Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Highland Park Skilled Nursing And Wellness Center during CMS and state inspections, most recent first.
Failure to Prevent Resident-to-Resident Physical Abuse: Two residents were involved in a physical altercation after one resident told the other to shower. The resident who refused the shower kicked a privacy curtain into the other resident's face and repeatedly punched him, causing minor facial bleeding and a darkened area near the eye. A CNA later found one resident on the floor and the other in bed, and an LVN noted blood on the injured resident's face. The residents had diagnoses including dementia/encephalopathy and mobility or medical issues, and the facility policy defined punching and kicking as physical abuse.
A resident with dementia and impaired mobility developed upper extremity discoloration and swelling, but the physician was not notified when the change in condition was first observed. Nursing documentation and staff interviews confirmed the discoloration, swelling, and associated discomfort, and the DON stated bruising and swelling required physician notification under facility policy.
A resident with dementia, difficulty walking, and a forearm fracture had skin checks and progress notes documenting upper extremity discoloration and slight swelling. The notes and skin check forms stated the physician was notified, but the TX nurse later said she did not notify the physician and had documented it in error. The DON stated the nurse should not record physician notification unless it actually occurred, and that records must remain accurate and intact.
Medication administration was not performed per physician orders for two residents. An LVN did not follow ordered g-tube flush amounts or flush between meds for a resident receiving Amiodarone, Amlodipine, and Vitamin C, and more than half of the Amiodarone spilled during administration. The same LVN also gave Percocet to another resident whose pain was 7.5/10 even though the PRN order was for pain 8-10.
Medication administration errors resulted in a 50% error rate after an LPN failed to follow ordered g-tube flush instructions for a resident receiving Amiodarone, with medication spilling during administration and no flush between meds, and gave Percocet to another resident whose pain score did not meet the ordered 8-10 range. The DON/ADON stated the orders should be followed and that omitting flushes or spilling medication means the resident may not receive the full dose.
Improper Food Storage and Kitchen Sanitation: A dietary aide was observed in the kitchen without a hair net, with hair exposed, despite facility dress code and infection control policies requiring hair restraint. In addition, open bags of sugar and pasta were left unsealed, an expired bag of grits remained in dry storage, and a trashcan was stored next to clean pots, pans, and baking ware, with overflow and food waste splashed onto clean items.
Unlabeled visitor food was found in a resident refrigerator used for personal food items brought in by family and friends. Three food containers were observed without a resident's name, and the DS confirmed the facility policy required food brought in by visitors to be clearly labeled with the resident's name and date received.
Failure to Obtain Informed Consent for Psychotropic Medications: Two residents with documented capacity to make decisions received antidepressant and antipsychotic medications without signed informed consent forms in the record. One resident denied signing consent for Trazodone, and the other resident’s consent form for Aripiprazole and Doxepin was also unsigned while both medications were administered per physician orders and MAR documentation.
Cracked Walls and Peeled Paint in Resident Room: A resident's room had cracked walls and peeled-off paint, and the resident said this made him uncomfortable because he thought spiders could come out of the cracks. The ADON stated the condition was not safe, sanitary, or home-like, and the facility policy called for a pleasant, safe, clean, comfortable, and homelike environment.
Failure to document depression behaviors for a resident receiving Remeron: staff were ordered to monitor and record the number of behavioral occurrences each shift, but the MAR showed only check marks instead of numeric counts. The resident had depression, COPD, hemiplegia, hemiparesis, and moderately impaired cognitive skills, and the LVN and ADON stated the documentation should have included hash marks or numbers so the care team could track whether the resident’s behavior was improving.
Inaccurate PASARR Level 1 Screening: A resident admitted with depression, schizophrenia, and epilepsy had MDS documentation showing schizophrenia and use of antipsychotic and antidepressant medications, but facility staff completed a PASARR Level 1 that stated the resident did not have SMI and was not on psychotropic meds. The screening concluded that a Level 2 PASARR was not required. The MDSN and ADON stated the PASARR was not accurate because it did not reflect the resident’s schizophrenia or psychotropic medication use.
Failure to follow up on a resident’s ENT authorization for audiogram and tympanogram testing led to a deficiency. The resident was hard of hearing, had cognitive impairment, and had a physician order for audiology consults with follow-up as indicated. The ENT recommended audiological testing and follow-up, but the SSD stated the authorization was not followed up, and the ADON stated it should have been, along with a care plan for hard of hearing.
A resident with impaired cognition, difficulty walking, lack of coordination, and osteoarthritis was care planned to require supervision while smoking and staff safekeeping of smoking materials. However, the resident was observed smoking outside on the patio without supervision during the scheduled smoke break. The AC stated he did not observe the resident while smoking, and the ADON confirmed the resident required supervision and that unsupervised smoking was not acceptable.
Fluid Restriction Not Followed for A Resident on Dialysis: A resident with ESRD and severe cognitive impairment had a physician-ordered 1000 ml/day fluid restriction that was also reflected in the care plan and MAR. The MAR documented 1,040 ml of fluid given in one day, and the ADON acknowledged the amount exceeded the ordered limit; facility dialysis policy stated diet and fluid restrictions would be followed as ordered.
Medication Spilled During Amiodarone Administration: An LVN was observed administering Amiodarone HCL to a resident via G-tube, and more than half of the dose spilled during the process. The LVN stated the resident did not receive the full dose and that the physician’s order was not followed. The resident had HTN, hypertensive heart disease with HF, and dementia, and the facility policy required medications to be given in accordance with the prescriber’s written orders.
A facility failed to store two unopened latanoprost eye drop bottles in the medication refrigerator as required by policy and the manufacturer’s instructions. An LVN observed the eye drops in the med cart instead of refrigerated, and the ADON stated they should have remained refrigerated until opened to maintain potency; the ADON also stated the medication in the cart may not be as effective and may be toxic.
Nebulizer Equipment Not Changed Per Policy: A resident with COPD and an order for nebulizer tx had a breathing mask, tubing, and respiratory set-up bag stored in the room without a date of first use, with tubing hanging outside the bag and touching the floor. An LVN and the IPN confirmed the equipment should be changed every 7 days and that it was overdue, contrary to facility policy.
Care plans for two residents were not individualized or resident-centered. One resident with a hx of falls, impaired cognition, and dependence for multiple ADLs had a fall risk score of 5, but the care plan did not include interventions such as more frequent rounds or offering snacks as needed. Another resident with ESRD on dialysis, AFib, and anemia had a physician-ordered 1000 ml/day fluid restriction, but the care plan did not reflect the ordered limit.
Resident rooms in multiple-occupancy areas did not meet the required 80 sq. ft. per resident in 12 of 22 rooms. Surveyors observed the affected rooms, reviewed the facility’s accommodation analysis, and found several rooms with 2 to 4 beds measuring below the minimum per-resident space, although residents were observed to have enough room to move freely and one resident stated there was enough space for personal belongings.
A resident with toxic encephalopathy, depression, impaired safety awareness, and severe mobility limitations, who had a documented history of elopement and multiple recent elopement attempts, was not adequately supervised or protected despite care plan identification of elopement risk. On the day of the incident, staff noted increased confusion and observed the resident trying to open an exit door, but no 1:1 observation, wander guard, or enhanced monitoring was implemented, and staff instead attempted to block the exit with a medication cart. The resident was last seen in her room at lunchtime and was later found missing, having exited through a door opened for visitors, in contrast to facility policies requiring individualized elopement risk interventions and person-centered monitoring systems.
A resident with multiple chronic conditions was administered Ativan without a specific behavioral indication in the physician's order, and staff failed to monitor or document the resident's behaviors and side effects as required by facility policy. Interviews and record reviews confirmed that the MAR and MPDM forms lacked necessary documentation, and staff did not follow protocols for psychotropic medication management.
A resident with end-stage renal disease missed a scheduled hemodialysis treatment due to transportation issues, and the facility failed to arrange alternate transportation. Additionally, the resident was not monitored for fluid overload, and blood pressure medications were not administered as ordered. These failures led to the resident experiencing severe symptoms, requiring transfer to a hospital for emergency treatment.
A resident with multiple health conditions had medications left unattended on their bedside table by an LVN, contrary to facility policy. The resident was not approved for self-administration, and the medications were left unlabeled and uncovered, posing a risk of accidental ingestion by others. Staff confirmed this practice was against policy, which requires medications to be stored in the medication cart if refused.
The facility did not update the Daily Posted Nurse Staffing information from 2/14/2025 to 2/25/2025, as required by its policy. An observation on 2/25/2025 revealed that the posted staffing information was outdated by eight days. RN 1, covering for the DON, confirmed the lapse and acknowledged the importance of daily updates to ensure adequate staffing for resident care.
The facility failed to maintain the dignity and privacy of two residents. A resident with Alzheimer's was fed by a CNA who stood instead of sitting at eye level, violating the facility's policy. Another resident with an indwelling catheter had their urinary collection bag uncovered, contrary to the facility's requirement for dignity bags to ensure privacy. These actions did not align with the facility's policies aimed at promoting resident dignity and respect.
The facility failed to accurately assess the MDS for two residents, omitting diagnoses of anxiety and depression despite evidence of these conditions and prescribed medications. This oversight could hinder the development of individualized care plans, as confirmed by staff interviews and record reviews.
The facility failed to provide necessary respiratory services for three residents, leading to potential health risks. A resident with COPD was not given the prescribed continuous oxygen therapy, and their equipment was not properly labeled. Another resident's nebulizer equipment was improperly stored, and a third resident received excessive oxygen, contrary to physician orders.
The facility failed to follow proper food storage and dish sanitization practices. Several food items were improperly labeled or stored, with some past their use-by dates, and the dishwasher was operated below the required temperature. These deficiencies could lead to foodborne illness among residents.
The facility failed to maintain proper waste management as two dumpsters were observed with overflowing trash, causing the lids to remain open. The Maintenance Supervisor confirmed that the facility policy required trash to be compressed to keep lids closed, preventing the attraction of pests. The Waste Management policy indicated that waste containers must be closable and food waste should be placed in covered garbage cans.
The facility failed to update care plans for two residents. One resident's fall care plan was not revised after a fall with injury, despite being at high risk for falls. Another resident's care plan was not updated to reflect a new fluid restriction order. Both failures were acknowledged by facility staff, highlighting a lack of adherence to policies requiring care plan updates following changes in condition or physician orders.
A resident with dementia and mobility issues experienced a fall with a head injury, but the facility failed to conduct a Post Fall Evaluation, neuro checks, or an IDT meeting as required by their policy. The ADON confirmed these actions were not taken, despite the facility's Fall Management Program outlining these necessary steps.
A resident with an indwelling urinary catheter did not receive appropriate care as per physician's orders, leading to delayed identification of a potential UTI. Despite observations of sediment and concentrated urine, there was no documentation or physician notification, contrary to facility policy. The resident's medical history included conditions that increased UTI risk.
A facility failed to monitor the fluid intake of a resident on dialysis with a fluid restriction, leading to a deficiency. The resident's fluid intake exceeded the prescribed limits, and there was no record of fluid intake with medication administration. Staff were unaware of the fluid restriction, and facility policies were not followed, posing a risk of fluid overload or dehydration.
A resident with multiple diagnoses, including dementia and psychosis, was left with eight medications unattended on their nightstand by an IPN, contrary to facility policy. The resident was not approved for self-administration, and the IPN admitted to leaving the medications due to a disruption. This failure to supervise medication administration posed a risk of medication errors and potential harm.
A facility failed to act on a pharmacy consultant's recommendations during a Medication Regimen Review for a resident with type 2 diabetes, depression, and dementia. The review identified issues with medication administration, including the concurrent use of Saxagliptin and Sitagliptin, missing 'Do not crush' instructions for Ferrous Sulfate, and incorrect timing for Repaglinide. The facility lacked a designated staff member to review and follow up on these recommendations, resulting in no action being taken.
The facility did not ensure daily temperature checks of the Activity Room Refrigerator, which stored food brought by family for a resident, as required by policy. The temperature log lacked entries for several days, and the Dietary Services Supervisor confirmed the oversight.
The facility failed to meet the required 80 square feet per resident in 12 out of 22 rooms, with measurements ranging from 64.6 to 76.6 square feet per resident. Despite the deficiency, residents reported comfort, and observations showed adequate space for mobility aids and care provision. The Department recommended a waiver for the affected rooms.
A resident with severe cognitive impairments and multiple diagnoses, including malnutrition, refused more than 50% of meals for three consecutive times. The facility failed to notify the physician as required by policy, which considered this a Change of Condition (COC). The Director of Nursing confirmed the oversight, which could delay necessary care for the resident.
The facility failed to promote dignity for two residents by not covering a urinary catheter bag and standing above a resident while feeding. Staff acknowledged the importance of these actions for resident dignity, but they were not followed.
The facility failed to provide necessary ADL care and communication devices for two residents. One resident with severe cognitive impairment was not given a communication device in their primary language and was improperly positioned in bed. Another resident faced communication barriers due to the lack of a communication device in their preferred language. Staff interviews and observations confirmed the absence of required communication tools and proper positioning, leading to deficiencies in care.
The facility failed to ensure a safe environment for two residents, leading to potential risks for falls, injuries, and delayed care. One resident's room was cluttered, impeding emergency access, while another resident's overhead trapeze setup posed entanglement and injury risks. Staff acknowledged these hazards, but the facility's safety policies were not adequately followed.
The facility failed to ensure sanitary conditions in food storage and preparation, with issues including an oven with an unreadable temperature knob and improperly labeled or expired food items in the kitchen and dry storage.
The facility failed to follow its Antibiotic Stewardship protocol, leading to the inappropriate administration of antibiotics to two residents who did not meet the McGeer's Criteria. The physician was not notified of the residents' screening scores, resulting in unnecessary antibiotic use.
The facility failed to provide education, offer, and document the updated COVID-19 vaccinations for the year 2023-2024 for 96 out of 105 employees. Interviews and record reviews revealed incomplete documentation and lack of a clear process for notifying all employees about the vaccination clinic, placing residents and staff at risk for possible COVID-19 infection.
The facility failed to ensure that the call light was within reach of three residents, leading to a potential delay in the provision of services and assistance with ADLs. The call lights for these residents were found in inaccessible locations, contrary to their care plans and facility policy.
The facility failed to accurately document a resident's eating ability on the MDS. Despite being assessed as needing substantial/maximal assistance, the resident was observed eating independently with minimal assistance. Staff interviews confirmed the resident's ability to feed herself, highlighting a discrepancy in the MDS documentation.
The facility failed to accurately complete the PASRR form for a resident with schizophrenia, leading to the resident not receiving necessary psychiatric treatment. Despite medical records indicating a diagnosis of schizophrenia and the use of psychotropic medications, the PASRR forms were incorrectly marked as negative. Interviews with staff revealed lapses in the submission and verification process of the PASRR forms.
The facility failed to update the care plan for a resident with a history of seizures, despite changes in prescribed seizure medications. The care plan did not reflect all current medications, which was acknowledged by both the Registered Nurse Supervisor and the Director of Nursing.
A resident was found hiding Colace capsules to avoid taking too much medication, leading to a failure in proper medication administration as per the facility's policy. The DON confirmed that nurses must observe residents taking their medications to prevent double dosing or missed doses.
The facility failed to ensure a shower chair used by residents was in good condition and free from stains. A CNA was observed using a stained and worn-out shower chair, which was confirmed by the RNS, MS, and DON to be unsuitable for use. The facility's policy emphasized providing a safe, clean, and comfortable environment, which was not upheld in this instance.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect two residents from resident-to-resident physical abuse when Resident 2 struck Resident 1 during an altercation in their shared room. Resident 1 was admitted and readmitted to the facility with diagnoses including unspecified hydronephrosis, essential hypertension, and difficulty walking, and his MDS indicated no cognitive impairment for daily decision making. Resident 2 was admitted with diagnoses including encephalopathy, type 2 diabetes mellitus with unspecified complications, and dementia in other diseases classified elsewhere, and his MDS indicated moderate cognitive impairment with supervision or touching assistance needed for several activities of daily living. Resident 1 stated that he told Resident 2 to take a shower because Resident 2 was filthy, after which Resident 2 kicked the privacy curtain into Resident 1's face and repeatedly punched him with his fists from Resident 1's left side. Resident 1 stated he then struck Resident 2 with one fist and was unsure whether Resident 2 landed on the floor next to his bed or on his bed. During observation, Resident 1 had a darkened area near his left lower eye corner and no wound on his lips, and he stated he had felt blood on his left eye corner and left lips but that the areas had healed. A CNA stated she had gone to prepare Resident 2 for a shower, but Resident 2 refused, and she later heard a noise from the room and saw Resident 2 on the floor next to his own bed and Resident 1 in his bed. An LVN stated he separated the residents after arriving at the room, saw blood on Resident 1's face, and called the physician for wound care and treatment. The DON stated the staff reported the incident and that both residents had been roommates for a few months. The facility policy defined physical abuse to include hitting, punching, and kicking and stated the facility identifies, corrects, and intervenes in situations in which abuse is more likely to occur.
Failure to Notify Physician of Resident Change in Condition
Penalty
Summary
The facility failed to ensure the resident’s physician was informed when the resident developed a change in condition involving upper extremity skin discoloration and swelling. The resident had diagnoses including dementia and difficulty walking, and the Minimum Data Set indicated moderate cognitive impairment with assistance needed for several activities of daily living. Admission assessment documentation indicated no skin issues were present, but on 6/18/2026 a progress note and skin check documented upper extremity discoloration and slight swelling, and the same findings were again documented on 6/19/2026. During interviews, an LVN stated she observed discoloration and slight swelling of the resident’s left lower arm on 6/18/2026 and later swelling of the left upper arm on 6/19/2026, with facial grimacing when the arm was touched. The TX nurse stated the resident had a hunched posture, did not want to raise the arm to put on a sweater, and that the swelling had not gone down since it was first observed. The DON stated bruising and swelling were considered a change in condition and that the physician should have been informed on 6/18/2026 when the licensed nurse noted swelling and discoloration of the resident’s left upper arm, but the doctor was not informed. The facility policy required the licensed nurse to assess the change in condition and notify the physician and family.
Inaccurate Documentation of Physician Notification in Skin Checks
Penalty
Summary
The facility failed to maintain clinical records in accordance with accepted professional standards for one resident by inaccurately documenting skin check forms dated 6/18/2026 and 6/19/2026. The resident had diagnoses including dementia, difficulty walking, and a fracture of the forearm, and the MDS dated 5/22/2026 indicated moderate impairment in cognitive skills for daily decision making. The MDS also showed the resident required supervision or touching assistance with toileting hygiene, showering/bathing, lower body dressing, putting on/taking off footwear, and personal hygiene, and setup or clean up assistance with eating, oral hygiene, and upper body dressing. Progress notes on 6/18/2026 at 9:57 AM and 6/19/2026 at 9:29 AM documented upper extremity discoloration and slight swelling, and both notes stated the physician was notified. The corresponding skin check forms for both dates also documented the discoloration and swelling and indicated the physician was notified. During interview, the TX Nurse stated she did not notify the physician on either date and that she made an error documenting that the physician had been notified. The DON stated the nurse should not document physician notification if she did not call the physician, and that medical records need to maintain accuracy and integrity to ensure the resident receives the right services.
Medication Administration Not Performed Per Physician Orders
Penalty
Summary
Pharmaceutical services were not provided in accordance with physician orders for two residents during medication administration observations and record review. One resident had diagnoses including hypertension, hypertensive heart disease with heart failure, and dementia, and was assessed as severely impaired in cognitive skills for daily decision making. The resident had physician orders for Amiodarone HCL 200 mg by mouth daily for ventricular arrhythmias and for g-tube flushing with 30 mL of water before and after medication administration, with 5 mL in between each medication. During observation, an LVN flushed the resident’s g-tube with 15 mL of water before medications instead of the ordered 30 mL. The LVN then administered Amiodarone through the g-tube, and more than half of the medication spilled onto the resident. The LVN administered Amlodipine and Vitamin C without flushing the g-tube between medications, then flushed with 15 mL of water after administration. In interview, the LVN stated she did not follow the physician’s ordered flush amounts, that the Amiodarone spilled so the resident did not receive the full dose, and that the physician’s order was not followed. A second resident had diagnoses including adult failure to thrive, acute kidney failure, and a stage 3 pressure ulcer/injury, and was independent in cognitive skills for daily decision making. The resident had an order for Percocet 5-325 mg every 8 hours as needed for pain level 8-10, with instructions to hold if sleepy or respiratory rate was less than 12. During observation, the resident reported pain at 7.5 out of 10, yet the LVN administered Percocet. In interview, the LVN stated the medication should not have been given because it was ordered only for pain levels of 8-10 and acknowledged not following the physician’s order.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to keep its medication error rate below 5 percent. Surveyors identified 3 medication errors out of 25 observed medication administration opportunities, resulting in a 50% error rate for two sampled residents. The errors involved Resident 4 and Resident 8 during observed medication passes. Resident 4 had diagnoses including hypertension, hypertensive heart disease with heart failure, and dementia, and the MDS indicated severe impairment in cognitive skills for daily decision making. The physician ordered Amiodarone HCL 200 mg daily and ordered the g-tube to be flushed with 30 mL of water before and after medications, with 5 mL in between each administration. During observation, LVN 2 flushed the g-tube with only 15 mL before giving medications, administered Amiodarone through the g-tube with more than half of the medication spilling onto the resident, gave Amlodipine and Vitamin C without flushing between medications, and then flushed with 15 mL after administration. LVN 2 stated the ordered flush amounts were not followed, that the Amiodarone spilled so the resident did not receive the full dose, and that the physician's order was not followed. Resident 8 had diagnoses including adult failure to thrive, acute kidney failure, and a stage 3 pressure ulcer/injury. The MDS indicated the resident was independent in cognitive skills for daily decision making and received pain medications as needed. The physician ordered Percocet 5-325 mg every 8 hours as needed for pain level 8-10, with instructions to hold if sleepy or respiratory rate was less than 12. During observation, Resident 8 reported pain at 7.5 out of 10, yet LVN 2 administered Percocet. LVN 2 later stated the medication should not have been given because the order was for pain levels 8-10 and acknowledged that the physician's order was not followed.
Improper Food Storage and Kitchen Sanitation
Penalty
Summary
Dietary Aide 1 was observed in the kitchen without a hair net, with hair exposed, during a concurrent observation and interview with the Dietary Supervisor. The aide stated he should have worn a hair net while in the kitchen so his hair would not get into the food residents consume. The Dietary Supervisor reviewed the facility's Dress Code policy and stated the facility did not have hats for staff with short hair, but per facility policy the aide should have been wearing a hat while in the kitchen. The supervisor also stated it was important to follow the policy to prevent staff hair from going into residents' food during food preparation. The facility also failed to properly handle and store food and kitchen items. During observation, one bag of sugar and one bag of dried pasta were open and not tightly sealed, and the Dietary Supervisor stated they should have been sealed after opening. A bag of grits in dry storage was observed with an expiration date of 6/3/2025 and was identified as expired. In the kitchen, a trashcan was stored under the sink next to clean skillets, pots, and baking pans; the supervisor stated there had been a plastic divider, but it broke and had not been replaced. Later, the trashcan was observed overflowing, with the lid resting on clean baking pans and food waste particles splashed onto the pans. The supervisor stated the trashcan should not be stored next to clean dishes, cooking wares, and baking ware because trash can contaminate them and affect food served to residents.
Unlabeled Visitor Food in Resident Refrigerator
Penalty
Summary
The facility failed to ensure that all food items brought into the facility by visitors for residents were labeled and dated with the resident's name, as required by its policy titled Food Brought in by Visitors. During an observation in the Activity Room, three food containers were seen in the resident refrigerator used for personal food items brought in by family and friends, and none of the containers were labeled with a resident's name. In a concurrent interview and record review, the Dietary Supervisor reviewed the facility policy dated 5/22/2025, which stated that food brought by visitors should be placed in a food container clearly labeled with the resident's name and date received and stored in a designated refrigerator. The Dietary Supervisor stated the food items should be labeled with the resident's name and that proper labeling was important to prevent staff from mistaking one resident's food for another and to ensure residents received their correct food.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent before administering psychotropic medications to two sampled residents. Resident 1 was admitted and readmitted with diagnoses including osteoarthritis, DM, and chronic kidney disease, and the H&P stated the resident had the capacity to understand and make decisions. The record showed an informed consent form for Trazodone HCL 50 mg dated 7/27/2025, but the form did not contain Resident 1’s signature. The physician order dated 1/21/2026 directed Trazodone HCL 50 mg at bedtime for depression as manifested by inability to sleep, and the MAR showed the medication was administered from 3/1/2026 through 3/11/2026. During interview, the ADON stated Resident 1 was self-responsible and the facility should obtain consent before placing an order for an antidepressant, and Resident 1 stated he did not give or sign consent for Trazodone HCL. Resident 28 was admitted with diagnoses including heart failure and obstructive and reflux uropathy, and the H&P stated the resident had the capacity to make medical decisions. The record included an informed consent form for Aripiprazole 5 mg and Doxepin HCL 100 mg dated 12/18/2025, but the form did not contain Resident 28’s signature. Physician orders showed Doxepin HCL 100 mg at bedtime for depression as manifested by inability to sleep and Aripiprazole oral film 5 mg in the morning for schizophrenia as manifested by verbal aggression and anger outburst. The MAR showed Aripiprazole was administered from 3/1/2026 through 3/12/2026 and Doxepin was administered during the same period, while the consent form remained unsigned by the resident.
Cracked Walls and Peeled Paint in Resident Room
Penalty
Summary
The facility failed to maintain a comfortable, safe, and homelike environment for one resident by allowing the resident's room to have cracked walls and peeled-off paint. During observation and interview, the resident stated that the cracks in the walls and the peeled-off paint made him feel uncomfortable because he thought spiders could come out from the cracks. The resident was identified as being admitted with diagnoses including heart failure and obstructive and reflux uropathy, and the MDS indicated he was independent in cognitive skills for daily decision making while requiring partial/moderate assistance with toileting hygiene, bathing, dressing, and footwear. During interview, the ADON stated that cracked walls and peeled paint were not acceptable because they were not safe, sanitary, or home-like for the resident, and added that bugs or spiders could come out of the cracks in the walls. The facility policy for resident rooms and environment stated that residents should be provided a pleasant environment and a safe, clean, comfortable, and homelike environment.
Failure to Document Depression Behaviors for Resident Receiving Remeron
Penalty
Summary
The facility failed to ensure that depression behaviors for one resident were monitored and documented as ordered while the resident was receiving Remeron for depression. The resident was readmitted with diagnoses that included depression, COPD, hemiplegia, and hemiparesis. The MDS dated 3/7/2026 indicated the resident had moderately impaired cognitive skills for daily decision making, was dependent for toileting hygiene and showering/bathing, required partial/moderate assistance with oral hygiene, and needed setup or clean-up assistance with eating. The MDS also indicated the resident was receiving an antidepressant medication. The resident’s order summary directed staff to monitor target behaviors for use of Remeron due to depression manifested by poor oral intake of less than 50 percent and to indicate the number of behavior occurrences, or mark not applicable if no behaviors occurred. Review of the MAR showed staff were to monitor and document the number of behavioral occurrences every shift, but entries for the day, evening, and night shifts on 3/10/2026 and 3/11/2026 contained only check marks and no numeric values. During interview, the LVN stated licensed staff should have documented a number for how many times the resident’s behavior occurred, but did not, and the ADON stated staff should have used hash marks to document the resident’s depression behavioral occurrences so the care team could monitor whether the resident’s behavior was improving.
Inaccurate PASARR Level 1 Screening
Penalty
Summary
The facility failed to complete an accurate PASARR Level 1 screening for one resident who was admitted with diagnoses including depression, schizophrenia, and epilepsy. The resident’s MDS documented depression and schizophrenia, use of antipsychotic and antidepressant medications, intact cognitive skills for daily decision making, and varying levels of assistance with activities of daily living. However, the PASARR Level 1 screening completed by facility staff stated the resident was not diagnosed with a serious mental illness and was not prescribed psychotropic medications, and it concluded that a Level 2 PASARR evaluation was not required. During interview, the MDS Nurse stated the resident was readmitted and another PASARR Level 1 screening was completed, but the screening was not accurate because it did not reflect schizophrenia or the use of three psychotropic medications. The Assistant Director of Nursing stated PASARR is a behavioral health evaluation of diagnoses and medications to assess for special services, and that the resident’s Level 1 screening was not accurate. Facility policy stated all residents are to be screened for mental illness and intellectual disability or related conditions, and that a new PASARR is completed if there has been a significant change in the resident’s condition.
Failure to Follow Up on Hearing Services Authorization
Penalty
Summary
Failure to assist a resident in gaining access to vision and hearing services occurred when the facility did not follow up on Resident 55’s authorization for audiogram and tympanogram testing after an ENT appointment. Resident 55 was admitted with diagnoses including hypertension, history of falling, and difficulty walking, and the MDS dated 1/6/2026 indicated the resident was moderately impaired in cognitive skills for daily decision making and required varying levels of assistance with activities of daily living. A physician order dated 12/30/2025 directed audiology consults with follow up treatment as indicated. During observation on 3/9/2026, Resident 55 stated she was hard of hearing and could not hear what the surveyor was saying. Review of the ENT visit dated 1/21/2026 showed a plan to recommend audiological testing and follow up after audio testing, with authorization for audio and tympanogram and audio follow up. The Social Services Director stated she did not, and should have, followed up on the ENT authorization to ensure the resident’s hearing did not decline. The ADON also stated the authorization for audio and tympanogram should have been followed up after the ENT appointment, and that Resident 55 did not have a care plan for hard of hearing.
Failure to Supervise Resident While Smoking
Penalty
Summary
The facility failed to provide supervision for one sampled resident who was reviewed for smoking. Resident 29 had diagnoses including difficulty walking, lack of coordination, and osteoarthritis. The resident’s MDS indicated moderately impaired cognitive skills for daily decision making and partial/moderate assistance with toileting hygiene, bathing, dressing, and putting on/taking off footwear. The care plan for chronic tobacco use, revised 2/18/2026, stated that the resident requires supervision while smoking and that staff are to keep smoking materials for safekeeping. The facility’s Smoke Break Assignment dated 3/11/2026 indicated the Admissions Coordinator would supervise residents during smoke break starting at 11:00 AM. On 3/11/2026 at 11:20 AM, Resident 29 was observed smoking outside on the patio with no supervision. During interview, the Admissions Coordinator stated he did not observe Resident 29 while he was smoking and said the resident requires supervision and it was not acceptable for the resident to smoke without supervision for safety reasons and to prevent accidents. The ADON also stated the resident requires supervision while smoking and that it was not acceptable for the resident to be unsupervised because the resident could injure himself or cause a fire.
Fluid Restriction Not Followed for Resident on Dialysis
Penalty
Summary
Resident 13, who was admitted to the facility with diagnoses including ESRD, cognitive communication deficit, and dependence on renal dialysis, had a physician order dated 1/2/2026 for a fluid restriction of 1000 ml per day. The resident’s MDS dated 1/9/2026 indicated severe impairment in cognitive skills for daily decision making and that the resident required substantial to maximal assistance with eating and oral hygiene and was dependent for several activities of daily living, including toileting hygiene, bathing, dressing, and footwear. The care plan for dialysis, revised 3/7/2026, also identified a fluid restriction of 1000 ml per day, and the MAR for 3/2026 documented the same restriction. Review of the MAR showed that on 3/1/2026, Resident 13 received 640 ml on the morning shift, 240 ml on the evening shift, and 160 ml on the night shift, for a total of 1,040 ml. During interview, the ADON acknowledged that the resident received more fluid than ordered and stated that this was not acceptable because the resident could get fluid overload. Facility policy titled Dialysis Management, dated 1/14/2026, stated that diet and fluid restrictions would be followed as ordered.
Medication Spilled During Amiodarone Administration
Penalty
Summary
Resident 4, who had diagnoses including hypertension, hypertensive heart disease with heart failure, and dementia, was assessed as severely impaired in cognitive skills for daily decision making and required substantial to maximal assistance with several activities of daily living. The resident’s physician order dated 9/22/2025 directed Amiodarone HCL 200 mg by mouth once daily for ventricular arrhythmias. During a medication administration observation on 3/11/2026 at 8:00 AM, LVN 2 was observed administering Amiodarone to Resident 4 via the G-tube, and more than half of the medication spilled onto the resident. In interview, LVN 2 stated she spilled the Amiodarone during administration, so the resident did not receive the full dose, and that the physician’s order was not followed. The ADON stated that if a medication is spilled during administration, the resident does not receive the full dosage and the physician should be notified. The facility policy indicated medications are to be administered in accordance with written prescriber orders.
Improper Storage of Unopened Latanoprost Eye Drops
Penalty
Summary
The facility failed to ensure safe pharmaceutical services by not refrigerating two unopened latanoprost eye drop bottles in accordance with facility policy and the manufacturer’s instructions. During a medication cart observation and interview, LVN 1 found Resident 7’s and Resident 36’s latanoprost eye drops stored inside the medication cart instead of in the designated medication refrigerator. LVN 1 stated the unopened eye drops should remain refrigerated until opened so the medication stays potent. During interview, the ADON stated the two bottles should have been kept in the refrigerator until opened to maintain potency and said the eye drops in the medication cart may not be as effective and may be toxic for the resident. Facility policy on medication storage stated medications requiring refrigeration are to be kept between 36 F and 46 F, and the medication administration guidelines required medications to be properly oriented to the facility’s medication distribution system, including storage. The FDA prescribing information for Xalatan (latanoprost) Ophthalmic Solution stated unopened bottles should be stored under refrigeration at 2 to 8 C (36 to 46 F) and protected from light.
Nebulizer Equipment Not Changed Per Policy
Penalty
Summary
The facility failed to ensure that Resident 37’s breathing treatment mask, tubing, and respiratory set-up bag were changed every seven days per policy. Resident 37 was admitted and readmitted with diagnoses including COPD, presence of a cardiac device, and paroxysmal atrial fibrillation. The resident’s MDS dated 1/31/2026 indicated moderately impaired cognitive skills for daily decision making and dependence with eating, oral hygiene, toileting hygiene, lower body dressing, and personal hygiene, with substantial to maximal assistance needed for bed mobility and transfers. A physician order dated 2/27/2026 directed ipratropium bromide inhalation solution via nebulizer every 12 hours for wheezing. During observation on 3/11/2026 at 8:33 AM, the resident’s breathing treatment mask and tubing were stored inside a respiratory set-up bag dated 3/1/2026, with some tubing hanging outside the bag and touching the floor. There was no date of first use labeled on the mask or tubing. During interview, LVN 1 stated the mask, tubing, and respiratory/patient set-up bag are supposed to be changed every seven days by morning shift nurses, and that the items should have been changed on 3/8/2026 but were not. The Infection Preventionist Nurse confirmed the equipment should be stored inside a clean respiratory set-up bag, labeled with the date of first use, and changed every seven days to prevent respiratory infection and cross contamination. The facility policy titled Nebulizer (small volume), revised 1/14/2026, stated the nebulizer equipment is to be placed back into the resident’s set-up bag and changed every seven days and as needed.
Care Plans Missing Fall and Fluid Restriction Interventions
Penalty
Summary
The facility failed to develop individualized, resident-centered care plans for two residents. One resident was admitted with diagnoses including difficulty walking, lack of coordination, and a history of falls. The MDS dated 2/3/2026 showed the resident was moderately impaired in cognitive skills for daily decision making and dependent for multiple activities of daily living, including toileting hygiene, bathing, dressing, footwear, and personal hygiene. A fall risk assessment dated 1/27/2026 showed a fall risk score of 5, and LVN 2 stated the resident had a tendency to get up on her own unassisted. During review of the fall risk care plan, the ADON stated the plan should have included more frequent rounds because the resident gets up on her own and should have included offering snacks during snack time or as requested by the resident. The second resident was admitted and later readmitted with diagnoses including end stage renal disease, dependence on renal dialysis, unspecified atrial fibrillation, and unspecified anemia. The MDS showed no impairment in cognitive skills for daily decision making and indicated the resident needed supervision or touching assistance for several ADLs and set up or clean-up assistance for eating and oral hygiene. Physician orders dated 2/5/2026 included a fluid restriction of 1000 ml per day, with specific amounts assigned for meals and each nursing shift. During review of the care plan, LVN 2 and the ADON stated the resident-centered care plan did not reflect the ordered fluid restriction.
Resident Rooms Did Not Meet Minimum Square Footage Requirements
Penalty
Summary
The facility failed to ensure that 12 of 22 resident rooms met the required minimum of 80 square feet per resident in multiple-occupancy bedrooms. During observations from 3/9/2026 to 3/12/2026, Rooms 3, 4, 5, 6, 7, 8, 11, 14, 15, 16, 17, and 18 were identified as not meeting the square footage requirement for each resident. The report states that the affected rooms had applications for room variance and that residents in those rooms were observed to have enough space to move freely inside the rooms. The facility’s Client Accommodation Analysis Form dated 3/9/2026 showed several rooms measuring less than the required square footage per resident, including rooms with 2, 3, and 4 beds and per-resident space ranging from 64.6 sq. ft. to 76.6 sq. ft. Observations also noted that residents in the affected rooms had beds and side tables with drawers, and there was adequate room for wheelchairs, walkers, canes, or a Hoyer lift. During interviews, one resident stated there was enough space in the room for herself and her belongings, and another resident stated he had enough space in his room for himself and his belongings.
Failure to Supervise High-Risk Resident Resulting in Elopement
Penalty
Summary
The deficiency involves the facility’s failure to adequately supervise, monitor, and implement safety measures for a resident with known elopement risk and cognitive impairment, resulting in an elopement. The resident was admitted with diagnoses including toxic encephalopathy, depression, difficulty walking, and lack of coordination, and had intermittent ability to understand and make decisions. Therapy notes documented that the resident was unsteady when walking and standing, required substantial/maximal assistance to walk ten feet, had a mobility function score of 0, and had impaired safety awareness. The care plan identified the resident as being at risk for decline in functional status and safety concerns during daily care tasks, and also documented a history of elopement at home and prior elopement or attempted leaving the facility without informing staff. On the day of the incident, the resident’s Change of Condition note indicated an increase in confusion that was a persistent change from usual cognitive function and documented that the resident had attempted to elope multiple times prior to the successful elopement. The resident was last seen in her room at 12:30 PM when lunch was delivered, and at 1:05 PM a CNA noted the resident was not in the room when picking up the lunch tray. By approximately 1:20 PM, staff determined the resident was missing and activated a code yellow. Interviews revealed that earlier that day the RN observed the resident attempting to open the exit door and redirected her back to her room after 12:30 PM, and the RN reported that the resident had tried to elope at least four times prior to successfully leaving. The RN stated a huddle was called to inform staff, including the primary CNA, to be more vigilant in watching the resident, although the primary CNA later reported not recalling this huddle, while another CNA confirmed it occurred. Staff interviews and policy review showed that the facility did not implement enhanced monitoring or safety devices consistent with the resident’s identified elopement risk and change in condition. The DON acknowledged that if staff knew the resident was attempting to exit through the door, the resident would be at risk for elopement and that the physician should have been notified to obtain an order for a wander guard. The DON also stated the resident should have been closely monitored with staff visually seeing the resident at all times or placing the resident on 1:1 observation, and that these interventions were not implemented. The RN reported that despite multiple elopement attempts, the resident did not have a 1:1 sitter, and staff instead tried to block the exit door with a medication cart. The facility’s wandering and elopement and resident safety policies required assessment of elopement risk, development of a person-centered care plan, and establishment of observation or monitoring systems, including more frequent safety checks when indicated, but the resident was able to leave through the exit door when visitors exited and was not observed by staff as she left.
Failure to Monitor and Document Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic drug use, specifically Ativan, by not providing a specific indication for its use and not monitoring for manifested behaviors or side effects as required by facility policy and care plan. The resident in question had multiple diagnoses, including congestive heart failure, dementia, and diabetes mellitus, and was assessed as having severely impaired cognitive skills and being dependent on staff for all activities of daily living. The care plan indicated the resident had episodes of agitation and anxiety, with interventions to administer medications as ordered and monitor for side effects and effectiveness, as well as to document behaviors and potential causes. Record reviews revealed that the physician's order for Ativan lacked a specific manifested behavior for restlessness, which was necessary for accurate monitoring and administration. Interviews with the DON, LVN, MDS Nurse, and ADON confirmed that the order did not specify the required behavioral manifestations, and that staff did not document or monitor the resident's specific behaviors or side effects associated with Ativan use. The Medication Administration Record (MAR) and Monthly Psychoactive Drug Management (MPDM) forms did not reflect any monitoring for the resident's behavior or side effects during the period when Ativan was administered. Facility policies required that any order for psychoactive medications include a specific behavior manifestation and that residents be monitored for side effects and adverse consequences, with all occurrences documented monthly. Staff interviews and record reviews confirmed that these policies were not followed, resulting in incomplete and inaccurate documentation regarding the resident's behavior and medication use. This failure to follow established protocols led to the deficiency cited in the report.
Failure to Ensure Timely Hemodialysis and Medication Administration
Penalty
Summary
The facility failed to ensure that a resident received necessary hemodialysis treatment as scheduled, which was critical due to the resident's end-stage renal disease. On the day of the scheduled treatment, the transportation company contracted by the resident's insurance was unable to provide a driver, resulting in the resident missing the dialysis appointment. Despite multiple calls to the transportation company, no alternate transportation was arranged, even though a list of backup transportation options was available at the nurses' station. Additionally, the facility did not transcribe the physician's order to monitor the resident for signs and symptoms of fluid overload after the missed dialysis treatment. This oversight meant that the resident was not adequately monitored for potential complications arising from the missed treatment. Furthermore, the resident's blood pressure medications were not administered as ordered, which could have helped manage the resident's hypertension after the dialysis was canceled. As a result of these failures, the resident experienced shortness of breath, chest pain, and elevated blood pressure later that day, necessitating transfer to a general acute care hospital. The hospital records indicated that the resident suffered from acute fluid overload, bilateral pleural effusions, and pulmonary edema, requiring immediate medical intervention, including hemodialysis and other treatments to stabilize the resident's condition.
Medications Left Unattended at Bedside
Penalty
Summary
The facility failed to maintain an environment free from accident hazards by allowing a Licensed Vocational Nurse (LVN) to leave medications unattended on a resident's bedside table. This incident involved a resident with multiple diagnoses, including end-stage renal disease, hypertension, atrial fibrillation, and diabetes mellitus. The resident, who had intact cognition but required supervision for certain activities, was not approved for self-administration of medications. Despite this, medications were left at the bedside, posing a risk of accidental ingestion by other residents. During an observation, it was noted that the medications were left unlabeled and uncovered on the bedside table. Both a Certified Nurse Aide and an LVN confirmed the presence of the medications and acknowledged that leaving them unattended was against facility policy. The Registered Nurse Supervisor also confirmed that medications should not be left at the bedside and should be stored in the medication cart if refused by the resident. The facility's policies emphasized the importance of maintaining a safe environment and outlined procedures for handling medication refusals, which were not followed in this instance.
Failure to Update Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the Daily Posted Nurse Staffing information was updated and posted in accordance with its policy from 2/14/2025 to 2/25/2025. During an observation on 2/25/2025, it was noted that the Census and Direct Care Service Hours Per Patient Day (DHPPD) form displayed was dated 2/12/2025, indicating that the information had not been updated for eight days. This lapse was confirmed during an interview and record review with RN 1, who was covering for the Director of Nursing (DON) in her absence. RN 1 acknowledged that the DHPPD should be updated and posted daily at the beginning of each shift, and the failure to do so meant that the staffing information for the current day was not available. The facility's policy, titled Nursing Department - Staffing, Scheduling & Postings, revised on 1/22/2025, mandates that the facility post specific staffing information daily. This includes the facility name, current date, total number, and actual hours worked by registered nurses, licensed vocational nurses, and certified nurse aides, as well as the resident census. The policy emphasizes the importance of calculating projected and actual staffing hours to ensure adequate staffing levels for resident care. The failure to adhere to this policy had the potential to leave residents and visitors uninformed about the facility's staffing and census, as well as hinder the facility's ability to address staffing shortages effectively.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to uphold the dignity and respect of two residents by not adhering to its own policies. For Resident 35, who has Alzheimer's disease and severely impaired cognitive skills, the facility's policy requires staff to sit at eye level while assisting with feeding to avoid intimidating the resident. However, during an observation, CNA 2 was seen standing while feeding Resident 35, contrary to the facility's Restorative Dining Program policy. This policy aims to improve mealtime behavior, self-image, and socialization skills for residents who are unable to feed themselves. For Resident 43, who has an indwelling catheter due to obstructive uropathy, the facility's policy mandates that urinary collection bags be covered with a dignity bag to maintain the resident's privacy and dignity. During an observation, Resident 43's catheter bag was found uncovered, and CNA 1 confirmed the absence of a dignity bag. The Director of Nursing acknowledged that the facility's policy requires catheter bags to be covered to ensure residents' dignity and respect, as outlined in the facility's Resident Rights - Quality of Life policy.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate assessments of the Minimum Data Set (MDS) for two residents, leading to potential issues in developing and implementing individualized care plans. Resident 42 was admitted with diagnoses including dementia with agitation, mood disturbance, psychotic disturbance, and anxiety disorder. However, the MDS did not reflect the anxiety disorder diagnosis, despite the resident being prescribed Buspirone for anxiety. Interviews with staff confirmed the resident exhibited anxiety symptoms, such as screaming and repetitive movements, which were not documented in the MDS. Similarly, Resident 49 was admitted with diagnoses of Chronic Obstructive Pulmonary Disease (COPD), anxiety, and depression. The MDS for this resident also failed to include the active diagnoses of anxiety and depression, even though the resident was prescribed medications like Buspirone, Sertraline, and Trazadone for these conditions. The psychological evaluation indicated moderately severe depressive symptoms and severe anxiety symptoms, yet these were not reflected in the MDS assessments. The MDS Nurse acknowledged the omissions in both cases, stating that the MDS should accurately reflect the residents' diagnoses to ensure proper care and monitoring. The facility's policy on the Resident Assessment Instrument (RAI) process emphasizes the importance of accurate assessments, which was not adhered to in these instances, potentially affecting the residents' overall well-being.
Failure to Administer Prescribed Respiratory Care
Penalty
Summary
The facility failed to provide necessary respiratory services for three residents, leading to potential health risks. Resident 49, who was diagnosed with Chronic Obstructive Pulmonary Disease (COPD), anxiety, and depression, was not administered the prescribed 2 to 3 liters per minute (LPM) of continuous oxygen therapy as indicated in the physician's order. During an observation, it was noted that Resident 49's oxygen concentrator was off, and the resident was not receiving any oxygen therapy, contrary to the physician's order for continuous administration. Additionally, the plastic respiratory equipment bag containing the nasal cannula tubing was not labeled or dated, which is against the facility's infection control policy. Resident 21, who also had COPD and other pulmonary conditions, had their nebulizer equipment improperly stored. The nebulizer, nebulizer cup, and aerosol mask were observed unbagged on the bedside table, which is a violation of the facility's policy requiring respiratory equipment to be stored in a labeled and dated bag to prevent contamination and infection. Resident 54, diagnosed with COPD and respiratory failure, was administered oxygen at a rate of 5 to 6 LPM, exceeding the physician's order of 2 to 3 LPM. This discrepancy was confirmed by a licensed vocational nurse who acknowledged the error and the potential harm of administering excessive oxygen, especially for a resident with COPD. The facility's policy mandates that oxygen be administered as prescribed, and deviations from this can lead to serious complications, including respiratory acidosis.
Improper Food Storage and Dish Sanitization Practices
Penalty
Summary
The facility failed to adhere to its food storage and handling policies, as observed during a survey. Several food items in the facility's kitchen were found to be improperly labeled or stored. Specifically, numerous refrigerated and frozen items were either past their use-by dates or lacked proper labeling, including items such as sausage, cheese frosting, turkey meat, tomato paste, spaghetti, milk, sour cream, apple juice, almond milk, gelatin cocktail, bread rolls, corn, carrots, juice, paprika, cayenne pepper, sugar cookies, baking soda, cereal, biscuit mix, and rice. The Dietary Services Supervisor (DSS) confirmed that per facility policy, all food items should be labeled with a receive date and a use-by date once opened, and items must be discarded after the use-by date to ensure food safety for residents. Additionally, the facility failed to ensure proper sanitization of dishes. During an observation, a staff member ran the dishwasher with the hottest temperature reaching only 100 degrees Fahrenheit, below the required 120 degrees Fahrenheit. The staff member admitted to not checking the temperature gauge during the cycle. The DSS stated that facility policy requires staff to check the temperature during each dishwashing cycle and to rerun the cycle if the temperature does not reach at least 120 degrees Fahrenheit. The facility's policy also mandates routine monitoring of the dish machine to ensure appropriate wash and rinse temperatures are maintained, and any deviations must be reported to the Dietary Manager. These deficiencies have the potential to result in foodborne illness among the residents consuming food at the facility.
Improper Waste Management in Facility Dumpsters
Penalty
Summary
The facility failed to ensure that two of three garbage dumpsters had their lids closed and were not overflowing with trash, as required by the facility's policy. During an observation, two dumpsters were seen with trash overflowing, causing the lids to remain open. This was confirmed during an interview with the Maintenance Supervisor, who stated that the facility policy required trash to be compressed to keep the lids closed and prevent the attraction of flies and rodents. A review of the facility's Waste Management policy indicated that waste containers must be closable and food waste should be placed in covered garbage cans.
Failure to Update Care Plans for Two Residents
Penalty
Summary
The facility failed to update and revise the care plan for two residents, Resident 42 and Resident 33, as per the facility's policy. Resident 42's fall care plan was not updated after a fall with injury occurred on January 3, 2025. Despite being at high risk for falls, as indicated in the Fall Risk Evaluation dated November 15, 2024, and having a history of falls, the care plan was not revised to include new interventions after the second fall. The Assistant Director of Nursing and the MDS Nurse both acknowledged that the care plan should have been updated to address the underlying causes of the fall and to implement new interventions. Resident 33's care plan was not revised to reflect an updated fluid restriction order from the physician dated January 15, 2025. The care plan still contained outdated fluid restriction measurements, which did not align with the physician's order. Licensed Vocational Nurse 1 confirmed that the care plan was not updated, and the Assistant Director of Nurses emphasized the importance of updating the care plan to prevent potential health issues such as fluid overload, edema, or dehydration. The facility's policies and procedures require that care plans be reviewed and revised following changes in a resident's condition or new physician orders. However, in these cases, the care plans for Residents 42 and 33 were not updated as required, potentially affecting the quality of care and services provided to these residents.
Failure to Conduct Post-Fall Evaluations and Meetings
Penalty
Summary
The facility failed to meet professional standards of quality for one resident, identified as Resident 42, by not conducting necessary evaluations and meetings following a fall with an injury. Resident 42, who was admitted with diagnoses including dementia with psychotic disturbance, lack of coordination, and reduced mobility, experienced a fall resulting in a laceration to the left upper eyebrow. Despite the fall and the resident's altered mental status and behavioral symptoms, the facility did not conduct an Interdisciplinary Team (IDT) meeting, a Post Fall Evaluation, or a neurological exam as required by their policy. The Assistant Director of Nursing (ADON) confirmed that the facility's policy mandates a post-fall evaluation, neuro checks for unwitnessed falls or head injuries, and an IDT meeting within 24 hours to revise the care plan. However, these actions were not taken for Resident 42 after the fall on January 3, 2025. The facility's Fall Management Program policy, reviewed in January 2025, outlines these requirements, but the licensed nurses failed to document the fall details, perform the necessary evaluations, or revise the care plan, as confirmed by the ADON during the review.
Failure to Monitor and Document Catheter Care
Penalty
Summary
The facility failed to provide appropriate care and services for a resident with an indwelling urinary catheter, as indicated in the physician's orders. The resident, who had a history of malignant neoplasm of the prostate, benign prostatic hyperplasia, obstructive uropathy, and reflux uropathy, was at risk for urinary tract infections (UTIs). The physician's orders required the staff to assess urinary drainage for signs and symptoms of infection every shift, including cloudiness, color, sediment, blood, odor, and amount of urine output. Observations revealed that the resident's Foley catheter tubing had small to moderate amounts of white sediment and concentrated yellow urine, indicating potential signs of infection. However, there was no documentation of these observations in the resident's Treatment Administration Record (TAR), Progress Notes, or Change of Condition/Situation, Background, Assessment, Request/Recommendation (COC/SBAR) forms. The Treatment Nurse confirmed that the presence of sediment or cloudiness should have been documented and reported to the physician for further evaluation and potential laboratory testing. Interviews with the Director of Nursing (DON) and the Treatment Nurse highlighted that the facility's policy required staff to monitor and report any signs of infection to the physician. The DON stated that minimal sediment or cloudiness should be monitored for eight hours, while moderate to severe sediment or cloudiness required immediate physician notification. The lack of documentation and communication with the physician regarding the resident's catheter condition resulted in a delayed identification of a potential UTI, which could lead to worsening infection and delayed treatment.
Failure to Monitor Fluid Intake for Dialysis Resident
Penalty
Summary
The facility failed to accurately monitor the fluid intake for a resident with fluid restrictions and on dialysis, leading to a deficiency in care. The resident, who was admitted with end-stage renal disease and dependent on dialysis, had a physician's order for a fluid restriction of 1000 ml per day. However, the facility did not adhere to this order. Certified Nurse Assistant 4 confirmed that the resident's fluid intake exceeded the prescribed limits during meals, and there was no awareness of the fluid restriction. Additionally, the Licensed Vocational Nurse 1 admitted that there was no record of the fluid intake associated with medication administration, which was supposed to be documented in the Medication Administration Record. The Assistant Director of Nurses acknowledged that the CNAs were not supposed to provide extra fluids to the resident and that the fluid intake from meals and medications should have been recorded. The facility's policies and procedures for dialysis care and fluid restriction were not followed, as there was no documentation of fluid intake, and the staff failed to monitor and ensure compliance with the fluid restriction. This lack of monitoring and documentation had the potential to cause fluid overload or dehydration, posing a risk to the resident's health.
Failure to Supervise Medication Administration
Penalty
Summary
The facility failed to provide proper pharmaceutical services by not supervising the medication administration for one of the residents, identified as Resident 39. During a record review, it was found that Resident 39 was not approved for self-administration of medications and was not allowed to keep medications at the bedside. Despite this, eight medications were left on the nightstand by the Infection Prevention Nurse (IPN) without supervision. The IPN admitted to leaving the medications unattended due to being disrupted, acknowledging that this was against the facility's policy, which requires medications to be administered directly by the licensed nurse preparing them. Resident 39, who was admitted with diagnoses including atherosclerosis, chronic pulmonary edema, psychosis, and dementia, was found to have intact cognitive skills for daily decision-making according to the Minimum Data Set. However, the resident required assistance with daily activities and was at risk for self-care performance deficits due to mood disorder and forgetfulness. The care plan for Resident 39 included maintaining a safe environment and providing assistance as needed. The failure to supervise medication administration posed a risk of medication errors and potential harm to Resident 39 and other residents who might access the medications.
Failure to Act on Pharmacy Consultant's Recommendations
Penalty
Summary
The facility failed to act upon the Pharmacy Consultant's recommendations during the Medication Regimen Review (MRR) for December 2024 for one of the sampled residents, Resident 41. The MRR, conducted by the consulting pharmacist, identified several irregularities in Resident 41's medication regimen, including the concurrent use of Saxagliptin and Sitagliptin, the absence of a 'Do not crush' instruction for Ferrous Sulfate, and the timing of Repaglinide administration. These recommendations were not reviewed or acted upon by the facility, as indicated by the Medication Administration Record (MAR) for December 2024, which showed that the medications were administered without addressing the pharmacist's recommendations. Resident 41, who was initially admitted and later readmitted to the facility, had a medical history that included type 2 diabetes mellitus, depression, and unspecified dementia. The resident's Minimum Data Set (MDS) assessment indicated moderate cognitive impairment and a need for substantial assistance with daily activities. Despite these needs, the facility did not ensure that the pharmacist's recommendations were reviewed and communicated to the attending physician, as required by the facility's policy and procedure for medication regimen reviews. Interviews with the Director of Nurses (DON), a licensed vocational nurse (LVN 1), and the Assistant Director of Nurses (ADON) revealed that there was no designated staff member responsible for reviewing and following up on the MRR. The responsibility was informally assigned to all licensed nurses, leading to a lack of accountability and oversight. As a result, the irregularities identified in the MRR were not addressed, and the attending physician was not notified, which could have led to potential adverse medication outcomes for Resident 41.
Failure to Monitor Refrigerator Temperatures for Resident Food
Penalty
Summary
The facility failed to ensure that the temperature of the Activity Room Refrigerator, which contained food brought by family members for a resident, was checked daily as per the facility's policy. During an observation and interview with the Dietary Services Supervisor (DSS), it was noted that the refrigerator contained a food container labeled with a resident's room number and bed, indicating it was brought by the resident's family. The facility's Policy & Procedure required that refrigerator temperatures be checked routinely throughout the day and maintained at 41 degrees or below. However, the temperature log for the refrigerator did not have documented temperatures from February 3 to February 9, both in the morning and evening. The DSS confirmed that staff should have checked and documented the refrigerator temperatures according to the policy.
Deficiency in Resident Room Space Requirements
Penalty
Summary
The facility failed to ensure that 12 out of 22 resident rooms met the regulatory requirement of providing at least 80 square feet per resident in multiple resident bedrooms. This deficiency was identified through observations, interviews, and record reviews conducted from February 10 to February 13, 2025. The rooms in question, specifically Rooms 3, 4, 5, 6, 7, 8, 11, 14, 15, 16, 17, and 18, were found to have less than the required space per resident, with measurements ranging from 64.6 to 76.6 square feet per resident. Despite this, some residents expressed comfort with their space during interviews, and observations indicated that there was adequate room for mobility aids and the provision of care. The facility's Client Accommodation Analysis Form confirmed the deficiency, listing specific room measurements that fell short of the required square footage. For instance, one room with three beds measured 194 square feet, equating to only 64.6 square feet per resident. Despite the spatial limitations, observations noted that residents had enough space to move freely and that the care provided was not compromised. The Department recommended approval of a room waiver request for the affected rooms, acknowledging the facility's efforts to maintain adequate care and mobility within the limited space.
Failure to Notify Physician of Resident's Meal Refusal
Penalty
Summary
The facility failed to notify the resident's physician when a resident, who was diagnosed with protein-calorie malnutrition, dementia, Alzheimer's disease, and dysphagia, refused more than 50% of meals for three consecutive times. The resident was admitted with severe cognitive impairments and was dependent on assistance for daily activities, including eating. Despite the resident's refusal to eat, which was documented in the Nutrition Meal Intake records, the physician was not informed as required by the facility's policy. The facility's policy stated that if a resident ate less than 50% for three consecutive meals, it should be considered a Change of Condition (COC), and the physician should be notified. However, the Director of Nursing confirmed that the physician was not informed of the resident's poor meal intake. Additionally, the resident's care plan required monitoring and reporting changes in behavior or appetite loss, which was not adhered to. This oversight had the potential to delay necessary care and services for the resident, who was already at risk of severe malnutrition.
Failure to Promote Resident Dignity
Penalty
Summary
The facility failed to promote dignity and respect for two residents by not ensuring proper handling of a urinary catheter bag and inappropriate feeding assistance. Resident 16, who had diagnoses including COPD, UTI, and difficulty walking, was observed with an uncovered urinary catheter bag, which should have been covered with a dignity bag to protect the resident's dignity. Multiple staff members, including CNAs and the Director of Nursing, acknowledged that the dignity bag should have been used to cover the catheter bag, but it was not in place when the resident returned from the hospital. Resident 11, who had diagnoses including nontraumatic subarachnoid hemorrhage, atrial fibrillation, and epilepsy, was observed being fed by a CNA who stood above the resident's eye level. The CNA admitted that she should have been sitting at eye level with the resident but did not do so because there was no available chair. Another staff member, an LVN, confirmed that feeding residents at eye level is important for their dignity and to encourage proper eating. The facility's policy on resident rights emphasizes treating all residents with kindness, respect, and dignity, which was not adhered to in these instances.
Failure to Provide Necessary ADL Care and Communication Devices
Penalty
Summary
The facility failed to provide necessary care and services to ensure the residents' abilities in activities of daily living (ADLs) for two sampled residents. Resident 15, who has severe cognitive impairment and multiple diagnoses including bilateral primary osteoarthritis of the knee and Alzheimer's disease, was not provided with a communication device in their primary language and was observed in an uncomfortable and improper bed position. Despite the care plan indicating the need for alternative communication tools and proper positioning, these interventions were not implemented. The Director of Nursing acknowledged the lack of frequent visual checks to ensure proper positioning and the absence of a communication board at the bedside. Resident 29, diagnosed with end-stage renal disease and other conditions, also faced a communication barrier due to the lack of a communication device in their primary language. The resident, who is capable of understanding and making decisions, reported difficulty in communicating with staff who did not speak their preferred language. The care plan for Resident 29 included the use of communication boards and translation assistance, but these measures were not in place. Interviews with staff confirmed the reliance on other staff members for translation and the absence of communication boards at the bedside. The facility's policies on positioning and body alignment, as well as accommodation of residents' communication needs, were not followed. The failure to provide appropriate communication devices and ensure proper positioning in bed for these residents led to deficiencies in their care. Observations and interviews with staff and residents highlighted the lack of adherence to the care plans and facility policies, resulting in inadequate support for the residents' ADLs and communication needs.
Failure to Ensure Safe Environment for Residents
Penalty
Summary
The facility failed to ensure a safe environment for Resident 16 and Resident 36, leading to potential risks for falls, injuries, and delayed care. Resident 16's room was cluttered with multiple items such as nightstands, an oxygen concentrator, and a trash can, which were placed parallel to the bed. This clutter was observed to impede quick access to the resident in case of an emergency. Despite the resident's high fall risk and the use of medications that increase fall risk, the room arrangement was not adjusted to mitigate these hazards. The Director of Nursing (DON) acknowledged that the room was not free of accident hazards and that the clutter could delay staff response in an emergency situation. Additionally, the room was smaller than the required 80 square feet per resident, necessitating a room waiver, which further complicated the safety concerns for Resident 16, who was already at high risk for falls and anxiety attacks that could lead to injury. Resident 36's environment also posed safety risks. The resident had an overhead trapeze with multiple cords hanging from it, including the call light and bed remote. This setup was observed to be unsafe as the cords could potentially entangle the resident, who had periods of confusion. During an observation, the trapeze was seen making contact with the resident's face, which the resident confirmed was uncomfortable and unavoidable due to the need to reach the call light and bed remote. Staff, including a Registered Nurse (RN) and a Certified Nurse Assistant (CNA), acknowledged that the trapeze setup was not safe and could cause injury. The DON also confirmed that the trapeze could injure the resident if it made contact with her face or head. The facility's policies on resident safety and accommodation of needs were not adequately followed, as evidenced by the unsafe conditions in the rooms of Resident 16 and Resident 36. The clutter in Resident 16's room and the unsafe trapeze setup in Resident 36's room were not addressed, despite the known risks and the facility's own procedures requiring regular evaluation of resident safety. These deficiencies highlight a failure to provide a safe environment, putting residents at risk for accidents and delayed care.
Deficiencies in Food Storage and Preparation
Penalty
Summary
The facility failed to ensure the storage, preparation, and distribution of food were conducted under sanitary conditions for fifty-two residents. The first deficiency was observed in the kitchen where the conventional oven's temperature knob had no visible settings, making it difficult for the dietary staff to determine the correct cooking temperature. Both the Dietary Staff Supervisor (DSS) and the Cook confirmed that they had to guess the temperature, which could result in improperly cooked food. The Maintenance Supervisor also acknowledged the issue, stating that the faded numbers on the temperature knob could be dangerous as it is crucial to know the exact temperature when cooking food for residents. The second deficiency involved improper labeling and storage of food items in the kitchen produce refrigerator and dry storage. Several food items, including Parmesan cheese, mayonnaise, pickle relish, liquid whole eggs, cream cheese, frozen sausage, pizza dough, and doughnuts, were either past their expiration dates or not labeled with a received or expiration date. Additionally, items in the dry storage such as black eye peas, ground black pepper, oregano leaves, domestic paprika, and dark chili powder were not labeled with open or expiration dates. The DSS admitted to missing the expired food items during inventory checks and acknowledged that all staff should ensure proper labeling and checking of food items. The facility's policies and procedures on food storage, which require all items to be correctly labeled and dated, were not followed.
Failure to Implement Antibiotic Stewardship Protocol
Penalty
Summary
The facility failed to implement its protocol for Antibiotic Stewardship, leading to the inappropriate use of antibiotics for two residents. Resident 16, who had diagnoses including COPD, pneumonia, sepsis, and UTI, was prescribed Cefepime despite not meeting the McGeer's Criteria for antibiotic use. The Infection Prevention Nurse (IPN) confirmed that the resident's screening score was zero, indicating a suspected infection that did not meet the criteria for antibiotic administration. The physician was not notified of this score, and the antibiotic was administered regardless, contrary to the facility's protocol and the purpose of the Infection Screening Evaluation. Similarly, Resident 35, with diagnoses including ESBL resistance, an open wound, and diabetes with neuropathy, was prescribed Ertapenem Sodium without meeting the McGeer's Criteria. The IPN confirmed that Resident 35's screening score was also zero, and the physician was not informed. The antibiotic was administered despite the resident not meeting the criteria, and the physician was not consulted to confirm the necessity of the antibiotic. The Director of Nursing (DON) acknowledged that the physician should have been notified when the McGeer's Criteria score was zero, to determine whether to continue with the antibiotic. The facility's policy on Antibiotic Stewardship, which aims to optimize antibiotic use and reduce inappropriate prescriptions, was not followed, leading to the potential for antibiotic resistance and adverse side effects in the residents.
Failure to Provide and Document Updated COVID-19 Vaccinations for Staff
Penalty
Summary
The facility failed to provide education, offer, and document the updated COVID-19 vaccinations for the year 2023-2024 for 96 out of 105 employees. This deficiency was identified through interviews and record reviews, which revealed that the Employee List and Vaccines form was incomplete and did not indicate how many employees were offered, received, or declined the updated COVID-19 vaccine. Several staff members, including a Certified Nursing Assistant (CNA), the Infection Prevention Nurse (IPN), and the Director of Nursing (DON), confirmed that they were either not offered the updated vaccine or did not have the necessary consent or refusal forms on file. The IPN admitted that the updated vaccines were not ordered for the employees and that there was no clear process for notifying all employees about the vaccination clinic, given their different work schedules and shifts. The facility's policy, revised on 8/2/2023, stated that the facility would continue to offer vaccines and booster doses per the requirements of CMS, CDC, and ACIP and document such. However, the facility did not adhere to this policy, as evidenced by the lack of documentation and incomplete Employee List and Vaccines form. The CDC recommends the 2023-2024 updated COVID-19 vaccines to protect against serious illness, but the facility failed to ensure that all employees were offered and documented for the updated vaccine, placing residents and staff at risk for possible COVID-19 infection due to missed vaccination dosages.
Failure to Ensure Call Lights Were Within Reach
Penalty
Summary
The facility failed to ensure that the call light was within reach of three residents, leading to a potential delay in the provision of services and assistance with activities of daily living (ADLs). Resident 5, who had diagnoses including difficulty walking, lack of coordination, and schizophrenia, was found with their call light placed inside a closed drawer of the nightstand. This was observed during a room check, and the Certified Nursing Assistant (CNA) confirmed that the call light should have been clipped to the bed. The Director of Nursing (DON) acknowledged that the call light being out of reach was inappropriate and not in line with the resident's care plan, which required the call light to be within reach due to the resident's risk for falls and fluctuating cognitive capacity. Resident 27, who had severe cognitive impairments and a history of falls, was found with their call light cord wrapped and hanging on the wall above the bed frame. This was observed during a room check, and the CNA confirmed that the call light should have been placed on the bed. The DON reiterated that the call light should be within reach unless otherwise specified in the resident's care plan, which was not the case for Resident 27. The care plan indicated the need for the call light to be within reach due to the resident's risk for falls and impaired mobility. Resident 15, who had severe cognitive impairments and required total assistance for ADLs, was found with their call light inside the nightstand drawer, out of reach. This was observed during a room check, and both the CNA and a Registered Nurse (RN) confirmed that the call light should be clipped to the bedside. The DON stated that it was not appropriate for the call light to be inside a drawer, as the resident would not be able to call for help or assistance. The facility's policy and procedure on call systems also indicated that call cords should be placed within the resident's reach.
Inaccurate MDS Documentation for Eating Ability
Penalty
Summary
The facility failed to ensure the assessment entries on the Minimum Data Set (MDS) related to eating were accurately documented for Resident 6. Resident 6, who was admitted with diagnoses including anorexia, legal blindness, and unspecified hearing loss, was assessed on the MDS as requiring substantial/maximal assistance with eating. However, observations and interviews revealed that Resident 6 was able to eat by herself with minimal assistance, such as being informed about the location of food on her plate and occasional encouragement to eat. This discrepancy between the MDS documentation and the actual ability of Resident 6 to eat independently was noted during an observation and confirmed through interviews with the Certified Nursing Assistant (CNA 6) and the Infection Control Nurse (IPN 2). Both staff members indicated that Resident 6 could feed herself despite her impairments. During a review of Resident 6's MDS with the Minimum Data Set Coordinator (MDSC), it was revealed that the MDS entry for eating was based on the weekly notes of licensed nurses, interviews, and documents from CNAs, as well as the MDSC's assessment. The MDSC acknowledged that the MDS should reflect the correct level of acuity and that Resident 6's eating ability should have been documented as requiring set-up or clean-up assistance rather than substantial/maximal assistance. The MDSC also admitted that they did not remember if they had assessed Resident 6's eating ability during the look-back period. The facility's policy on the Resident Assessment Instrument (RAI) process, which aims to provide accurate resident assessments, was not adhered to in this case, leading to the inaccurate documentation on the MDS for Resident 6.
Inaccurate PASRR Completion for Resident with Schizophrenia
Penalty
Summary
The facility failed to ensure the preadmission screening assessment (PASRR) form was accurately completed for a resident with a mental illness. Resident 24, who had diagnoses including schizophrenia, was admitted and readmitted to the facility with a negative PASRR Level I screening. The PASRR forms dated 8/31/2023 and 1/29/2024 incorrectly indicated that Resident 24 did not have a serious diagnosed mental disorder or was prescribed psychotropic medications, despite medical records showing otherwise. This led to the resident not receiving the necessary psychiatric level of treatment and evaluation in the facility. Interviews with the Admission Coordinator (AC) and Minimum Data Set Coordinator (MDSC) revealed that the facility staff were responsible for submitting and verifying the PASRR forms. The AC admitted to incorrectly filling out the PASRR forms, failing to include Resident 24's diagnosis of schizophrenia and the use of psychotropic medications. The MDSC confirmed that Resident 24 had been diagnosed with schizophrenia and was on psychotropic medication at the time of readmission, and acknowledged that the PASRR should have been corrected within seven days. The Director of Nursing (DON) emphasized the importance of accurate PASRR completion to determine appropriate care and placement for residents. The facility's policy required a new PASRR upon readmission if there was a significant change in the resident's condition. However, the PASRR for Resident 24 was not updated accurately, leading to a deficiency in providing the necessary psychiatric care and evaluation for the resident.
Failure to Update Care Plan for Resident with Seizures
Penalty
Summary
The facility failed to review and revise the care plan for one of the residents who has a history of seizures. The resident was admitted with diagnoses including nontraumatic subarachnoid hemorrhage, paroxysmal atrial fibrillation, and epilepsy. The resident's Minimum Data Set (MDS) indicated moderately impaired cognition and required substantial assistance with daily activities. Despite having a physician's order for multiple seizure medications, the resident's care plan did not reflect all current seizure medications, including Depakote, Levetiracetam, and Vimpat, after the discontinuation of Dilantin. During an interview, the Registered Nurse Supervisor (RNS) acknowledged that the care plan should have been updated to include all current seizure medications. The Director of Nursing (DON) also confirmed that all licensed staff are responsible for revising and updating care plans and that the resident's medication should have been revised when Dilantin was discontinued. The facility's policy indicated that care plans should be reviewed and revised based on assessed needs, new problems, changes in condition, and other appropriate times, which was not followed in this case.
Failure to Ensure Proper Medication Administration
Penalty
Summary
The facility failed to ensure that Resident 40 received all medications in accordance with the physician's order and the facility's policy and procedure. During a medication pass observation, Resident 40 was found in possession of three clear red capsules of Colace, a stool softener, which he had hidden in a zip lock bag. Resident 40 admitted to hiding the pills because he did not want to take too much and risk having diarrhea. This was confirmed by the Infection Prevention Nurse, who verified that the capsules in Resident 40's possession were indeed Colace capsules that he was supposed to take. The Medication Administration Record indicated that Resident 40 had been administered all 56 doses of Colace from 3/1/2024 to 3/27/2024, suggesting that the resident had been hiding the medication for some time. During an interview, the Director of Nursing stated that Licensed Vocational Nurses are required to observe residents taking their medications to ensure compliance. The failure to do so could lead to double dosing, missed medications, and potential adverse reactions. The facility's policy on medication administration mandates that medications must be given to the resident by the Licensed Nurse preparing the medication, and the nurse must chart the drug, time administered, and initial their name with each medication administration. The incident with Resident 40 highlights a lapse in this procedure, as the resident was able to hide the medication without the nurse's knowledge, potentially leading to an overdose or other harm.
Deficient Shower Chair Condition
Penalty
Summary
The facility failed to ensure that a shower chair used by residents was in good condition and free from stains. During an observation, a CNA was seen pushing a white shower chair with brown and yellowish stains and a ripped plastic woven backrest. The Registered Nurse Supervisor confirmed that the stains were old and the chair needed to be replaced, stating she would not want to sit on it if she were a resident. The Maintenance Supervisor was unaware of the chair's condition and agreed it should not be used. The Director of Nursing also acknowledged the poor condition of the chair and emphasized that CNAs should report old equipment to the charge nurse for replacement. The facility's policy, revised on 1/1/2012, indicated that residents should be provided with a safe, clean, comfortable, and homelike environment. The policy emphasized the importance of providing residents with a pleasant environment and person-centered care that focuses on their comfort, independence, and personal needs and preferences. The failure to maintain the shower chair in good condition was a deviation from this policy, potentially affecting the residents' dignity and self-worth.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Los Angeles
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| York Healthcare & Wellness Centre | 0.9 mi | ★★★★★ | 18 | 0 |
| Montecito Heights Healthcare & Wellness Centre, Lp | 0.9 mi | ★★★★★ | 27 | 0 |
| Huntington Healthcare Center | 1.7 mi | ★★★★★ | 21 | 0 |
| College Vista Post-acute | 1.9 mi | ★★★★★ | 0 | 0 |
| South Pasadena Care Center | 2.3 mi | ★★★★★ | 8 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.