Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Heritage Manor during CMS and state inspections, most recent first.
Two residents with ESRD were admitted and retained while receiving PD even though the facility did not have PD listed in its facility assessment or an approved PD program. Records showed nightly PD orders and treatment logs, and family members stated the facility provided PD daily and did not tell them it lacked the license to do so. The ADM stated nursing staff assisted with PD initiation and disconnection, while the DON stated the residents should not have been admitted for PD care.
Two residents who required PD were transferred out after the facility determined it could not provide PD because it lacked the needed license. Although both residents were cognitively intact and wanted to remain in the facility, the IDT and physician ordered transfer to a GACH, and family members reported they felt they had no choice and were disappointed by the move. One family member also reported the resident missed daily PD and the hospital ER staff questioned the transfer.
PD Monitoring and Order Transcription Failures: Two residents receiving PD had deficient care and oversight. One resident with ESRD had PD treatments set up and disconnected by nursing staff, but the MAR, TAR, and PD logs lacked documented vital signs and cardiac, respiratory, and skin assessments before, during, and after treatment. Another resident was allowed to self-disconnect PD without documented competency assessment, care planning, or IDT review, and the PD order was incomplete because it did not clearly specify when to use dextrose 1.5% versus 2.5%.
Failure to Post Current Nurse Staffing Information: The facility did not ensure the nurse staffing projection sheet was updated and posted with accurate current staffing information for the 7 AM - 3 PM shift when surveyors arrived. A Census and Direct Care Services Hours per Patient Day sheet and an older staffing projection sheet were posted by the Nurse's Station, and the DSD stated the overnight RN supervisor had not updated the projection sheet for the shift. The facility policy required the staffing sheet to be posted daily with the current date and census at the beginning of each shift.
Failure to monitor bleeding signs for residents on anticoagulant and antiplatelet therapy and to specify a safe max daily dose for ondansetron. A resident with severe cognitive impairment received Eliquis and Aspirin, another resident received Eliquis, and a third resident received Brillinta plus Aspirin; care plans required monitoring for bleeding and bruising, but the records did not show the required monitoring, and a large bruise on one resident’s hand was not documented or reported. A fourth resident had an ondansetron order without a max daily dose, allowing a potentially excessive PRN dose range until the order was later clarified.
Improper food storage and handling were observed in the kitchen when staff found an open bag of mixed vegetables and expired ice cream stored in the freezer, along with an ice scoop kept inside the ice machine. Kitchen staff and the DS acknowledged the items were stored incorrectly, and the RD stated the scoop should never be kept in the machine and expired or open food should not be stored in the freezer.
A facility failed to follow infection control practices for multiple residents. A resident’s nasal cannula was found on the floor instead of stored in a labeled plastic bag, two roommates were improperly cohorted when one had ESBL E. coli in urine and the other was receiving PD, an IV dressing lacked visible date and initials, and a bedside storage bin contained multiple opened and used items including saline, honey products, ointment, gel, and eye drops. The DON and IP confirmed the issues and referenced the facility’s infection control policies.
A facility failed to maintain resident dignity for two residents. One resident with dementia and a suprapubic catheter was observed with the urinary drainage bag hanging exposed without a privacy bag, despite staff stating a dignity bag should be used unless refused. Another resident with cirrhosis and fronto-temporal neurocognitive disorder was left undressed from the waist down in a shower chair in the middle of the room with the door open while a CNA left to assist another resident, and the DON stated this violated dignity and privacy.
Call lights were not kept within reach for three residents with impaired cognition and dependence in multiple ADLs. Observations found one call light hanging on a roommate’s bed, another on the floor near an oxygen concentrator, and another covered by a blanket and hanging nearly to the floor. Staff and the DON stated call lights must be within reach and used to assist residents with their needs.
A RN failed to notify the physician when a resident with DM, severe cognitive impairment, and low BP became drowsier than usual. The RN started IV 5% Dextrose Normal Saline on her own, documented a TO herself, and infused the fluid at 200 mL/hr even though the physician later stated he had not ordered that treatment and expected to be called first when there was a change in condition.
The facility failed to fully complete and send the required transfer/discharge notice to the LTC Ombudsman for two residents. One resident had severe cognitive impairment, was dependent for ADLs, and was transferred to a GACH after a change in condition, but the notice listed the wrong reason for transfer. Another resident’s notice was faxed to the Ombudsman without the reason for discharge/transfer included. Staff acknowledged the notices were incomplete and did not accurately inform the Ombudsman.
An RN initiated and documented IV 5% Dextrose in NS for a resident with DM without first obtaining a physician order, backdating the telephone order after starting the infusion. In a separate event, a Treatment Nurse reinserted a Foley catheter for a resident after the catheter had been discontinued, but there was no documented physician order for the reinsertion. Interviews confirmed staff knew the orders were not properly obtained or transcribed.
A resident with weight loss and malnutrition had ordered snacks/nourishments, but staff did not document the percentage consumed, and the RN stated the weight loss was not reported to the MD or RD. Another resident with ESRD on PD had a 1500 mL fluid restriction, but nursing did not monitor or document fluid intake, and staff stated they were not aware of the restriction. The DON confirmed there was no nursing monitoring of the resident’s fluid intake.
A white unknown tablet was found on the floor in a medication room during an observation with an LVN. The LVN said she did not know what the tablet was or why it was there, and the DON stated nurses are required to check medication rooms each shift for loose medications. Facility policy required medications to be stored securely and unused or contaminated drugs to be disposed of according to policy.
Failure to Explain Arbitration Agreement Terms: A resident with encephalopathy and severely impaired cognition had an AA signed by the RP, but the RP said he was not given a copy and was not told the agreement was optional or that it could be rescinded within 30 days. The BOA stated he explained that an arbitrator would decide disputes instead of a jury, but he did not know about the 30-day rescission option, while the BOM stated staff were expected to explain the AA’s purpose and that signing was not required for admission.
Call Light Not Within Reach: A resident with a hip fracture, Parkinson's disease, and impaired cognition was observed in bed unable to reach her call light after a CNA forgot to place it within reach following a shower. The resident stated she needed help but could not call staff because she did not know where the call light was, and the cord was seen hanging over the headboard out of reach. The DON stated the call light should be within residents' reach at all times, and facility policy required the call system to be accessible while the resident was in bed.
Surveyors found multiple food safety deficiencies during meal service in a conference room used as a temporary tray line area. An expired, ready-to-eat turkey sandwich remained in the refrigerator past its labeled use-by date, contrary to facility policy and FDA Food Code requirements. Staff serving food in the conference room did not have hair nets readily available, and a staff member wiped food contact surfaces with a kitchen towel that was then left on the counter instead of being stored in a sanitizer solution, with no sanitizer bucket or test strips present in the room. In addition, milk served during lunch was measured at 52.5°F, above the required 41°F or below for TCS foods, and staff reported there was no ice available in the conference room to maintain proper cold holding temperatures.
The facility failed to use its QAA/QAPI process to monitor and manage a temporary food service system put in place after the kitchen elevator became inoperable. Staff began transporting food and beverages by stairwell and using a conference room as a serving area, but no performance improvement project or monitoring was implemented for sanitation, infection control, or staff safety. Surveyors found expired food in the conference room refrigerator and cold beverages held above required temperatures, while the conference room lacked proper means to keep items cold. Food deliveries were left in the parking lot and carried by staff down the stairs to the basement kitchen. The RD’s sanitation audits did not include the conference room, and staff did not receive routine training or evaluation on safe food transport, fall prevention, or injury risk related to the new procedures, despite QA meetings discussing the elevator outage.
The facility failed to maintain a functional kitchen elevator, leaving it inoperable for an extended period despite prior maintenance recommendations, and did not notify the district office about the ongoing outage. As a result, dietary staff were required to carry all food, beverages, and supplies up and down stairs between the basement kitchen and an upstairs conference room used as a temporary meal staging and service area, with staff observed making multiple trips, becoming visibly fatigued, and one staff injury reported. Surveyors found cold beverages held above 41°F in a warm conference room without ice, and staff reported that vendor deliveries were left in the parking lot and then manually transported to the kitchen over a prolonged period, potentially delaying refrigeration. These practices were inconsistent with the facility’s own food safety and storage policies and FDA Food Code requirements for proper hot and cold holding and prompt refrigerated storage.
A deficiency occurred when a resident did not receive treatment and care in accordance with physician orders and their documented preferences and goals, resulting in care that was not individualized or consistent with regulatory requirements.
A resident with type 2 DM was admitted with no orders for insulin or hypoglycemic medications, yet the care plan included interventions for diabetes medication administration and blood sugar monitoring. Staff confirmed the care plan was not tailored to the resident's actual needs and was initiated before a full IDT review, leading to inaccurate and non-resident-specific interventions.
A licensed nurse responsible for MDS assessments did not complete required annual competency evaluations for two consecutive years. The nurse was unaware of the facility's comprehensive care plan policy, a key aspect of their role. The DON confirmed the lapse, and facility records showed that annual competency checks, including care planning, are mandated to ensure staff maintain necessary skills and knowledge.
A resident with a history of type 2 diabetes and cognitive impairment did not receive a comprehensive monthly medication regimen review by the consultant pharmacist. The pharmacist failed to review the full diagnoses, previous medication orders, and relevant records, resulting in the omission of diabetes medication and subsequent hyperglycemia.
A resident with acute respiratory failure, COPD exacerbation, and pulmonary hypertension experienced a significant decline in respiratory status. Despite physician orders for close monitoring, oxygen titration, and immediate notification of the physician and emergency services, staff failed to assess, document, and respond appropriately when the resident's oxygen saturation dropped. The LVN did not follow orders to increase oxygen, did not notify the physician or call 911, and did not implement the resident's POLST. The resident's condition worsened and resulted in death, with facility policies and procedures not followed throughout the event.
Staff failed to maintain privacy for multiple residents during personal care by not closing privacy curtains or providing alternative visual barriers when curtains were removed for cleaning. In several cases, residents were exposed during care without their consent, and staff did not follow facility policy to ensure privacy and dignity.
Dietary staff, including the Dietary Manager and Facility Cook, did not follow required recipes or measure ingredients when preparing pureed foods for residents on modified diets. Instead, staff estimated thickener amounts and did not verify food texture, resulting in inconsistent and inappropriate food consistencies. Facility policies and recipes required specific measurements and procedures, but these were not followed, and there was no system to check the final product before serving.
The facility did not follow its own food safety policies by failing to properly store a flour scoop to prevent contamination and by not calibrating a food thermometer according to established procedures. The scoop was left exposed on top of the flour container instead of being stored in a plastic bag, and the thermometer was incorrectly calibrated, with staff accepting an inaccurate temperature reading. These actions did not meet professional standards for food safety and equipment handling.
The facility did not have effective systems in place to ensure dietary staff followed pureed food recipes, resulting in improper food texture for all residents on pureed diets. Additionally, the facility failed to identify, investigate, and respond to an adverse event involving a resident who expired from respiratory distress, with staff not documenting vital signs, notifying the physician, or following POLST preferences. These deficiencies were not addressed by the QAPI committee, despite repeated concerns.
A resident with cognitive impairment and respiratory conditions was not served a meal at the same time as other residents in the dining room, resulting in the resident waiting at least 17 minutes and feeling disrespected and frustrated while watching others eat. Staff interviews indicated a lack of communication regarding the resident's presence in the dining room, leading to the delay.
A resident with acute respiratory failure and COPD exacerbation experienced a significant drop in oxygen saturation, but staff failed to immediately notify the physician or follow emergency protocols as required by facility policy and physician orders. The resident's condition deteriorated rapidly, and the physician was only contacted after the resident had expired. Documentation and interviews confirmed that vital signs were not properly recorded, and appropriate interventions were not initiated in a timely manner.
Two residents experienced an unclean and unsafe environment due to unresolved maintenance issues, including a broken sliding screen door with holes and tears and missing floor tiles under a bed following a water leak. Despite repeated notifications and existing preventative maintenance policies, the facility did not repair these issues for over a month, impacting the comfort and quality of life for the affected residents.
A resident with hypertension and hyperlipidemia was discharged home with home health services, but the MDS assessment was incorrectly coded as a discharge to an acute hospital. The error was identified during a review of records and acknowledged by the MDS Nurse, who confirmed the MDS did not accurately reflect the resident's actual discharge disposition.
A resident with impaired vision and multiple medical conditions did not have a care plan addressing his need for new eyeglasses, despite an optometrist's recommendation and the resident's reports of worsening vision. Staff were unaware of the resident's vision concerns, and there was no documentation or tracking of the eyeglasses order, resulting in unmet care needs.
A resident with severe cognitive impairment developed a pressure injury on the left big toe that progressed from partial-thickness to full-thickness loss while in the facility. Despite wound care notes recommending new footwear and the care plan identifying improper footwear as a risk, there was no assessment or intervention regarding the resident's shoes. The resident continued to wear tight, uncomfortable sneakers, and staff did not evaluate footwear as a contributing factor, contrary to facility policy.
A nurse failed to check a resident's heart rate before administering antihypertensive medications and did not provide food with Metoprolol and Metformin as ordered, resulting in a medication error rate above 5%. The resident, who had diabetes and hypertension and was dependent on staff, received medications contrary to physician orders and facility policy.
A nurse failed to check a resident's heart rate before administering Metoprolol and Amlodipine, as required by physician orders and facility policy. The nurse only checked blood pressure and was about to give the medications when prompted by a surveyor to check the heart rate, which was then found to be within the safe range. The resident had cognitive impairment and was dependent on staff, and the omission was confirmed as a significant medication error.
A resident with dysphagia and cognitive impairment was repeatedly served pureed food that was too thick and lumpy, contrary to physician orders and care plan requirements for a thin consistency. The resident's family member reported having to bring in homemade food due to the facility's failure to provide the correct texture, and direct observations confirmed the food did not meet prescribed standards. The dietary manager and registered dietician acknowledged the inconsistency, and the cook admitted to not following facility recipes.
A dirty and rusty commode was discovered in a shared bathroom used by six residents. Housekeeping staff were unaware of the issue and could not confirm if the restroom had been checked for cleanliness. The maintenance supervisor confirmed the commode had been in poor condition for several days, despite facility policies requiring sanitary equipment and regular preventative maintenance.
A resident's responsible party reported aggressive and rude behavior by a nurse to the Social Service Assistant (SSA), who failed to initiate a grievance process or inform the Social Service Director (SSD). The facility's policy requires prompt grievance resolution, but the SSD was unaware of the issue, and the Director of Nursing (DON) was not informed. This failure increased the risk of negative psychosocial impact on the resident.
A resident with dementia and osteoporosis fell from a shower chair in an LTC facility when a CNA left her unattended. The resident, who was dependent on staff for bathing, opened the armrest and fell, resulting in a fractured humerus. The CNA did not report the fall immediately and moved the resident without a nurse's assessment, violating facility policy. The resident was later transferred to a hospital for non-operative treatment.
A resident with severe cognitive impairment was found with ecchymosis and a skin tear, but the facility failed to report the injury of unknown source within the required two-hour timeframe. The CNA noticed the discoloration but did not report it immediately, leading to a delay in notifying the DPH. The facility's policy mandates immediate reporting to ensure resident safety and compliance.
A facility failed to follow its wound care protocol when an LVN did not change gloves or wash hands after handling a soiled dressing on a resident with a Stage 4 pressure ulcer. The LVN continued to treat the resident's wounds without performing necessary hand hygiene, contrary to the facility's policy. The resident had a history of diabetes, hypertension, sepsis, and antibiotic-resistant bacteria, and was dependent on staff for daily activities.
The facility failed to implement an effective infection prevention and control program during a Covid-19 outbreak, leading to improper cohorting of residents. A resident who tested positive for Covid-19 was mistakenly moved into a room with negative residents due to the lack of a proper line listing and reliance on verbal reports. The IP nurse did not consult local health department or CDC guidelines, relying instead on online resources, which contributed to the deficiency.
A resident with cognitive impairments and mobility issues eloped from the facility without staff knowledge. Despite expressing a desire to go home earlier, the resident left unnoticed, and the facility was only informed of the elopement by a family member. The facility's policy on preventing elopements was not effectively implemented.
A CNA was observed standing while feeding three residents, contrary to facility policy requiring staff to be seated to maintain dignity and prevent choking. The residents, who have severe cognitive impairments and are dependent on staff for eating, were fed in a manner that could compromise their dignity and safety. Staff interviews and policy reviews confirmed the importance of seated feeding.
The facility failed to develop comprehensive care plans for three residents, leading to potential risks in their care. One resident lacked a care plan for oxygen therapy, another for sepsis and pneumonia, and a third for medication preferences. Staff confirmed the absence of necessary care plans, which are essential for consistent and effective care.
The facility failed to properly assess, monitor, and evaluate a resident's skin condition related to MASD and fungal infection. The care plan was not implemented, weekly skin assessments were not conducted, and the primary physician was not notified of the worsening condition. The resident experienced severe pain and distress due to the untreated skin condition.
The facility failed to provide appropriate pain management for a resident with severe MASD and fungal dermatitis, resulting in unrelieved severe pain. Despite the resident's complaints and visible signs of discomfort, the staff did not assess or manage her pain effectively, and no pain medication was administered.
The facility failed to complete performance reviews and Annual Core Clinical Competencies (ACCC) for eight of nine CNAs, potentially impacting the quality of care provided to residents. The new Director of Staff Development (DSD) confirmed that the previous DSD did not conduct the required competency checks for 2023, leaving the CNAs' skills assessments incomplete or not done since 2022. The Administrator acknowledged the issue, emphasizing the necessity of annual competency checks to ensure proper care for residents.
The facility failed to label and date food items in the kitchen, including chicken bouillon, rice, sliced peaches, tofu, and green peas, as required by their policy and professional standards. The DSS and DON acknowledged that these items should have been labeled and dated to ensure they were fresh and safe for consumption.
Admission and retention of residents requiring PD without approved PD services
Penalty
Summary
The facility failed to ensure that two sampled residents received services in accordance with the facility’s capabilities and available resources when it admitted and retained residents who required peritoneal dialysis (PD) without having an established PD program and the necessary services to safely provide PD care as approved by the State Agency. The deficiency was identified through interview and record review and involved Resident 1 and Resident 2, both of whom had end stage renal disease (ESRD) and were receiving PD while residing in the facility. Resident 1 was admitted with ESRD and infection and inflammatory reaction due to PD. Records showed Resident 1 had the capacity to understand and make decisions and was receiving PD for ESRD. Orders documented PD treatments using Dianeal with 1.5% Dextrose and later 1.5% Dextrose Solution, followed by Extraneal, with nightly treatments beginning at 7 PM. Treatment logs and the MAR showed PD treatments were provided across multiple periods during the resident’s stay. Resident 2 was admitted with ESRD and dependence on renal dialysis. Records showed Resident 2 had intact cognitive skills and was receiving PD upon admission. Orders documented PD using 2.5% Dextrose solution with nightly treatments beginning at 7 PM, and the MAR and treatment records showed PD treatments were provided during the resident’s stay. Family members stated the facility provided PD treatment every day and that they were not told the facility did not have the license to provide PD in the facility. Resident 1 stated she agreed to be admitted because she was told the facility could provide PD treatment and she did not know the facility was not allowed to provide PD. The facility assessment did not include PD services. The Administrator stated nursing staff assisted with initiating and disconnecting PD treatments and that the facility had the dialysis solutions and equipment on hand. The DON stated the facility should not have admitted the two PD residents and that providing PD service to them could put them at risk for infection and other complications. The facility policy required evaluation of the level of care needed prior to admission, and the CDPH guidance stated SNFs seeking to provide PD services must apply for approval of the optional service and notify CDPH before starting PD services.
Unsafe discharge of residents needing PD
Penalty
Summary
The facility failed to ensure a safe and appropriate discharge for two residents who required peritoneal dialysis (PD). Both residents were admitted with end-stage renal disease and were documented as having the capacity to understand and make decisions. Their assessments showed they required PD, and one resident also needed assistance with eating, oral hygiene, and other activities of daily living. Despite this, the facility later determined it was unable to provide PD because it did not have the license to offer that service. On the same day, the interdisciplinary team informed both residents that the facility could not safely meet their clinical needs at that level of care. The records show the physician ordered transfer to a general acute care hospital, and both residents were transferred there. The transfer/discharge notices stated the move was necessary for the residents’ welfare because their needs could not be met in the facility. Interviews showed the residents and their family members did not want the transfer and felt they had no choice in the matter. Family members stated the facility told them it could no longer provide PD and did not spend time looking for another place for one resident. One family member reported the resident was sent to a hospital emergency room, where staff were surprised by the transfer, and that the resident did not receive daily PD that day. The other family member stated the resident felt kicked out and was relying on the facility to find an appropriate place to continue PD and rehabilitation. The administrator and DON confirmed the facility had admitted and retained both residents while lacking the license to provide PD services.
PD Monitoring and Order Transcription Failures
Penalty
Summary
The facility failed to provide safe, appropriate peritoneal dialysis (PD) services for two residents who required PD. For one resident, the record showed diagnoses including end stage renal disease (ESRD) and dependence on renal dialysis, with cognitive status documented as intact and the resident receiving PD treatments on admission. The care plan called for monitoring changes in behavior, condition before and after treatment, and signs of complications such as changes in level of consciousness, skin elasticity, heart and lung sounds, edema, bleeding, bacteremia, and septic shock. The resident’s PD orders included treatment with low calcium 2.5% solution and later 2.5% dextrose for five cycles, but the facility did not document ongoing assessment and oversight before, during, and after PD treatments. During observation, the resident’s room contained a Homechoice Claria PD machine, dialysis supplies, and written instructions for ending therapy and manually draining the machine. The resident stated that nursing staff set up and connected the PD machine in the evening and disconnected the catheter in the morning. When the PD treatment was observed, an LVN prepared the machine, connected the solution bags and cassette, and began treatment. Later, an RN disconnected the catheter and covered the site. Review of the PD logs, MAR, and TAR showed no documentation of vital signs, cardiac, respiratory, or skin assessments before, during, or after PD treatments. Staff interviews confirmed there was no documented monitoring of the resident’s mental status, cardiac status, respiratory status, or skin assessment, and the DON stated that such monitoring was important because PD residents were clinically unstable and required continuous oversight. For the second resident, the record showed ESRD, infection and inflammatory reaction due to a PD catheter, and no cognitive impairment on the MDS. The resident was receiving PD with Extraneal, and the physician order summary listed five cycles over 10.5 hours with fill volumes and a final fill. The resident was observed disinfecting and disconnecting the PD catheter from the dialysis machine by herself while an LVN was present. The LVN stated the resident usually disconnected herself and that nurses allowed it, and the DON stated the facility had no documentation confirming the resident was trained and competent to self-administer or self-disconnect PD. The DON also stated the facility did not develop a care plan or conduct an IDT meeting regarding self-administration and self-disconnection. The report also found that the physician order for the second resident’s PD solution was not specific about when to use dextrose 1.5% or dextrose 2.5%. An LVN stated the administered fluid was not transcribed to the physician order and could not explain when each dextrose concentration should be used. A hemodialysis nurse stated the order should have included the percentage of dextrose and the indication for use, and the DON stated correct transcription of orders was important to ensure residents received the correct order.
Failure to Post Current Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the accurate and current staffing data sheet showing the total number of actual hours worked by RNs, LVNs, and CNAs was posted for the 7 AM - 3 PM shift when the survey team entered the facility on 4/25/2025 at 8:30 AM. During observation on 4/25/2026 at 8:35 AM, a Census and Direct Care Services Hours per Patient Day document dated 4/25/2026 was seen posted by the Nurse's Station and showed a patient census of 91. During the same observation at 8:38 AM, a Nursing Staff Projection document dated 4/24/2026 was also seen posted by the Nurse's Station and showed a census of 89 for each shift, including 7 AM - 3 PM. During interview and record review on 4/28/2026, the DSD reviewed a photo of the Nursing Staff Projection sheet dated 4/26/2026 timed at 8:45 AM and stated that the Nursing Staff Projection was not updated by the 11 PM - 7 AM RN supervisor for the 7 AM - 3 PM shift on 4/25/2026. The DSD stated that on weekends and holidays, the RN supervisor of the 11 PM - 7 AM shift was responsible for completing the CHHPD and the Nursing Staff Projection sheet. Review of the facility's policy titled Nurse Staffing Posting Information, dated 9/16/2024, showed that the Nurse Staffing Sheet was to be posted daily, include the current date and resident census, and be posted at the beginning of each shift.
Failure to Monitor Anticoagulant/Antiplatelet Therapy and Specify Safe Ondansetron Dose
Penalty
Summary
The facility failed to monitor residents receiving anticoagulant or antiplatelet medications for signs and symptoms of bleeding in accordance with their care plans. Resident 3 was admitted with acute respiratory failure with hypoxia, cachexia, and DM, and had severely impaired cognition. The resident had orders for Aspirin 81 mg daily for CVA prophylaxis and Eliquis 2.5 mg twice daily for CVA prophylaxis. The care plan directed staff to monitor for blood in the urine or stool, unusual bleeding, bleeding from the gums or nose, excessive wound bleeding, large hemorrhagic areas, and petechiae, but the record did not show documented monitoring for these signs. RN 3 stated no monitoring was being done because it was in the care plan, and the DON stated there were no physician orders for monitoring because the facility had removed them after being told monitoring was not needed if it was in the care plan. Resident 40 was admitted with dementia, DM, and atrial fibrillation and had severely impaired cognition. The resident received Eliquis 2.5 mg twice daily for DVT prevention. The care plan required monitoring and documentation of adverse reactions to anticoagulant therapy, including blood in urine or stool, severe headaches, nausea, vomiting, diarrhea, muscle or joint pain, lethargy, bruising, blurred vision, shortness of breath, appetite loss, mental status changes, vital sign changes, bleeding gums, nosebleeds, unusual bruising, lab changes, blood pressure changes, and blood clot. The record did not show documented evidence that staff monitored the resident for these adverse reactions in accordance with the care plan. Resident 75 was admitted and later readmitted with DM and kidney failure and had moderately impaired cognition. The resident had orders for Brillinta 60 mg twice daily for MI and Aspirin delayed release 81 mg for CVA prophylaxis, and received both medications during the review period. The care plan required monitoring for bleeding and bruising related to antiplatelet therapy. During observation, a large dark purple bruise was noted on the left anterior hand, and the resident stated he probably bumped his hand on the doorway. RN 3 stated the bruise had not been reported to the physician because nursing was not aware of the condition and the need to monitor for bruising or bleeding due to antiplatelet use. CNA 5 gave inconsistent statements about when and to whom the bruise had been reported, and the DON stated there was no change of condition or physician notification for the bruises observed three days earlier. The resident record did not document the bruising. The facility also failed to include a maximum daily dose in the physician order for Resident 65’s ondansetron. Resident 65 was admitted with muscle wasting and atrophy and COPD and had severely impaired cognition. The order was for Ondansetron 8 mg every 6 hours as needed for nausea/vomiting for 14 days, but it did not specify the adult maximum dose. RN 1 stated the resident had vomiting and received Ondansetron doses on two occasions, and during review she stated the maximum daily allowance was 24 mg per day and that she would verify the dosage with pharmacy. The order was later clarified to include a limit not to exceed 24 mg in 24 hours, and the DON stated the dosage had exceeded the recommended dosage and was a potential for overdosing.
Improper Food Storage and Handling in Kitchen
Penalty
Summary
Food was not stored and served in accordance with professional standards for food service safety for 69 residents receiving food from the kitchen. During an observation in the kitchen, surveyors found one open bag of mixed vegetables stored in the freezer, ten cups of expired ice cream stored in the freezer, and an ice scoop stored inside the ice container machine. During the observation and interview, kitchen staff stated the opened vegetable bag had been overlooked and should have been discarded, and that the ice cream had expired the day before and should have been discarded rather than kept in the freezer. During a concurrent observation and interview, the Dietary Supervisor acknowledged that the ice scoop should not have been left inside the ice machine and stated there were plans to install a hook outside the machine, but that task had not yet been completed. The Registered Dietitian later stated that the ice scoop should never be stored inside the ice machine, expired food should never be stored in the freezer, and open bags in the freezer can be exposed to freezer elements and affect the taste of the food. The facility policy titled Food Safety and Food Storage, revised 12/19/2022, stated that food safety practices shall be followed throughout the facility's entire food handling process and that food should be stored in a manner that helps prevent deterioration or contamination.
Infection control failures with oxygen equipment, room cohorting, IV labeling, and bedside storage
Penalty
Summary
The facility failed to implement its infection prevention and control program for multiple residents. Resident 106 had an order for oxygen via nasal cannula as needed, but during observation the nasal cannula was found laying on the floor next to the head of the bed. RN 2 stated the nasal cannula should be stored in a clear plastic bag when not in use to prevent contamination, and the DON stated oxygen nasal cannulas should be stored properly inside a labeled clear plastic bag when not in use because they can become contaminated if they fall on the floor and are then used by the resident. The facility policy for Oxygen Administration stated delivery devices should be kept covered in a plastic bag when not in use. Resident 62, who had end stage renal disease and was receiving peritoneal dialysis, was roomed with Resident 46, who had an active urinary infection with ESBL E. coli and was on contact isolation precautions. The two residents were observed sharing the same room. The Infection Preventionist stated Resident 46 was placed on contact isolation due to ESBL E. coli in the urine and that Resident 62 should not have been cohorted with Resident 46 because Resident 62 was at high risk for infection due to kidney failure and peritoneal dialysis. The DON also stated the residents should not have been placed in the same room. The facility’s policies for peritoneal dialysis and transmission-based precautions addressed cohorting and room placement based on risk factors and pathogen transmission. Resident 43 had an IV catheter in the right foot with a transparent dressing that was unlabeled at the time of observation. There was no visible date or initials showing when the dressing had last been changed. RN 2 stated she had inserted the IV catheter two days earlier and had placed a label sticker with the date and initials, but it could not be found at the time of observation. RN 2 and the DON stated the date and initials should be visible at all times so staff would know when the IV was inserted and when the dressing required changing. The facility’s IV therapy policy stated IV sites are changed every 72 hours unless otherwise ordered. Resident 67 had a three-drawer plastic storage bin at the bedside containing multiple opened and used items, including bottles of normal saline, Medihoney, Bacitracin Zinc ointment, Silverhoney, ultrasound gel, artificial tears lubricant eye drops, and linens and personal care items. The Infection Preventionist removed the bin from the room and stated the items should not have been stored at the bedside because of infection control concerns. The TXN stated the facility had not provided several of the items and that family members had brought them in, while the DON stated staff had not checked what was stored in the bin or addressed the storage issue with family members or staff. The facility’s Infection Prevention and Control Program required a safe, sanitary, and comfortable environment to help prevent the development and transmission of infections.
Failure to Protect Resident Dignity During Catheter Care and Post-Shower Assistance
Penalty
Summary
The facility failed to maintain Resident 1's dignity by not covering the resident's urinary drainage bag with a privacy bag. Resident 1 was admitted and readmitted with diagnoses including dementia, lack of coordination, anxiety disorder, and atonic bladder status post suprapubic catheter. The resident's MDS indicated moderately impaired cognition, and the physician order required maintenance of the suprapubic catheter and drainage bag as needed. During observation, Resident 1 was sitting on the side of the bed with the catheter drainage bag hanging on the side of the right bed rail without a privacy bag. The resident did not respond when asked about comfort with the exposed drainage bag. The TXN stated staff are responsible for ensuring a dignity bag covers the urinary bag unless the resident refuses, and the DON stated residents with a Foley bag should have a dignity bag unless they refuse. The facility also failed to provide privacy to Resident 49 while being assisted after a shower. Resident 49 was admitted with diagnoses including cirrhosis of the liver and fronto-temporal neurocognitive disorder, and the H&P stated the resident did not have the capacity to understand and make decisions. The MDS indicated the resident required maximal assistance. During observation, Resident 49 was sitting in a shower chair in the middle of the room wearing no clothes or covering from the waist down, and the bedroom door was open to the hallway. The CNA stated she was dressing Resident 49 but left to assist another resident and forgot to cover the resident before leaving. The DON stated facility nurses should never leave a resident undressed and exposed in the middle of the room because it violates dignity and privacy.
Call Lights Not Kept Within Residents’ Reach
Penalty
Summary
The facility failed to keep resident call lights within reach for three sampled residents, contrary to its policy and procedure titled, Call Lights: Accessibility and Timely Response. Resident 65 had diagnoses including muscle wasting and atrophy and COPD, and the MDS indicated severely impaired cognition and dependence in multiple ADLs. Although the care plan directed staff to keep the call light within easy reach, an observation found the call light hanging on the side of the roommate’s bed and not reachable to the resident. A CNA stated the resident was able to use the call light but had not realized it was out of reach. Resident 3 had diagnoses including acute respiratory failure with hypoxia, cachexia, and DM, and the MDS indicated severely impaired cognition and dependence in multiple ADLs. The care plan also directed staff to keep the call light within easy reach, but an observation found the call light on the floor near the oxygen concentrator. Resident 1 had diagnoses including dementia, lack of coordination, and anxiety disorder, with moderately impaired cognition and dependence in multiple ADLs. An observation found the call light covered under the blanket and hanging off the side of the bed nearly touching the floor and unreachable to the resident. Staff interviews and the DON stated that call lights must be within residents’ reach and answered timely.
Failure to Notify Physician Before Starting IV Fluids
Penalty
Summary
The facility failed to inform Physician 1 of a significant change in condition for Resident 38 when RN 3 assessed the resident on the morning of 4/25/2026 and found the resident drowsier than usual with a blood pressure of 86/50 mmHg. Resident 38 had diagnoses including Type 2 DM, lumbar spinal stenosis, and chronic viral Hepatitis B, and the H&P and MDS indicated the resident did not have capacity to understand and make decisions and had severely impaired cognitive skills. Instead of notifying Physician 1 before treatment, RN 3 initiated IV 5% Dextrose 0.9% Normal Saline on her own and documented a telephone order herself at 8:00 AM to reflect when she began the IV. RN 3 stated she chose the dextrose-containing fluid because Resident 38 was diabetic and she believed it would raise blood pressure more quickly. During observation later that morning, Resident 38 was sleeping in bed with an unlabeled IV bag of 5% Dextrose Normal Saline infusing at 200 mL/hr into the IV catheter site in the right hand. Physician 1 stated he did not prescribe IV 5% Dextrose Normal Saline at 200 mL/hr for Resident 38 and expected nurses to call and notify him first when there was a change in condition. The DON stated RN 3 did not notify Physician 1 before starting the IV fluids and that Physician 1 needed to be aware of the resident's change in condition to prescribe the most appropriate intervention. The facility's policy required notification of the resident, physician, and family or legal representative when there was a significant change in physical, mental, or psychosocial condition, and the RN job description included observing for changes in status and notifying the physician and resident's family or representative.
Incomplete Transfer/Discharge Notices Sent to Ombudsman
Penalty
Summary
The facility failed to ensure the required Notice of Proposed Transfer/Discharge was fully completed and sent to the Long-Term Care Ombudsman for two sampled residents. In both cases, the notice was not completed in full before being sent, and the Ombudsman was not accurately informed of the residents’ reasons for transfer or discharge. The deficiency involved Resident 7 and Resident 101. Resident 7 was admitted to the facility with diagnoses including sepsis, acute respiratory failure with hypoxia, and Type 2 DM with hyperglycemia. The history and physical indicated the resident did not have the capacity to understand and make decisions, and the MDS indicated severely impaired cognitive skills and dependence for ADLs and functional mobility. The record showed Resident 7 was transferred to a GACH after a change in condition that required transfer via 911, but the Notice of Transfer/Discharge dated 3/9/2026 did not indicate the appropriate reason for the transfer. The MRD and RN acknowledged that the document did not select the correct reason and that the Ombudsman was not accurately informed. Resident 101 was admitted with diagnoses including pancytopenia and heart failure. The record included an order indicating the resident may discharge with home health and equipment, and the facility faxed the Notice of Transfer/Discharge to the Ombudsman. However, the copy sent did not include the reason for the resident’s transfer/discharge. The MRD stated the facility must send a completed copy of the form to the Ombudsman with the reason for discharge or transfer, and acknowledged that the copy sent for Resident 101 was not filled out and did not include a reason.
Unauthorized IV Fluid Administration and Foley Catheter Reinsertion Without Documented Physician Orders
Penalty
Summary
For one resident with DM, an RN transcribed and initiated IV 5% Dextrose in Normal Saline without first obtaining a physician order. The resident had a history of Type 2 DM with hyperglycemia, severe cognitive impairment, and no capacity to understand or make decisions. On the morning of the event, the resident was observed sleeping in bed with an unlabeled IV bag of 5% Dextrose Normal Saline infusing into the IV site in the right hand at 200 mL/hr. The resident’s blood pressure had been documented as 86/50 mmHg earlier that morning. During record review and interviews, RN 3 stated she observed the resident was more drowsy than usual and decided to start IV fluids before notifying the physician. RN 3 stated she wrote the telephone order herself and backdated it to 8:00 AM to reflect when she began the IV, and she selected the dextrose-containing fluid because the resident was diabetic and she believed it would raise blood pressure more quickly. RN 1 stated she later transcribed the order into the electronic record, and the physician stated he did not prescribe IV 5% Dextrose Normal Saline at 200 mL/hr and expected nurses to notify him first when a resident had a change in condition. For another resident with a Foley catheter, the physician ordered the catheter discontinued and directed bladder scans with in-and-out catheterization if residual urine was greater than 250 mL. The Foley catheter was discontinued, but later the Treatment Nurse reinserted a Foley catheter after the resident reported inability to void. The Treatment Nurse stated there was no documented physician order for the reinsertion and that she believed a new order was not needed because the resident had previously had a Foley catheter. LVN 3 also stated there was no documentation recording a physician order for reinsertion, and the DON stated a new physician order should have been obtained before reinsertion and transcribed into the medical record.
Failure to Monitor Snack Intake and Fluid Restriction
Penalty
Summary
The facility failed to ensure adequate nutrition monitoring for a resident with weight loss and protein-calorie malnutrition. The resident was admitted with diagnoses including muscle wasting and atrophy, COPD, and protein-calorie malnutrition, and the care plan directed staff to provide the ordered diet, monitor and record intake after every meal, and have the RD evaluate and recommend diet changes as needed. The resident’s MDS showed severely impaired cognition and dependence for multiple activities of daily living, including eating. The resident’s weight record showed a loss from 125 lbs. to 122 lbs. over 22 days. The record also showed physician-ordered nourishments/snacks, but there was no documented evidence that the percentage intake of those snacks was monitored or recorded. Staff interviews indicated that CNAs and RNAs did not document snack intake, and one RN stated the weight loss was not reported to the physician or RD because staff wanted to monitor for another week. The RD stated she expected nursing to be aware of snack refusal or poor intake so she could intervene early, and the DON stated staff should document the amount of snack intake. The facility also failed to monitor fluid intake for a resident receiving PD and ordered a 1500 mL fluid restriction. The resident had ESRD, was receiving PD treatments, and the care plan and nutritional assessment both identified the 1500 mL restriction with nursing and dietary portions of the daily fluid allowance. During observation, the resident had a water pitcher and cup at bedside and stated he drank sips throughout the day and did not know how much he consumed. Staff interviews showed no separate documentation of liquid intake at meals, no monitoring on the MAR or TAR related to the fluid restriction, and nursing staff stated they were not aware of the restriction. The DON confirmed there was no nursing monitoring of the resident’s fluid intake.
Loose Unknown Tablet Found in Medication Room
Penalty
Summary
A white round unknown medication tablet was found on the floor in one of the two medication rooms during an observation of the medication room with the LVN. The LVN stated she did not know what medication it was or why it was on the floor, and stated nurses should check the medication rooms for loose tablets and discard them into the medication disposable bin to prevent medication errors. During an interview, the DON stated nurses are required to check the medication rooms each shift to ensure no loose medications are present, and that any loose or unknown tablets found on the floor should be discarded in the Medication Disposal bin according to facility policy. Review of the facility's policies on Medication Storage and Destruction of Unused Drugs showed that medications are to be stored according to manufacturer recommendations with proper sanitation, security, and segregation, and that unused, contaminated, or expired prescription drugs are to be disposed of in accordance with state laws and secured until destroyed.
Failure to Explain Arbitration Agreement Terms
Penalty
Summary
The facility failed to ensure that the arbitration agreement was adequately explained so the resident’s responsible party could understand its terms for one sampled resident. Resident 65 was admitted with diagnoses including encephalopathy, and the history and physical dated 4/4/2026 stated that the resident did not have the capacity to understand and make decisions. The MDS dated 4/7/2026 indicated severely impaired cognition and dependence or substantial/maximal assistance with multiple activities of daily living, including toileting hygiene, bathing, dressing, oral hygiene, and eating. Resident 65’s arbitration agreement, dated 4/9/2026, was signed by Family Member 1. During interview, Family Member 1 stated he signed the agreement but did not receive a copy, and he was not told that the agreement was not required for admission or that it could be rescinded within 30 days if not understood. The Business Office Assistant stated he explained that the arbitration agreement involved a neutral third party deciding the outcome instead of a jury, but he did not know and did not inform residents or responsible parties that it could be rescinded within 30 days. The Business Office Manager stated the Business Office Assistant was expected to explain the purpose of the agreement, that signing was optional and not required for admission, and that the agreement could be canceled within 30 days. The facility policy titled Binding Arbitration Agreement stated that the resident or representative must be explicitly informed of the right not to sign the agreement as a condition of admission or as a requirement to receive care.
Call Light Not Within Resident Reach
Penalty
Summary
The facility failed to ensure a call light was within reach for Resident 46, who was admitted with diagnoses including a displaced fracture of the base of the right femur and Parkinson's disease. The resident's MDS dated 3/26/2026 indicated moderately impaired cognition and memory, partial/moderate assistance needed with eating, oral hygiene, and personal hygiene, and dependence on toileting hygiene, shower/bathe self, and chair/bed-to-chair transfer. During a concurrent observation and interview, Resident 46 was found in her room with the door closed, sitting in bed with the head of the bed elevated more than 60 degrees. The resident stated she needed a tissue but could not reach it and was unable to call staff because she did not know where her call light was. The call light cord was observed hanging over the headboard, out of her reach. CNA 1 stated she forgot to put the call light within the resident's reach after showering her in the morning, and the DON stated the call light should be within residents' reach at all times. The facility policy stated the call system would be accessible to residents while in their bed within the resident's room.
Improper Food Storage, Sanitation, and Cold Holding Temperatures During Meal Service
Penalty
Summary
Surveyors identified deficiencies in food safety and sanitation practices related to food storage and handling in a conference room being used as a temporary food service area. During observation of the conference room refrigerator, one prepared turkey sandwich was found with a use-by date of 2/22/26–2/23/26 that had not been discarded after expiration. The Dietary Supervisor (DS) stated that sandwiches were prepared the day before, served the next day, and discarded if not used by the labeled date, and acknowledged that the sandwich in the refrigerator was expired and should have been discarded. Facility policy and the 2022 FDA Food Code require ready-to-eat, time/temperature control for safety (TCS) foods to be labeled, dated, monitored, and used, frozen, or discarded by the use-by date. Additional deficiencies were observed in hygienic practices and surface sanitation in the same conference room tray line area. There were no hair nets readily available in the conference room, even though it was being used as a temporary food serving area. The DS stated that staff wore hair nets from the basement kitchen but confirmed that hair nets should be readily available in the conference room to prevent hair from contacting food. A staff member was observed wiping food contact surfaces with a kitchen towel and then placing the towel on the counter instead of storing it in a sanitizer solution between uses. The staff member stated that kitchen towels should be stored in sanitizer solution when not in use and that there was no sanitizer solution available in the conference room. The DS confirmed that a sanitizer solution bucket should have been present and that there were no sanitizer test strips in the conference room to verify sanitizer effectiveness, despite facility policy and FDA Food Code requirements for wiping cloths to be held in appropriate sanitizer solution. Surveyors also found improper cold holding temperatures for TCS beverages during lunch service in the conference room. Using the facility’s thermometer, the temperature of milk held for cold storage and served during lunch was measured at 52.5°F, above the required 41°F or below. The dietary aide reported that beverages were stored in the kitchen freezer to make them very cold before being brought to the conference room, and the DS stated that the conference room became warm during meal service, causing cold beverage temperatures not to remain at or below 41°F. The DS also stated there was no ice available in the conference room to keep beverages cold before service. Facility policy and the 2022 FDA Food Code require monitoring and maintaining proper hot and cold holding temperatures for TCS foods and beverages to keep them out of the danger zone.
Failure to Use QAPI to Monitor Temporary Food Service After Elevator Outage
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a QAA/QAPI plan to monitor and manage changes in food service operations after the kitchen elevator became inoperable. The elevator, which connected the basement kitchen to upper floors, had been broken since the last quarter of 2024, and staff began transporting food and beverages via the stairwell and using the conference room as a food distribution and serving area. Despite this significant operational change, the facility did not establish a performance improvement project or monitoring system under QAPI to oversee sanitation, infection control, or safety related to this temporary food service arrangement. Surveyors observed multiple issues in the temporary conference room service area and in the process of transporting and receiving food. In the conference room, a sandwich with an expiration date of 2/22/26–2/23/26 was found stored in a reach-in refrigerator past its use-by date. During lunch service, cold beverages were out of temperature range, with apple juice at 46.9°F and milk at 52.5°F, while the Dietary Supervisor acknowledged that cold foods and beverages should be at 41°F or below and that the conference room was warm and lacked ice for proper cold holding. The Registered Dietitian’s monthly sanitation audits were limited to the kitchen and did not include the conference room where food was being temporarily served. Additional observations and interviews showed that staff were manually carrying beverages and large pans of food up the stairs from the basement kitchen, and food vendors were leaving deliveries in the parking lot for staff to bring down the stairwell to the kitchen. The Dietary Supervisor reported that only one staff member had been injured during this period and acknowledged that no in-services on fall injuries or fall prevention had been provided, and that staff were not routinely trained in injury risk prevention while delivering food via the stairwell. The Administrator confirmed that while the elevator outage was discussed in monthly QA meetings, there was no documentation of a performance improvement project or monitoring of sanitation and infection control in the conference room, nor ongoing training and evaluation of staff skills and knowledge related to the new food transport and service procedures, despite facility policy requiring the QAA committee to identify quality issues, implement corrective plans, and monitor performance.
Failure to Maintain Functional Kitchen Elevator Resulting in Unsafe Food Handling and Staff Strain
Penalty
Summary
Facility staff and leadership failed to maintain a safe and functional environment by allowing the kitchen elevator, which connects the basement kitchen to the main floor, to remain inoperable for an extended period. The Assistant Administrator and Maintenance Supervisor reported that the elevator had been broken since the last quarter of 2024, with documented elevator company recommendations for maintenance and replacement that were not completed after early September 2024. The Administrator stated the elevator ultimately was deemed not repairable and needed replacement, and that the facility notified the state construction authority about the replacement project but did not notify the district office about the existing inoperable elevator. Because the elevator was not functioning, the facility relocated food distribution and tray set-up to an upstairs conference room and required dietary staff to transport all food, beverages, and supplies via the stairwell. Surveyors observed the conference room being used as a food distribution and serving area, containing a steam table, plate warmer, refrigerator, meal carts, and a fan. Dietary staff were seen repeatedly carrying trays of beverages and large pans of food up and down the stairs from the basement kitchen, with one dietary aide observed making multiple trips, breathing heavily, and sweating. The Dietary Supervisor confirmed that since the elevator failure, staff had been using the stairwell for food delivery and vendor deliveries, and reported that one staff member had been injured during this period and that the facility had not provided in-services on safe food delivery or fall prevention related to this change in process. Surveyors also identified failures in maintaining proper food temperatures and timely refrigerated storage under these altered conditions. During lunch service in the conference room, cold beverages such as apple juice and milk were measured at 46.9°F and 52.5°F, respectively, while the Dietary Supervisor acknowledged the room was warm during service, there was no ice available in the conference room, and that cold foods should be held at 41°F or below. In the basement, staff and the Dietary Supervisor described that food and supplies were now left by vendors in the parking lot and then carried down the stairs by kitchen staff, with one dietary aide stating it could take about two hours to bring supplies when working alone and acknowledging that dairy products left outside for a long time could spoil. These practices conflicted with the facility’s own food safety and storage policies and the FDA Food Code requirements for hot and cold holding and immediate refrigeration upon receipt.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
A deficiency was identified when treatment and care were not provided in accordance with physician orders, as well as the resident's preferences and goals. The report notes a failure to ensure that care was individualized and aligned with the documented directives and wishes of the resident, as required by regulation.
Failure to Develop Resident-Specific Diabetes Care Plan
Penalty
Summary
The facility failed to develop a comprehensive, resident-centered care plan for a resident with type 2 diabetes mellitus. Upon admission and readmission, the resident's records indicated diagnoses including diabetes, hyperglycemia, gastrostomy, and dysphagia, with the resident being dependent on staff for multiple activities of daily living. The Minimum Data Set (MDS) assessment showed the resident had moderately impaired cognitive skills and was not prescribed insulin or any hypoglycemic medications. Despite this, the care plan initiated for the resident included interventions such as administering diabetes medications as ordered and monitoring for signs and symptoms of hyperglycemia and hypoglycemia, which were not applicable to the resident's current orders and condition. Interviews with nursing staff and review of the care plan revealed that the care plan was initiated before a full interdisciplinary team (IDT) care conference and did not accurately reflect the resident's needs or current medical orders. Staff confirmed that the interventions listed were not resident-specific and could cause confusion in care delivery. The facility's policy required the development of a comprehensive, person-centered care plan with measurable objectives and timeframes based on the resident's assessment, which was not followed in this instance.
Failure to Complete Annual Licensed Nurse Competency for MDS Nurse
Penalty
Summary
The facility failed to ensure that a licensed nurse specializing in Minimum Data Set (MDS) assessments completed the required annual competency evaluations for both 2023 and 2024. During interviews, the nurse admitted to not knowing the facility's policy and procedure for comprehensive care plans, which are essential for outlining all aspects of a resident's care. Another MDS nurse confirmed that developing comprehensive care plans is a key responsibility and that all MDS nurses should be familiar with the relevant policies. The Director of Nursing (DON) verified that the nurse had not completed the annual competency, which is intended to keep staff updated on necessary knowledge and skills. A review of facility records and policies showed that annual competency evaluations are part of the facility's training program for licensed nurses, with specific skills such as care planning included in the checklist. The facility's policies require ongoing training and competency assessments to ensure staff are equipped to provide person-centered care, including care planning, documentation, and communication with residents and families. The DON acknowledged the importance of these competencies for safe and effective resident care, and confirmed the deficiency in the nurse's training record.
Failure to Perform Comprehensive Medication Regimen Review for Diabetic Resident
Penalty
Summary
A deficiency occurred when the facility failed to ensure a licensed pharmacist performed a comprehensive monthly medication regimen review (MRR) for a resident with a diagnosis of type 2 diabetes mellitus. The resident, who had moderately impaired cognitive skills and was dependent on staff for daily activities, was admitted and readmitted with a history of diabetes and hyperglycemia. Despite this, the MRR for the relevant month only included a recommendation regarding gabapentin and did not address the absence of diabetes medication. The pharmacist did not review the resident's full list of diagnoses, previous medication orders, hospital records, or laboratory results, and therefore did not identify the lack of diabetes medication. Interviews revealed that the consultant pharmacist did not have access to the resident's complete diagnoses and only reviewed certain records if clarification was needed, rather than as a standard practice. The Director of Nursing confirmed that the pharmacist did not conduct a comprehensive review as required by facility policy, which mandates access to residents' medical records and a thorough monthly review. As a result, the resident did not receive necessary diabetes medication, leading to an episode of hyperglycemia.
Failure to Provide Timely and Appropriate Respiratory Care and Emergency Response
Penalty
Summary
The facility failed to provide necessary respiratory care and interventions for a resident diagnosed with acute respiratory failure with hypoxia, COPD exacerbation, and pulmonary hypertension. The resident had physician orders and a care plan requiring close monitoring of respiratory status, titration of oxygen therapy to maintain oxygen saturation at or above 94%, and immediate notification of the physician and emergency services in the event of significant changes. Despite these orders, when the resident was found with weakness, labored breathing, and an oxygen saturation of 88% while on oxygen via nasal cannula, the findings were reported to an LVN, but appropriate actions were not taken. The LVN did not follow physician orders to increase oxygen therapy or switch to a mask as required when the resident's oxygen saturation dropped further to 70%. There was no documentation of vital signs, treatments rendered, or timely notification to the physician. The LVN also failed to implement the resident's Physician Orders for Life-Sustaining Treatment (POLST), which included specific interventions for respiratory distress, and did not call 911 or escalate the situation as required by facility policy. The resident's condition continued to deteriorate, and the resident expired at the facility with the cause of death listed as cardiac dysrhythmia, acute respiratory distress, and pulmonary hypertension. Interviews and record reviews confirmed that the required assessments, documentation, and interventions were not performed. The facility's policies on oxygen administration, notification of changes, and medical emergency response were not followed. The failure to monitor, document, and respond appropriately to the resident's change in condition resulted in a delay in diagnosis, care, and respiratory services, ultimately leading to the resident's death.
Removal Plan
- The Director of Nursing (DON) and Registered Nurse (RN) supervisor evaluated current residents with oxygen order and/or with diagnosis of COPD for appropriate assessment and interventions.
- The Regional Nurse Consultant (RNC) provided one on one education to DON and Director Staffing Development (DSD) related to respiratory care, assessment and documentation, monitoring for any change of condition, oxygen administration as ordered by the physician, notification of the physician, escalation of emergent medical services (911) if needed, and implementation of POLST per resident preference.
- The Regional Nurse Consultant (RNC) conducted an interview with LVN 1 and CNA 1 regarding the death incident of Resident 98. The RNC investigated for the licensed nurse documentation, monitoring of change of condition and the reason for not calling 911 and for the possible root cause.
- The RNC provided one on one education to LVN 1 related to respiratory care, assessment and documentation, monitoring for any change of condition, oxygen administration as ordered by the physician including skills competency, notification of the physician, escalation of emergent medical services (911) if needed, and implementation of POLST per resident preference.
- The DON or designee conducted re-education for licensed nursing staff on the following topics: documentation, oxygen administration, compliance with individualized interventions in each resident's care plan, implementation of POLST and notification of the physician and following physician orders.
- The DON or designee started auditing residents with COPD and or Oxygen order 3 times weekly to ensure physician's orders were carried out, resident specific care plans were implemented, and necessary respiratory equipment/supplies were in place, and monitor if change of condition occurred. Upon identification, the DON or designee would immediately address concerns and remedy any audit deficiencies with the licensed nursing staff immediately.
- A Quality Assurance and Performance Improvement (QAPI) Plan was implemented to track and report on above audit findings. The findings will be presented for the monthly Quality Assessment and Assurance (QAA) meeting for a minimum of three months. After the initial three months, the QAA Committee will decide regarding the continued frequency of audits and subsequent reporting, with audits continuing at least monthly to sustain compliance.
- The RNC discussed regarding Chronic Obstructive Pulmonary Disease (COPD) and pulmonary hypertension with post-test to LVN 1 to ensure understanding of the medical condition.
- The DON or designee provided education to licensed nurses regarding COPD and pulmonary hypertension with post-test to ensure understanding of the medical condition.
Failure to Provide Privacy During Personal Care and Absence of Privacy Curtains
Penalty
Summary
The facility failed to ensure the privacy and dignity of four residents during the provision of personal care. In one instance, a certified nurse assistant (CNA) changed a resident's brief without closing the privacy curtain, leaving the resident exposed from the waist down. The CNA later stated that the curtain was left open because the room was hot, but acknowledged that the curtain should have been closed to maintain privacy. The resident was non-verbal and unable to communicate, and a family member indicated that exposure to strangers would upset the resident. The Director of Staff Development confirmed that privacy should always be maintained during care. In another case, a CNA cleaned and changed a resident's gown without drawing the privacy curtain, exposing the resident from the waist down. The CNA claimed the curtain was left open so the resident could watch TV, but the resident reported not requesting this and expressed being upset about the exposure. The resident had intact cognition and was dependent on staff for personal hygiene and dressing. The Director of Staff Development reiterated that privacy should always be provided during such care. Additionally, two residents in a shared room were left without privacy curtains when the curtains were removed for washing. Both residents were present in the room during this time, and the door was left open. The maintenance supervisor stated the curtains would be reinstalled later, and a CNA indicated that care would be delayed or the door closed until privacy was restored. The Director of Nursing stated that it was not acceptable to leave residents without privacy curtains and that temporary measures should be used to maintain privacy. Facility policies reviewed indicated that residents have a right to personal privacy and dignity during care.
Failure to Follow Pureed Diet Recipes and Measurement Protocols by Dietary Staff
Penalty
Summary
The facility failed to ensure that dietary staff, including the Dietary Manager and Facility Cook, demonstrated appropriate competencies and skill sets in preparing pureed diets for residents. Observations revealed that staff did not measure or follow recipes when preparing pureed foods such as chicken, noodles, vegetables, rice porridge, and desserts. Instead, staff added thickener powder by estimation, without referencing the required recipes or measuring the ingredients, resulting in inconsistent food textures. The recipes and policies required specific measurements and procedures to ensure the correct texture and nutritional content, but these were not followed during food preparation. During multiple observations, staff prepared pureed foods by blending unmeasured amounts of ingredients and adding thickener powder without using the prescribed measurements. The Dietary Manager and other dietary staff did not check or follow the recipes, and there was no system in place to verify the final texture of the pureed foods before serving. The Dietary Manager acknowledged that the pureed chicken and noodles were too sticky and did not meet the required consistency, and also stated uncertainty about who was responsible for checking the final product. There was no log or documentation of texture checks being performed. Interviews with staff confirmed that recipes were not followed, and thickener was added based on experience rather than measurement. The Registered Dietitian stated that following recipes is necessary to ensure both nutritional adequacy and safe texture for residents with swallowing difficulties. Review of facility policies and recipes confirmed the requirement to follow specific procedures and measurements for pureed food preparation, which were not adhered to by the dietary staff.
Failure to Follow Safe Food Handling and Thermometer Calibration Procedures
Penalty
Summary
The facility failed to adhere to proper sanitation and safe food handling practices as outlined in its own policies and procedures. During an observation in the kitchen dry storage room, a scoop used for flour was found resting on top of the flour container and not stored in a plastic bag as required. The Dietary Manager confirmed that the scoop should have been placed in a plastic bag to prevent potential contamination, but it was left exposed, likely due to staff oversight. Additionally, the facility did not ensure that dietary staff correctly calibrated the food thermometer used to check food temperatures. The Dietary Manager demonstrated the calibration process by submerging the thermometer in ice water and accepting a reading of 39°F as accurate, whereas the facility's policy specifies that the correct reading should be 32°F. The Dietary Manager Assistant confirmed that the thermometer was not calibrated correctly, which could result in inaccurate temperature measurements for food served to residents. Review of facility policies confirmed the requirements for both food handling and thermometer calibration were not followed.
Failure to Systematically Identify and Address Adverse Events and Dietary Protocols
Penalty
Summary
The facility failed to implement a systematic approach to identifying, investigating, analyzing, and utilizing data related to monitoring and preventing adverse events, as required by its own Quality Assurance and Performance Improvement (QAPI) policy. Specifically, the QAPI committee did not address or develop a written plan to ensure dietary staff followed pureed food recipes for all residents prescribed a pureed diet. Observations revealed that dietary staff did not measure thickener powder when preparing pureed foods, instead relying on estimation and taste, and there was no documentation or log verifying the correct texture of the food. The Dietary Manager and Registered Dietitian confirmed that recipes were not consistently followed, and the Administrator acknowledged that concerns about food texture had been raised multiple times but were not discussed or addressed in QAPI meetings. Additionally, the facility did not have a system in place to identify and investigate adverse events, as demonstrated by the handling of a resident who expired from respiratory distress related to COPD and pulmonary hypertension. The charge nurse on duty did not document vital signs, failed to notify the physician or RN of the resident's significant change in condition, and did not follow physician orders regarding oxygen administration. The Director of Nursing did not investigate the possible cause of death until prompted by surveyors, and the Administrator was not informed of the resident's death or the circumstances surrounding it, indicating a lack of oversight and failure to recognize and respond to adverse events as required by facility policy. Furthermore, the facility did not ensure that the resident's Physician Orders for Life-Sustaining Treatment (POLST) were implemented according to the resident's preferences. The charge nurse did not notify the physician or call for emergency assistance when the resident's condition deteriorated, and the death was not reported or investigated in a timely manner. The facility's own QAPI policy requires systematic identification, reporting, investigation, and prevention of adverse events, as well as documentation and monitoring, but these procedures were not followed in the cases observed.
Resident Not Served Meal Timely in Dining Room
Penalty
Summary
A deficiency occurred when a resident with chronic obstructive pulmonary disease and pulmonary edema, who also had moderately impaired memory and cognition, did not receive his meal tray at the same time as other residents dining in the communal dining room. During lunch, staff served meal trays to 11 out of 14 residents, leaving the resident in question waiting and observing others eat. The resident, seated at a corner table, waited at least 17 minutes before receiving his meal tray, during which time he ate a bread bun he had brought with him. The resident expressed feeling disrespected and frustrated by the delay and by having to watch others finish their meals before he was served. Staff interviews revealed that the resident typically did not eat lunch in the dining room, which may have contributed to the dietary staff not preparing his tray with the others. The treatment nurse acknowledged noticing the delay and stated that staff should have communicated the resident's presence to dietary staff to ensure all residents received their meals simultaneously. The facility's policy requires staff to protect and promote resident dignity, which was not upheld in this instance.
Failure to Notify Physician and Follow Emergency Protocols for Resident with Acute Respiratory Decline
Penalty
Summary
The facility failed to follow its policy and procedure regarding the notification of changes in a resident's condition, as well as professional standards of practice and physician orders, for a resident with acute respiratory failure, COPD exacerbation, and pulmonary hypertension. The resident had specific physician orders to monitor oxygen saturation and to notify the physician if the saturation dropped below 91% or was significantly lower than baseline. On the day of the incident, the resident's oxygen saturation was observed to decrease to 88% and then to 70%, but the physician was not notified immediately as required. CNA 1 reported to LVN 1 that the resident was experiencing labored breathing and a drop in oxygen saturation. LVN 1 assessed the resident, confirmed the low oxygen saturation, but did not document the vital signs, did not notify the physician, did not inform the RN on duty, and did not titrate the oxygen as per the physician's order. Instead, LVN 1 only called the physician after the resident had already passed away. Interviews with staff and review of documentation confirmed that the required notifications and interventions were not performed in a timely manner. The facility's policies required immediate action and notification of the physician in the event of significant changes in a resident's condition, including life-threatening situations. The failure to follow these policies and physician orders resulted in a delay in diagnosis, care, and services for the resident, who ultimately expired shortly after the onset of symptoms. Documentation and interviews confirmed that the expected standards of care and facility protocols were not followed during this critical event.
Failure to Maintain Safe and Homelike Resident Environments
Penalty
Summary
The facility failed to provide a homelike, safe, and clean environment for two residents by not addressing maintenance issues in their rooms. For one resident with dementia and hypertension, the sliding screen door in the room was out of track and had multiple holes and tears for over a month. The resident reported discomfort due to bugs, dirt, and leaves entering the room and stated that maintenance staff had been notified multiple times, but the issue remained unresolved. The Maintenance Supervisor confirmed that routine checks on screen doors were not conducted and that he was unaware of the problem until the survey, relying instead on staff reports that were not received. Another resident, who had severe cognitive impairment and was dependent for mobility, had unrepaired missing floor tiles below the bed due to a water leak that occurred about a month prior. The Certified Nurse Assistant confirmed the floor had not been repaired since the leak, and the Maintenance Supervisor acknowledged that, although the water pipe had been fixed, the floor remained unrepaired. Both staff members agreed that the resident should have a functional and homelike environment, but the necessary repairs had not been completed. Review of the facility's policies indicated that a preventative maintenance program was in place, requiring the maintenance of a safe, functional, and comfortable environment for residents. The policies also specified that the Maintenance Director was responsible for ensuring that the physical environment did not pose a safety risk and that all areas frequented by residents, including their rooms, should be maintained accordingly. Despite these policies, the facility did not address the reported maintenance issues in a timely manner, resulting in an unclean and unsafe environment for the affected residents.
Inaccurate MDS Discharge Coding for Resident Discharged Home
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for a resident who was discharged home with home health services. Specifically, the MDS was incorrectly coded to indicate that the resident had been discharged to an acute hospital, rather than to their home under the care of a home health agency. This discrepancy was identified during a review of the resident's records, which included physician orders clearly stating the discharge to home with home health services. The error was acknowledged by the MDS Nurse during a concurrent interview and record review, confirming that the MDS did not accurately reflect the resident's actual discharge disposition. The CMS Resident Assessment Instrument (RAI) Manual requires that MDS discharge assessments accurately document the resident's discharge location and care needs, which was not met in this instance. The resident involved had a medical history of hypertension and hyperlipidemia and was admitted to the facility prior to the discharge event.
Failure to Develop and Implement Vision Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with impaired vision who required new eyeglasses. Despite the resident's report of worsening vision and inability to read due to outdated eyeglasses, there was no care plan addressing his visual impairment. The resident had been seen by an optometrist, who recommended new prescription glasses, but the care plan and clinical records did not reflect this need or the optometry visit. Additionally, there was no documentation or tracking of the eyeglasses order by social services, and nursing staff were unaware of the resident's vision concerns until informed by the resident himself. The resident's medical history included intervertebral disc degeneration, diabetes mellitus, and a below-knee amputation. The Minimum Data Set indicated moderate cognitive impairment and a need for partial assistance with personal hygiene. Despite these complexities, the facility did not assess or document the resident's sensory changes or coordinate care following the optometry visit. Interviews with staff confirmed a lack of awareness and communication regarding the resident's vision needs, and the facility's policy required interdisciplinary care planning that was not followed in this case.
Failure to Assess and Address Footwear Contributing to Pressure Injury Progression
Penalty
Summary
A resident with chronic atrial fibrillation, dementia, and spinal stenosis was admitted and later readmitted to the facility. Upon admission, the resident's skin was noted to be warm and dry, with some discoloration but no pressure injuries (PIs) documented. On a later date, redness was observed on the left big toe, but no staging or detailed wound description was recorded at that time, and no change in condition documentation was created when the skin condition worsened. Over the following months, wound progress notes indicated the development and progression of a pressure injury on the resident's left big toe, advancing from partial-thickness tissue loss to a Stage 3 PI with full-thickness tissue loss. Despite recommendations in the wound notes for new footwear, there was no documented assessment or evaluation of the resident's shoes to determine their effectiveness in preventing further injury. The care plan identified improper footwear as a predisposing factor but did not include any interventions related to footwear. Observations and interviews revealed that the resident preferred to wear older, tighter white sneakers, which caused discomfort due to the wound, even though a newer pair of shoes had been provided by family. The treatment nurse was unaware of the footwear issue and had not assessed whether the shoes contributed to the pressure injury. The facility's policy required individualized interventions based on risk and skin assessments, but these were not implemented or documented in relation to the resident's footwear.
Medication Error Rate Exceeds 5% Due to Missed Vital Checks and Food Administration
Penalty
Summary
A medication pass observation revealed that a nurse failed to maintain a medication error rate of 5% or less, with three errors identified out of 29 opportunities, resulting in a 10.34% error rate. Specifically, the nurse did not check the resident's heart rate prior to administering Amlodipine and Metoprolol, as required by the physician's order, and also failed to provide food during the administration of Metoprolol and Metformin, both of which were ordered to be given with food. The nurse acknowledged forgetting to check the heart rate and not providing food at the time of administration. The resident involved had diagnoses of diabetes mellitus and hypertension, lacked the mental capacity to make medical decisions, and was dependent on staff for activities of daily living. Physician orders specified that Amlodipine and Metoprolol should be held if the systolic blood pressure was below 110 or heart rate below 60, and that Metoprolol and Metformin should be administered with food. The facility's medication administration policy required obtaining and recording vital signs as ordered and providing food and fluids as appropriate, but these procedures were not followed during the observed medication pass.
Failure to Check Heart Rate Before Administering Antihypertensive Medications
Penalty
Summary
A Licensed Vocational Nurse (LVN) failed to follow physician orders and facility policy by not checking a resident's heart rate prior to administering Metoprolol tartrate and Amlodipine, both medications prescribed for hypertension. The physician's order specifically required that these medications be held if the resident's systolic blood pressure was less than 110 or if the heart rate was less than 60. During a medication pass observation, the LVN prepared and was about to administer the medications after checking only the resident's blood pressure, omitting the required heart rate check. When questioned by the surveyor, the LVN acknowledged forgetting to check the heart rate and subsequently measured it, finding it to be 65 beats per minute before proceeding with administration. The resident involved had a history of diabetes mellitus and hypertension, was cognitively impaired, and dependent on staff for activities of daily living. The facility's policy required obtaining and recording vital signs as per physician orders, and the Director of Nursing confirmed the necessity of checking heart rate before administering these medications. The failure to check the heart rate as required constituted a significant medication error, as it did not comply with the physician's order or facility policy.
Failure to Provide Prescribed Pureed Diet Consistency for Resident with Dysphagia
Penalty
Summary
A deficiency was identified when a resident with a history of dysphagia, dementia, and recent pneumonia was not provided with food in the prescribed consistency. The resident had a physician order and care plan specifying a regular diet with pureed texture and thin consistency due to significant swallowing difficulties and risk for aspiration. Multiple assessments, including those by speech therapy and the registered dietician, emphasized the need for moist, thin pureed foods and close supervision during feeding. Despite these documented needs, the resident was repeatedly served pureed food that was too thick and contained lumps, as observed by both the resident's family member and facility staff. Observations revealed that the resident's family member had been bringing in homemade food and feeding the resident daily, stating that the facility's pureed food was too thick and caused the resident to gag and cough. During direct observation, the facility-provided pureed food was seen sticking to the spoon and not sliding off, with visible lumps, and the resident was observed coughing and unable to swallow the food. The dietary manager confirmed through a spoon test that the food did not meet the required thin consistency and acknowledged that the food was too thick, which could cause it to get stuck in the resident's mouth. Further investigation found that the facility's cook did not follow the facility's recipe for preparing pureed food, instead relying on personal experience and taste to determine texture. The registered dietician confirmed the importance of following recipes to ensure correct consistency, especially for residents at risk of aspiration and choking. The facility's policy required that foods be provided in the appropriate form as prescribed by the physician and assessed by the interdisciplinary team, but this was not followed in the resident's case.
Unsanitary Commode Found in Shared Resident Bathroom
Penalty
Summary
A deficiency was identified when a dirty and rusty commode was found in the shared bathroom between two rooms, used by six residents. During an observation, the unsanitary condition of the commode was noted. The housekeeper interviewed was unaware of the issue and stated she had not received any report about the commode's condition. She also could not recall if she had checked the shared restroom to ensure all equipment was clean and functional. The maintenance supervisor, upon concurrent observation, confirmed the commode was dirty and rusty and estimated it had been in that state for at least a few days. He acknowledged responsibility for ensuring all facility equipment was sanitary, clean, and functional. A review of the facility's policies and procedures revealed that maintaining a sanitary environment includes keeping resident care equipment clean and properly stored, and that a preventative maintenance program should be in place to ensure a safe, sanitary, and comfortable environment. The failure to identify and address the dirty and rusty commode resulted in an unsanitary environment for the residents using the shared bathroom.
Failure to Address Resident Grievance Promptly
Penalty
Summary
The facility failed to ensure prompt efforts were made to resolve grievances verbalized by a resident's responsible party (RP) and did not issue a written grievance decision in accordance with the facility's policy. The RP reported that during a visit, the admitting nurse was aggressive and rude to both the resident and the RP. This concern was communicated to the Social Service Assistant (SSA), who noted the issue but did not initiate a grievance process or inform the Social Service Director (SSD) responsible for handling grievances. The SSA only informed the Director of Nursing (DON) about the concern without further action. The facility's grievance policy requires prompt acknowledgment and resolution of grievances, but the SSD was unaware of the RP's concerns due to a lack of communication from the SSA. The SSD stated that if informed, she would have initiated a formal grievance process. The DON also stated she was unaware of any complaints and would have started an investigation if informed. The failure to address the grievance promptly and according to policy increased the risk of negative psychosocial impact on the resident's quality of life.
Resident Falls from Shower Chair Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure the safety of a resident who was at risk for falls and had a history of dementia and osteoporosis. The resident, who was totally dependent on staff for bathing, fell from a shower chair when a Certified Nursing Assistant (CNA) left the resident unattended to adjust her own clothing. The resident opened the armrest of the shower chair and fell to the floor, resulting in a fracture of the left humerus. The CNA did not immediately report the fall to a Registered Nurse (RN) and instead moved the resident back to the shower chair without a licensed nurse's assessment, contrary to the facility's policy. The resident was later found by an RN with swelling and pain in the left arm, and an X-ray confirmed a fracture. The resident was transferred to a general acute care hospital for further treatment, where it was determined that surgery was not an option due to the resident's comorbidities. The resident received non-operative treatment, including pain management and a splint for the fracture. Interviews with facility staff revealed that the CNA did not follow the facility's policy on incidents and accidents, which requires that a resident not be moved after a fall until assessed by a licensed nurse. The CNA admitted to not reporting the fall due to fear. The facility's policies on accidents and supervision, as well as fall prevention, were not adhered to, leading to the resident's injury.
Delayed Reporting of Injury of Unknown Source
Penalty
Summary
The facility failed to report an injury of unknown source within the required timeframe, as per their policy and procedure on Abuse, Neglect, and Exploitation. The incident involved a resident who was found with ecchymosis on both arms and a skin tear on the left forearm. The allegation of abuse was made at 8:30 AM, but the facility reported it to the Department of Public Health (DPH) at 1:23 PM, five hours later, instead of within the mandated two-hour window. The resident involved had been admitted to the facility with diagnoses including dementia, anemia, and lack of coordination. The resident was assessed to have severe cognitive impairment and was dependent on facility staff for daily activities. During an interview, the resident initially claimed someone had grabbed and hit her but later retracted the statement, appearing confused and disoriented. The facility's Social Services Director assured the resident of her safety, but the delay in reporting the incident was a breach of protocol. Interviews with facility staff revealed that a Certified Nursing Assistant (CNA) noticed discoloration on the resident's arm during morning care but did not report it immediately, as the resident was not in pain. The discoloration was later reported by the resident's family member. The Director of Staff Development confirmed that CNAs were trained to report any changes in a resident's condition immediately, which did not occur in this case. The facility's policies required immediate reporting of such incidents to ensure resident safety and compliance with state and federal regulations.
Failure to Follow Wound Care Protocol
Penalty
Summary
The facility failed to adhere to its policy and procedure for clean dressing changes, which led to a deficiency in the care of a resident with a Stage 4 pressure ulcer. During an observation, a Licensed Vocational Nurse (LVN) did not change gloves or wash hands after handling a soiled dressing while providing wound care to a resident. The LVN continued to use the same soiled gloves to clean and treat the resident's wounds, including a Stage 4 pressure ulcer on the right mid-back, without performing hand hygiene or changing gloves as required by the facility's protocol. The resident involved had a medical history that included diabetes, hypertension, sepsis, and antibiotic-resistant bacteria, and was dependent on staff for various activities of daily living. The facility's policy required handwashing and glove changes between handling soiled dressings and applying clean ones, which the LVN did not follow. This failure was confirmed through interviews with the LVN and the Infection Prevention Nurse, who emphasized the importance of hand hygiene in preventing infection spread.
Inadequate Infection Control and Cohorting During Covid-19 Outbreak
Penalty
Summary
The facility failed to implement an effective infection prevention and control program during a Covid-19 outbreak, as evidenced by the lack of a proper line listing and inadequate cohorting of residents. The Infection Preventionist (IP) nurse did not create a line listing for residents who tested positive for Covid-19 or were exposed, due to being occupied with testing and moving residents. This led to confusion and improper room assignments, such as moving a Covid-19 positive resident into a room with negative residents, increasing the risk of virus transmission. Resident 1, who tested positive for Covid-19, was mistakenly moved from Room A to Room B, where they were placed with Residents 3 and 5, both of whom tested negative. This error occurred because the facility's nurses began moving residents based on verbal reports without formal documentation or a line listing. The IP nurse later confirmed Resident 1's positive status and had to move them again to another room, as their original room was occupied by another positive resident. The IP nurse relied on online resources for guidance during the outbreak, neglecting to consult local health department or CDC guidelines. The facility's policy required heightened surveillance during periods of transmission, but the IP nurse was unable to track the necessary information due to the lack of a structured system. This deficiency in infection control practices had the potential to spread Covid-19 among residents, staff, and the community.
Resident Elopement Due to Insufficient Supervision
Penalty
Summary
The facility failed to provide sufficient monitoring and supervision to a resident who eloped from the facility. The resident, who had diagnoses including metabolic encephalopathy and chronic obstructive pulmonary disease (COPD), was admitted on 3/27/24. The resident's assessments indicated that he did not have the capacity to understand and make decisions for himself and required substantial assistance when walking. On 4/20/24, the resident was found missing at around 8 PM when a family member called the facility to inform them that the resident had gone home. The facility staff were unaware that the resident had left the premises or was missing until the family member's call. Interviews with the staff revealed that the resident had expressed a desire to go home earlier in the evening but was told he could not leave without a physician's order. Despite this, the resident managed to leave the facility unnoticed. The Director of Nursing (DON) confirmed that the resident left the facility without notifying the staff and that the facility was informed of the resident's departure by a family member. The facility's policy on elopements and wandering residents, dated 12/19/22, indicated that residents at risk for elopement should receive adequate supervision and have preventive measures in place, such as door locks and alarms, to help avoid elopements and prevent accidents. However, the staff interviews and the incident itself suggest that these measures were either not in place or not effectively implemented, leading to the resident's unsupervised departure from the facility.
Failure to Maintain Dignity During Feeding
Penalty
Summary
The facility failed to ensure that a Certified Nurse Assistant (CNA) was seated while assisting with feeding during meal times for three residents. During meal observations, the CNA was seen standing while feeding Residents 25, 33, and 388, which is against the facility's policy. This policy mandates that staff should be seated at eye level with residents during feeding to maintain their dignity and prevent choking hazards. The CNA admitted to standing due to a lack of available chairs and personal preference, despite knowing the protocol required her to be seated. Resident 25, who has severe cognitive impairments and requires supervision for eating, was observed being fed by the standing CNA. Similarly, Resident 33, who is dependent on staff for eating and has severe decision-making impairments, was also fed by the standing CNA. Resident 388, who is also dependent on staff for eating and has severe cognitive impairments, was observed in the same situation. All three residents have significant medical conditions, including dementia and dysphagia, which necessitate careful and respectful feeding practices. Interviews with other staff members, including another CNA and the Director of Staff Development (DSD), confirmed that the facility's policy requires staff to be seated while feeding residents to maintain their dignity and prevent choking. The DSD emphasized that standing while feeding can make residents feel rushed and emotionally distressed, and it poses a safety risk. The facility's policies and procedures were reviewed and confirmed to support these practices, highlighting the importance of treating residents with respect and dignity during mealtimes.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for three residents, leading to potential risks in their care. Resident 12, who was admitted with acute respiratory failure, COPD, and other conditions, did not have a care plan for oxygen therapy despite having an order for oxygen via nasal cannula. Interviews with staff confirmed the absence of a care plan, which is essential for consistent and effective care. The facility's policy mandates that care plans include specific details about oxygen therapy, but this was not followed for Resident 12. Resident 2, who was readmitted with sepsis, pneumonia, and other serious conditions, also lacked a care plan addressing these diagnoses. Despite being treated for these conditions, there was no care plan outlining the necessary interventions and goals. Staff interviews revealed that the absence of a care plan posed a risk to Resident 2's health, as it left staff without clear guidance on how to manage and monitor the resident's conditions. Resident 31, who preferred to take medications at different times than the facility's usual schedule, did not have a care plan or physician's order to accommodate this preference. Medications were found left on the resident's bedside table, which is against the facility's policy. Staff confirmed that there should have been a care plan and physician's order to address the resident's medication preferences, and the lack of these documents could reduce the effectiveness of the medications and pose a risk to other residents.
Failure to Assess and Monitor Resident's Skin Condition
Penalty
Summary
The facility failed to ensure that Resident 81 was properly assessed, monitored, and evaluated for skin breakdown related to moisture-associated skin damage (MASD) and fungal infection. The resident's care plan, which included specific interventions for monitoring and treating the skin condition, was not implemented effectively. The Treatment Nurse (TN) did not conduct weekly skin assessments as required, and Resident 81's name was not listed in the facility's computerized charting system to prompt these assessments. Additionally, the TN did not inform the physician or document a Change of Condition (COC) report when the resident's wound worsened, and the primary physician was not consulted before the Wound Consultant was involved in the resident's care. The physician order to leave the perineal area open to air at bedtime was also not implemented, and the primary physician did not physically assess the resident's skin condition to ensure the treatment was effective. Resident 81 was admitted to the facility with multiple diagnoses, including Type 2 Diabetes Mellitus, urinary tract infection, sepsis, immunodeficiency, adult failure to thrive, and pressure ulcer. The resident was cognitively intact but dependent on assistance for personal hygiene and toileting. Despite the care plan indicating the need for regular skin assessments and monitoring, the facility failed to document and follow through with these interventions. The TN admitted to forgetting to assess the resident's skin condition due to the resident not being listed in the assessment history report. The resident's condition worsened, with severe pain and increased skin breakdown, which was not adequately addressed by the facility staff. Interviews with the resident, TN, and other staff members revealed a lack of communication and documentation regarding the resident's skin condition. The primary physician was not notified of the worsening condition, and the Wound Consultant was consulted without the physician's prior assessment. The resident expressed significant pain and distress due to the untreated skin condition, which impacted her ability to move and participate in activities. The facility's policies and procedures for skin assessment, incontinence-associated dermatitis, and notification of changes were not followed, leading to a delay in appropriate treatment and care for Resident 81.
Failure to Provide Appropriate Pain Management
Penalty
Summary
The facility failed to ensure that Resident 81 was assessed and provided with appropriate pain management and interventions to relieve severe pain in the perianal and perineal areas due to severe Moisture Associated Skin Damage (MASD) and fungal dermatitis. Despite the resident's complaints of severe pain and visible signs of discomfort during wound care and hygiene activities, the staff did not take adequate measures to address her pain. The resident's care plan did not include specific interventions for pain management in the affected areas, and no pain medication was ordered or administered to the resident during the observed period. Resident 81, who was admitted with multiple diagnoses including Type 2 Diabetes Mellitus, urinary tract infection, sepsis, immunodeficiency, adult failure to thrive, and pressure ulcer, was cognitively intact and able to communicate her pain. Despite this, the staff failed to recognize and manage her pain effectively. The resident reported experiencing the worst pain she had ever felt, particularly during brief changes and wound treatments, yet the CNAs and nurses did not stop to assess her pain or provide pain relief. The resident's Medication Administration Record (MAR) showed no record of pain medication being administered, and the CNAs did not report the resident's pain to the charge nurse. Interviews with the staff revealed a lack of communication and awareness regarding the resident's pain. CNAs assumed that the charge nurse was already aware of the resident's pain, and the Treatment Nurse did not confirm whether pain medication was given before wound treatment. The Director of Nurses (DON) acknowledged that the resident should not have been left to suffer from pain and that the staff should have taken immediate action to provide pain relief. The facility's policy on pain management emphasized the importance of recognizing and managing pain, but this was not followed in the case of Resident 81.
Failure to Complete Annual Competency Checks for CNAs
Penalty
Summary
The facility failed to complete a performance review for eight of nine Certified Nurse Assistants (CNAs) based on the outcome of the review for each of the CNAs. The CNAs did not have a completed Annual Core Clinical Competencies (ACCC), which is an assessment and training on the CNAs' ability to perform clinical nursing care. This failure had the potential to result in the facility's CNAs not being able to provide quality care to the resident population based on the Facility Assessment. The Director of Staff Development (DSD) confirmed that the previous DSD did not use the CNA Core Clinical Competencies checklist for any of the 2023 competency skills checks, leaving all the facility's CNAs' skills checks either incomplete or not done. During a review of the binder containing all the staff's annual competency checklists, it was found that nine full-time CNAs had no ACCC done since 2022. The DSD confirmed that the previous DSD did not conduct any ACCC with all nine CNAs. The Administrator (ADM) also confirmed the issue and stated that it was unacceptable for the CNAs not to have their annual competency skills check since 2022, as their skills needed to be refreshed yearly to take care of the facility's residents. The facility's policy and procedure indicated that competencies and skill sets for all new and existing staff must be consistent with their expected roles and that training requirements should be met annually and as necessary based on the facility assessment.
Failure to Label and Date Food Items
Penalty
Summary
The facility failed to implement its policy and procedure on food storage and professional standards of practice for food service safety. During an initial kitchen observation, a brown powdery substance identified as chicken bouillon was found in a clear plastic container without a label or date of when it was opened or used by. Additionally, the facility's refrigerator contained rice, sliced peaches, tofu, and green peas in clear plastic containers, all without use-by dates or preparation dates. The Dietary Service Supervisor (DSS) acknowledged that these items should have been labeled and dated to ensure they were still fresh and safe for consumption. The Director of Nurses (DON) confirmed that food in the kitchen should be labeled and dated to prevent spoilage and ensure resident safety. The facility's policy and procedure on food storage, revised on a specific date, indicated that all food products should be inspected for safety and quality, dated upon receipt, when opened, and when prepared. The Food Code 2022 also requires ready-to-eat, time/temperature control for safety food to be clearly marked with the date or day by which the food should be consumed, sold, or discarded. The failure to label and date food items had the potential to result in food contamination or growth of microorganisms, posing a risk to residents' health.
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 7,153 citations issued within 25 miles in the last 12 months — including the 37 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 Monterey Park
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Monterey Park Conv Hosp | 0.2 mi | ★★★★★ | 0 | 0 |
| Del Mar Convalescent Hospital | 1.2 mi | ★★★★★ | 19 | 0 |
| Sunny Village Care Center | 1.3 mi | ★★★★★ | 24 | 0 |
| Atherton Baptist Home | 1.5 mi | ★★★★★ | 10 | 0 |
| Alhambra Healthcare & Wellness Centre, Lp | 1.5 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.