Licensed Vocational Nurse (LVN) donned a gown before administering medications via a gastrostomy tube to a resident on enhanced barrier precautions (EBP). The resident, who was admitted with diagnoses including encephalopathy and gastrostomy status, had severely impaired cognition and required maximal assistance for most activities of daily living. During an observation, the LVN was seen administering medications without wearing a gown, which was confirmed by the LVN in an interview. The Infection Preventionist (IP) stated that proper personal protective equipment (PPE) is necessary to prevent the spread of infection, especially for residents with indwelling medical devices. The facility also failed to ensure that a Certified Nursing Assistant (CNA) performed hand hygiene after picking up a dirty towel from the floor and before assisting a resident with lunch. The resident had intact cognition and required moderate assistance for most activities of daily living. During an observation, the CNA was seen picking up a dirty towel and then assisting the resident with their lunch tray without performing hand hygiene. The CNA confirmed this lapse in an interview, and the IP emphasized the importance of hand hygiene to prevent infection spread. Additionally, the facility did not label a urinal with a resident's name, which is required to prevent cross-contamination. The resident, who had severely impaired cognition and was dependent on assistance for personal care, was observed with unlabeled urinals in their room. The Restorative Nurse Assistant (RNA) and the Assistant Director of Nursing (ADON) confirmed that urinals should be labeled according to facility policy to prevent infection spread.
Failure to Provide Accessible Call Lights for Residents
Penalty
Summary
The facility failed to ensure that Resident 16's call light was within reach while the resident was in bed. Resident 16, who was admitted with diagnoses including chronic obstructive pulmonary disease, dysphagia following cerebral infarction, and hypertension, required substantial assistance with activities of daily living. During an observation, it was noted that the call light was hanging behind the bed and out of reach, which the resident confirmed they were unaware of its location. Both a Certified Nursing Assistant and the Assistant Director of Nursing acknowledged that the call light should always be within reach to prevent delays in care. The facility also failed to provide an adaptive call light for Resident 28, who was readmitted with conditions such as osteomyelitis of the vertebra, type 2 diabetes mellitus with diabetic neuropathy, and congestive heart failure. Resident 28 had impairments in both upper extremities, making it impossible to use the standard push-button call light provided. During observations, it was confirmed by both the Treatment Nurse and a Registered Nurse that Resident 28 was unable to press the call light button due to contracted wrists and hands, necessitating an adaptive call light to prevent delays in care. The facility's policy on call lights, last reviewed in August 2024, mandates that call lights be accessible to residents in various locations, including in bed, and that residents should be able to demonstrate how to use them. The failure to adhere to this policy for both residents resulted in the potential for delayed care, as neither resident could effectively signal for assistance when needed.
Failure to Inform Resident of Advance Directive Rights
Penalty
Summary
The facility failed to ensure that an advance directive was discussed and written information was provided to a resident, identified as Resident 6, or their responsible parties. This deficiency was identified during a review of Resident 6's admission records and Minimum Data Set (MDS), which indicated that the resident had the ability to make self-understood decisions and understand others. Despite this, the facility did not have a signed Patient Self-Determination Act of 1990 form for Resident 6, which is meant to inform residents of their right to formulate an advance directive. The Assistant Director of Nursing (ADON) confirmed that the absence of a signature on the form indicated that Resident 6 was not informed of their right to formulate an advance directive. This oversight violated the resident's right to be fully informed of their healthcare options and could potentially lead to conflicts with their healthcare wishes. The facility's policy, last reviewed in August 2024, mandates that all residents and their representatives be presented with written information about their rights to accept or refuse medical treatment and to formulate an advance directive upon admission.
Failure to Maintain Safe Room Temperature for Resident
Penalty
Summary
The facility failed to maintain a safe and comfortable temperature level for a resident, identified as Resident 30, which had the potential to result in loss of body heat and risk of hypothermia. Resident 30 was initially admitted on February 22, 2024, and readmitted on August 30, 2024, with diagnoses including acute embolism and thrombosis of deep veins of the right lower extremity, degenerative disease of the nervous system, and repeated falls. The resident had severely impaired cognition and was dependent on assistance for daily activities. During an observation on November 4, 2024, Resident 30 was found in his room, covered with a blanket, and expressed feeling cold. The Maintenance Supervisor Assistant measured the room temperature at 68 degrees Fahrenheit, which was below the facility's policy range of 70-75 degrees Fahrenheit. The Maintenance Supervisor later identified an open window in the bathroom as the cause of the low temperature. Interviews with the Maintenance Supervisor and the Assistant Director of Nursing confirmed that the temperature should be maintained within the specified range to ensure resident comfort. The facility's policy, last reviewed on August 15, 2024, indicated that room temperatures should be maintained at a comfortable level for residents, generally between 70-75 degrees Fahrenheit.
Failure to Develop Person-Centered Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for two residents, leading to deficiencies in addressing their specific needs. Resident 28, who was readmitted with multiple diagnoses including osteomyelitis, diabetes with neuropathy, and congestive heart failure, exhibited significant range of motion (ROM) limitations in the upper extremities. Despite being alert and oriented, Resident 28 was unable to move his arms without assistance and could not use the call light button, which was confirmed by both the resident and Treatment Nurse 1. The facility's records showed no care plan addressing these ROM limitations, as confirmed by Registered Nurse 1 and the Assistant Director of Nursing, indicating a failure to document and plan for the resident's needs. Similarly, the facility did not develop a care plan for Resident 50's bowel and bladder incontinence. Resident 50, who was readmitted with conditions such as gastroesophageal reflux disease and dysphagia, was frequently incontinent of bowel and bladder, requiring moderate assistance for daily activities. Despite these needs being documented in the Minimum Data Set, there was no corresponding care plan to address the incontinence, as confirmed by Registered Nurse 2. This lack of a care plan meant that the resident's care needs might not be adequately met, potentially leading to further complications. The facility's policy on comprehensive care planning, which mandates the development of a person-centered care plan with measurable objectives and timetables based on resident assessments, was not adhered to in these cases. The policy requires regular review and revision of care plans to reflect any changes in the resident's condition, but this was not done for Residents 28 and 50, resulting in a failure to provide necessary care and services.
Deficiencies in Resident Involvement and Care Plan Updates
Penalty
Summary
The facility failed to involve Resident 50 in two quarterly Interdisciplinary Team (IDT) Care Conferences, despite the resident having intact cognitive skills and no appointed representative. The care plan conferences were attended by representatives from various departments and a family member via telephone, but there was no documentation that the resident was invited or refused to attend. This omission deprived the resident of the right to participate in developing a resident-centered care plan, which is crucial for addressing the resident's needs effectively. Additionally, the facility did not revise the care plan for Resident 30 after the resident's symptoms of a burning sensation during urination resolved. The resident, who had severely impaired cognition and was dependent on assistance for daily activities, initially complained of pain during urination. A urinalysis and urine culture were conducted, revealing a significant bacterial presence. However, the resident's symptoms resolved within three days, and no new antibiotic orders were received. Despite this, the care plan was not updated to reflect the resolved symptoms, potentially leading to inappropriate care. The facility's policies and procedures emphasize the importance of involving residents and their representatives in care planning and ensuring care plans are based on comprehensive assessments. However, in these cases, the facility did not adhere to its policies, resulting in deficiencies in care planning for both residents. The lack of resident involvement and failure to update care plans as needed were identified as deficient practices during the survey.
Failure to Assess and Provide Equipment for Resident's Limited ROM
Penalty
Summary
The facility failed to comprehensively assess the limited mobility and range of motion (ROM) for Resident 28 upon readmission. Resident 28, who was readmitted with conditions including osteomyelitis of the vertebra, type 2 diabetes mellitus with diabetic neuropathy, congestive heart failure, and abnormalities of gait and mobility, was not provided with the appropriate equipment to maintain their maximum practicable independence. The resident was observed to have impairments in both upper extremities, with the right wrist contracted and the left hand mostly closed, rendering them unable to use the standard call light provided by the facility. Interviews and record reviews revealed that the initial nursing assessment failed to note the resident's upper extremity ROM limitations. The Occupational Therapy Evaluation also missed the left hand's ROM limitations, despite the resident's inability to push a call button. The facility's policy on call lights, which requires accessibility and the ability for residents to demonstrate usage, was not adhered to, resulting in the resident's inability to call for assistance, potentially delaying care.
Deficiencies in Fall Risk Evaluation and Medication Administration
Penalty
Summary
The facility failed to ensure a fall risk evaluation was completed after a fall incident involving a resident. The resident, who had a history of repeated falls and severely impaired cognition, was found on the floor and sent to a hospital for evaluation. Despite the fall, the facility did not conduct a fall risk evaluation immediately after the incident, and the subsequent evaluation inaccurately reported no falls in the past three months. This oversight had the potential to negatively impact the resident's care plan and the delivery of necessary services. Additionally, the facility did not adhere to medication administration protocols, as observed with a licensed vocational nurse (LVN) who left prepared medications unattended at a resident's bedside. The resident, who had severely impaired cognition and required maximal assistance for daily activities, was left with medications within reach while the LVN retrieved a stethoscope. This practice posed a risk of unauthorized access to medications by other residents, potentially leading to adverse effects or allergic reactions. The facility's policies on fall risk prevention and medication administration were not followed, as evidenced by the lack of timely fall risk assessments and the improper handling of medications. These deficiencies highlight lapses in the facility's adherence to its own procedures, which are designed to ensure resident safety and proper care management.
Failure to Provide Adequate Respiratory Care
Penalty
Summary
Licensed Vocational Nurse 1 (LVN 1) failed to provide necessary respiratory care to a resident, identified as Resident 242, in accordance with professional standards and physician orders. The deficiencies included not covering the suction catheter with a sleeve when not in use, not administering oxygen as per the physician's order, and not labeling the suction tubing with the date it was last changed. These actions were observed during a review of Resident 242's records and an observation on November 4, 2024, where the resident was found without the prescribed continuous oxygen administration, and the suction equipment was improperly maintained. Resident 242 had been admitted with serious health conditions, including malignant neoplasm of the colon, acute systolic heart failure, acute respiratory failure, and pleural effusion. The resident's physician had ordered continuous oxygen administration at 2 liters per minute via nasal cannula to maintain oxygen saturation above 94%. However, during an observation, the resident's oxygen saturation was found to be at 93% due to the oxygen not being administered. Additionally, the suction catheter was improperly stored, and the tubing was not labeled, increasing the risk of respiratory infection. The facility's policies required adherence to physician orders and proper maintenance of medical equipment, which were not followed in this instance.
Inappropriate Administration of Pain Medication
Penalty
Summary
The facility failed to administer pain medication as prescribed by the physician for a resident, identified as Resident 6. The resident was admitted with diagnoses including chronic obstructive pulmonary disease and muscle weakness. According to the physician's orders, the resident was prescribed hydrocodone-acetaminophen (Norco) to be administered orally every four hours as needed for severe pain, with a pain level of 7-10 on a numerical scale. However, a review of the Medication Administration Record (MAR) revealed that the resident was administered Norco on two occasions when their pain level was recorded as zero. During an interview and record review, Registered Nurse 2 confirmed that the medication was administered inappropriately on these occasions, as the resident's pain level did not warrant the use of Norco. The nurse acknowledged that administering the medication without the appropriate pain level could lead to unnecessary use and potential adverse consequences such as constipation, respiratory depression, and sedation, which could increase the risk of falls and injury. The facility's documentation on medication issues for older adults also highlighted the potential adverse effects of opioid analgesics like hydrocodone.
Failure to Complete Post-Dialysis Assessment
Penalty
Summary
The facility failed to complete a post-dialysis assessment for a resident who required dialysis services. The resident, admitted with end-stage renal disease and dependent on dialysis, had moderately impaired cognition and required substantial assistance with daily activities. On a specific date, the post-dialysis assessment was not completed, and there was no documentation of vital signs or assessment of the dialysis access site. This oversight was confirmed during a review with a Licensed Vocational Nurse, who acknowledged the missing documentation and stated that charge nurses are responsible for completing the assessment upon the resident's return to the facility. The Assistant Director of Nursing confirmed that licensed nurses are responsible for completing the post-dialysis assessment, which should include vital signs and signs of bleeding to ensure the resident's stability. The facility's policy on dialysis care, last reviewed in August 2024, requires the completion of a post-dialysis checklist, including documentation of vital signs, access site condition, skin condition, and any additional instructions from the dialysis unit. The failure to complete this assessment placed the resident at risk for complications associated with dialysis.
Deficiency in Room Size Requirements
Penalty
Summary
The facility failed to provide the required minimum of 80 square feet per resident in multiple resident bedrooms, as observed in four of the 38 resident rooms (Rooms 1, 3, 9, and 11). Each of these rooms contained two beds, but the floor area per resident was below the federal regulation requirement. Specifically, Room 1 had 73 square feet per resident, Room 3 had 77.5 square feet, Room 9 had 71.5 square feet, and Room 11 had 75.5 square feet. The minimum required square footage for a two-bed room is 160 square feet, which these rooms did not meet. Despite the deficiency in room size, during a resident council meeting, no concerns were raised by the residents regarding the size of the rooms. Additionally, general observations conducted on two consecutive days indicated that residents had ample space to move freely within their rooms. There was sufficient space for residents' freedom of movement and for nursing staff to provide care, as well as adequate space for beds, side tables, and resident care equipment.
Failure to Investigate Financial Abuse Allegation
Penalty
Summary
The facility failed to implement its policy and procedure for an allegation of financial abuse concerning a resident. The Business Office Manager (BOM) reported the financial abuse to the Social Security Administration (SSA) after discovering that the resident's son, who was the financial power of attorney, was using the resident's Social Security checks for personal expenses instead of paying the resident's share of cost for medical services. Despite this report, the Administrator (ADM) did not conduct a formal investigation or document the findings, as required by the facility's policy. The facility's policy mandates that the ADM, as the abuse coordinator, thoroughly investigate any alleged violations and report the results to the appropriate agencies within five working days. However, the ADM only engaged in informal conversations with the resident's son and did not document any investigation or conclusions. Additionally, the Director of Nursing (DON) was not informed of the financial abuse allegation, which resulted in the nursing department not completing an SBAR form or monitoring the resident for emotional distress or negative outcomes. The resident involved had moderately impaired cognition due to Alzheimer's Disease and hydrocephalus, making them vulnerable to financial abuse. The facility's failure to follow its abuse reporting and prevention policy, including conducting a thorough investigation and ensuring proper communication and monitoring, placed the resident at risk for further abuse and potential emotional distress.
Failure to Report Financial Abuse Investigation Results
Penalty
Summary
The facility failed to implement its policies and procedures for reporting a reasonable suspicion of a crime, specifically financial abuse, in accordance with Section 1150B of the Act. This deficiency involved a resident who was diagnosed with hydrocephalus and Alzheimer's Disease, and had moderately impaired cognition. The resident's financial power of attorney, their son, was receiving the resident's Social Security checks but was not paying the resident's share of cost for medical expenses. Instead, he used the funds for his daughter's school expenses, which was identified as financial abuse by the Business Office Manager (BOM). The BOM reported the financial abuse allegation to the State Survey Agency (SSA) on behalf of the resident. However, the Administrator (ADM), who is the abuse coordinator, did not conduct a formal investigation or document the findings. Despite being aware of the facility's policy and the requirement to report the investigation results within five working days, the ADM only engaged in informal conversations with the resident's son and did not complete a conclusion letter. This lack of formal documentation and reporting constituted a failure to comply with the facility's abuse reporting policy.
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.
Illustrative
What surveyors actually found near you
We read the 4,661 citations issued within 25 miles in the last 12 months — including the 25 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.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Van Nuys
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Valley Palms Care Center | 0.6 mi | ★★★★★ | 11 | 0 |
| The Care Center On Hazeltine, Llc | 0.7 mi | ★★★★★ | 12 | 0 |
| Valley Village Care Center | 1.2 mi | ★★★★★ | 27 | 0 |
| The Meadows Post Acute | 2.2 mi | ★★★★★ | 23 | 1 |
| Terrace Post Acute | 2.3 mi | ★★★★★ | 26 | 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 July 2026) and official state health department websites.