Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hollenbeck Palms during CMS and state inspections, most recent first.
A resident with CHF, HTN, and atrial fibrillation had severely impaired cognition and was dependent for ADLs. On one evening, the resident’s BP and HR were documented as low, and an ordered dose of bisoprolol, which included parameters to hold for low systolic BP and HR, was not administered. The RN did not recheck the resident’s vitals, did not notify the MD that the medication was held or that the resident had low BP and HR, and did not document the reason for withholding the dose, contrary to facility P&P requiring MD notification and nursing documentation when ordered meds cannot be given as prescribed.
A resident with CHF and Alzheimer’s was admitted with severe cognitive impairment and dependence for eating, but the ADON entered a pureed diet with thin liquids based only on a verbal report from an unknown staff member at the sending SNF. The transfer packet contained only a facesheet and medication list, with no written diet order or order summary, and staff did not promptly request the missing discharge/transfer orders as required by facility policy. Later review of the prior facility’s records showed the resident had actually been on a fortified, soft and bite-sized, liberalized diet with thin liquids, and a subsequent ST evaluation supported a diet upgrade, confirming that the resident had received an incorrect diet for several days after admission.
Incorrect LAL Mattress Settings for Two Residents: The facility failed to keep LAL mattresses set to the residents’ current weights for two residents receiving pressure ulcer care. One resident with a Stage 3 pressure ulcer was observed on a mattress set at 400 lbs despite weighing 111.6 lbs, and another resident was observed with the mattress set around 320 lbs despite weighing 86.3 lbs. The order summary, care plan, and staff interviews all indicated the settings should match the resident’s weight to support skin integrity and wound management.
Damaged and unsanitary food service items were observed in the kitchen and dining area, including a dented saltshaker with crusted residue, a pepper shaker with food residue and a dirty label, three burgundy plate covers that were peeling and chipped, and 27 black serving trays that were peeling and chipped. The ADON, RD, and DD confirmed the items were unacceptable and inconsistent with facility P&P for damaged dishware and sanitation.
A facility failed to keep call lights within reach for two residents whose care plans directed staff to do so. One resident with cardiomyopathy and generalized weakness was observed in bed with the call light hanging off the siderail and touching the floor, and the resident said she could not reach it; an LVN confirmed it was not within reach. Another resident with muscle weakness, AKI, and edema was observed multiple times in bed with the call light on the floor, and an LVN stated call lights should be within reach at all times. The facility policy stated call lights and hand bells are to be placed on the bed at all times and never on the floor or bedside stand.
A resident with severe cognitive impairment and dependence on staff for personal hygiene was observed in a wheelchair with dry, crusted discharge on one eye and visible food stains on her shirt. Staff stated residents should be clean, well-groomed, and free from stains and eye discharge to maintain dignity, and the resident’s care plan included assistance with personal hygiene, dressing, grooming, and clean clothes.
Failure to Monitor Sleep for Trazodone Use: A resident with dementia, MDD, and anxiety was prescribed Trazodone for insomnia, but nursing staff did not monitor hours of sleep to assess the medication’s effectiveness. The pharmacist consultant and ADON stated sleep monitoring was needed, and the ADON confirmed the resident had not been monitored since the initial order. Facility policy defined unnecessary drugs as those used without adequate monitoring.
A resident with dementia, MDD, and anxiety had a care plan for behaviors including crying, striking staff and others, and danger to self and others, but the plan was not revised to include a companion intervention noted in IDT records. The MDS nurse and ADON stated the companion should have been documented in the care plan to address the resident’s behavioral needs.
Failure to provide grooming and nail care for a resident dependent on staff for personal hygiene. The resident had dementia, muscle weakness, and depression, and was assessed as severely impaired in daily decision making. Staff observed the resident’s fingernails to be jagged, dirty, and discolored, and an LVN stated the nails needed trimming and could harbor bacteria. The care plan and facility policy both directed staff to provide grooming and check nails daily.
PICC External Catheter Length Not Documented After Dressing Change: A resident with a PICC line for TPN had a dressing change documented by RN, but the external catheter length was not measured or recorded as required by the care plan, IV therapy record, and facility P&P. The MDS nurse and ADON both confirmed there was no documentation of the catheter length after the dressing change; the RN note only stated the site was clean, dry, and intact.
Staff failed to don required PPE before entering a contact isolation room for two residents. One resident had severe cognitive impairment and dependence for multiple ADLs, and the other resident had dementia and was on contact isolation for herpes zoster. A CNA was observed cleaning and changing linens without a gown, and an LVN was observed picking up an item near a bedside without a gown, despite the facility policy and IP/ADON expectations that gown and gloves be worn on room entry.
The facility failed to adhere to infection control measures, including improper PPE use during medication administration via a gastrostomy tube, inadequate response to a water main break affecting the Legionella Water Management Program, and lack of hand hygiene during meal assistance. These deficiencies were observed through staff interviews and record reviews, highlighting lapses in infection prevention practices.
Three residents were at risk of scalding due to hot water temperatures exceeding 120°F in their bathrooms. Observations revealed that the water reached 128.6°F and 127.7°F, posing a burn risk. The facility failed to monitor and regulate these temperatures, despite policies requiring weekly checks. Residents with cognitive and physical impairments were particularly vulnerable.
A facility failed to maintain a medication error rate below 5%, with a 33.3% error rate observed for a resident. The resident, with significant medical conditions, received medications late, outside the permissible one-hour window. The LVN confirmed the late administration, and facility policies emphasized the importance of timely medication administration.
The facility failed to properly handle, prepare, and store food, risking foodborne illnesses for 56 residents. Observations showed unlabeled food items, expired products, and inadequate temperature monitoring. Interviews confirmed these deficiencies, highlighting lapses in food safety management.
The facility failed to properly dispose of garbage, with bins and dumpsters found uncovered and overfilled, contrary to policy. Observations revealed uncovered bins in the kitchen and overfilled dumpsters outside. Interviews with staff confirmed non-compliance with the facility's policy, which requires closed lids and clean areas around dumpsters to prevent pest attraction.
A facility failed to maintain a resident's dignity by not ensuring staff assisted the resident with eating at eye level. Despite instructions from the DSD, a CNA stood while helping a resident with multiple health issues, including Alzheimer's and COPD, during mealtime. This action violated the facility's policy on promoting dignity and respect.
The facility failed to maintain copies of advance directives in the medical charts of two residents, as required by policy. One resident, with severe cognitive impairment, and another, requiring substantial assistance, both lacked documented directives in their records. Staff confirmed the absence, highlighting the risk of not knowing residents' wishes during emergencies. The facility's policy mandates documentation of advance directives, which was not followed in these cases.
A resident with severe cognitive impairment and dependency on assistance was placed in a Geri chair without a proper restraint assessment. Despite an order for its use, facility staff, including the ADON and DON, confirmed that an interdisciplinary team assessment was not conducted, violating the facility's policy on physical restraints.
A resident dependent on staff for personal care was left soiled for an extended period, causing distress and potential harm. Despite using the call light for assistance, the resident was told to wait due to staff workload. Observations and staff interviews revealed that the CNA did not immediately address the resident's needs, nor did they seek help from other staff. The facility's policies on care and dignity were not followed, resulting in this deficiency.
A resident with severe cognitive impairment and dependence on supplemental oxygen was found with an empty oxygen tank, contrary to physician orders for continuous oxygen therapy. The facility's policy required adherence to physician orders, which was not followed, as confirmed by the ADON.
A resident did not receive their 8 AM medications on time, as they were administered at 10:22 AM, beyond the one-hour window allowed by the facility's policy. The resident, with a complex medical history, was dependent on assistance for daily activities and had several medications prescribed for conditions like hypertension and angina. The delay was confirmed by the ADON and DON, who noted the importance of timely medication administration to ensure efficacy and avoid adverse reactions.
A resident with bradycardia and hypertension was administered Amlodipine, Carvedilol, and Losartan despite having a heart rate of 59, which was below the physician-ordered parameters to hold the medications. The LVN did not recheck the vital signs or notify the physician, contrary to the facility's policy requiring verification of vital signs before medication administration.
The facility failed to post accurate and timely nurse staffing information in accessible locations, as required by policy. Observations showed outdated reports were posted, and the East wing lacked any postings. The Director of Staff Development prioritized floor coverage over updating staffing information, leading to non-compliance with the facility's policy.
A resident at high risk for falls experienced multiple falls due to the facility's failure to implement a specific fall care plan. The resident, with severe cognitive impairment, was left unsupervised, leading to significant injuries. The care plans lacked specific interventions, and staff assumed others would monitor the resident, resulting in inadequate supervision.
A resident was administered Lorazepam without a specific target behavior documented, contrary to the facility's policy. The resident had diagnoses of anxiety disorder, dementia, and depression. Staff interviews confirmed the absence of specific behavior indications in the medication order, which is necessary for appropriate administration. The facility's policy required psychotropic drugs to be used only for documented specific conditions.
A resident with anxiety disorder and dementia was restrained with a seatbelt in a wheelchair without a prior assessment. Facility staff confirmed that no physical restraint assessment was conducted, violating the facility's policy requiring such assessments before using restraints.
A resident with a history of falls and cognitive impairment was not provided with a comprehensive fall care plan, leading to a fall and subsequent hospitalization. The care plan lacked necessary interventions such as supervision and frequent checks, as required by the facility's policy. Additionally, a high-risk identification wristband was not used, contrary to the facility's procedures.
Failure to Notify MD and Document When Antihypertensive Dose Was Held for Low Vitals
Penalty
Summary
The deficiency involves the facility’s failure to follow its policy and procedure for medication and treatment administration and physician notification for a resident with significant cardiac conditions. The resident had chronic CHF, hypertension, and atrial fibrillation, and a care plan dated 9/22/2025 directed staff to monitor vital signs as needed and notify the physician of significant abnormalities. An MDS dated 9/25/2025 documented that the resident had severely impaired cognitive skills for daily decision making and required substantial to total assistance with transfers, mobility, and all ADLs, indicating high dependence on staff for care and monitoring. On 10/18/2025 at 7:03 PM, the resident’s BP was recorded as 72/51 mmHg and HR as 57 bpm, which were documented in the Weights and Vitals Summary and later in a progress note at 9:52 PM. The resident had an active order, dated 9/19/2025, for bisoprolol fumarate 10 mg orally every 12 hours for hypertension, with instructions to hold the medication if systolic BP was less than 110 or HR less than 60. RN 1 acknowledged in a phone interview that the evening dose of bisoprolol on 10/18/2025 was not administered because the resident’s BP and HR were low. Despite the low BP and HR and the held dose of bisoprolol, RN 1 did not notify the physician that the medication was not given or that the resident’s vital signs were low, and did not recheck the BP and HR after obtaining the low readings. The progress notes did not document any physician notification or repeat vital signs, nor did they record the reason the bisoprolol was withheld. The facility’s P&P titled Medication and Treatment Administration Records, revised 1/2026, required that medications be administered as prescribed, that the attending physician be notified when an order cannot be administered as prescribed, and that an explanation be recorded in the nurses’ notes when a routine medication is withheld. The ADON confirmed that RN 1 did not follow these requirements, resulting in the cited deficiency.
Failure to Verify and Continue Correct Therapeutic Diet on Admission
Penalty
Summary
The deficiency involves the facility’s failure to ensure a therapeutic diet was accurately clarified and continued upon admission for a resident transferred from another SNF. The resident was admitted with chronic congestive heart failure and Alzheimer’s disease and was severely cognitively impaired, requiring extensive to total assistance with mobility, ADLs, and eating. On admission, the Assistant Director of Nursing (ADON) entered an order for a pureed diet with thin liquids based solely on a verbal report from an unknown staff member at the sending facility, who stated the resident required one-on-one feeding and was on a pureed diet. The admission documentation received from the sending facility included only a facesheet and a medication list and did not contain the order summary or any written diet order. The facility’s own policy required that transfer records include nursing and dietary information in sufficient detail to provide continuity of care, and that if specified records were not received, staff were to contact the sending facility’s discharge planner or health information department to request the missing records. Despite this, no immediate effort was made at admission to obtain the resident’s complete discharge/transfer orders, including the diet order, from the sending facility. Subsequent review of the sending facility’s order summary showed that the resident’s actual diet at discharge was a fortified, soft and bite-sized, liberalized diet with thin liquids, not a pureed diet. A speech therapy evaluation was only ordered after the resident’s family later reported that the resident had not been on a pureed diet at the prior facility. The speech therapy evaluation then trialed a ground mechanical soft/thin liquids diet without signs or symptoms of aspiration and upgraded the diet accordingly. As a result of the initial failure to verify and reconcile the diet order at admission, the resident received an incorrect pureed diet for several days before the discrepancy was identified and addressed.
Incorrect LAL Mattress Settings for Two Residents
Penalty
Summary
The facility failed to ensure low air loss (LAL) mattresses were set at the correct weight-based settings for two sampled residents receiving pressure ulcer care. Resident 9 was admitted with diagnoses including muscle weakness, dementia, abnormal posture, and full incontinence of feces. The resident’s MDS showed severe cognitive impairment, dependence for toileting and personal hygiene, risk for pressure injury, and one Stage 3 pressure ulcer. The physician ordered an LAL mattress for wound management, and the care plan included use of the LAL mattress for wound management. During observations on 12/9/2025, Resident 9 was seen lying in bed with the LAL mattress set at 400 lbs, even though the resident’s documented weight was 111.6 lbs. LVN 2 stated the mattress should not have been set at 400 lbs and said the resident’s weight indicated it should have been set at 100 lbs. The ADON and the Treatment Nurse both stated the mattress should be set according to the resident’s weight, and the Treatment Nurse stated the 400-lb setting was not acceptable and could possibly worsen the Stage 3 pressure ulcer. Resident 28 was admitted and readmitted with diagnoses including cerebral ischemia and dementia with anxiety. The resident’s MDS showed severe cognitive impairment and dependence for transfers, bed mobility, dressing, footwear, personal hygiene, and eating. The order summary and care plan both directed that the resident have an LAL mattress set at the resident’s current weight to maintain skin integrity. During observation on 12/9/2025, Resident 28 was asleep in bed with the LAL mattress set around 320 lbs, while the EMR showed a current weight of 86.3 lbs. The Treatment Nurse stated the setting was not correct and defeated the purpose of the LAL, and the ADON stated settings of 300 lbs or more could make the mattress too firm and cause skin breakdown over bony prominences.
Damaged and Unsanitary Food Service Items
Penalty
Summary
The facility failed to ensure proper food handling and maintain the food service area in a clean and sanitary manner in accordance with its policy and procedure. During observation in the kitchen, one saltshaker was noted to be dented and dirty with crusted food residue. In Dining Room [ROOM NUMBER], three burgundy plate covers were observed to be peeling, chipped, and scratched, and 27 black serving trays were observed to be peeling and chipped. During concurrent observations and interviews, the ADON stated the saltshaker appeared rusted, dented, and crusted with dry leftover food residue, and that the pepper shaker was cracked and contained green food residue, which was unsanitary. The ADON also stated the burgundy plate covers showed wear and tear with peeling rubber and rough edges, and the black food trays had uneven edges, appeared melted and chipped, and had exposed brown-colored metal. The RD and DD confirmed these conditions and reviewed facility policies stating that dented, rusted, cracked, chipped, or otherwise damaged food service items and trays should be removed from service.
Call Lights Not Kept Within Reach for Two Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for two sampled residents, Resident 65 and Resident 6, in accordance with their care plans. The deficiency was identified through observation, interview, and record review in the environment care area. The report states that both residents had care plan interventions directing staff to keep the call light within reach and encourage use for assistance, and both residents were assessed as cognitively intact for daily decision making. Resident 65’s record showed diagnoses including obstructive hypertrophic cardiomyopathy and generalized muscle weakness. The resident was dependent for personal hygiene and needed partial/moderate assistance with walking, transfers, bed mobility, and dressing. During observation and interview, Resident 65 was in bed and the call light was wrapped around the left siderail and hanging to the floor; the resident stated she could not reach it and had a hard time reaching for things. LVN 1 also observed that the call light was hanging off the bed and was not within reach. Resident 6’s record showed diagnoses including muscle weakness, acute kidney failure, and edema, and the resident was dependent for oral hygiene, toileting hygiene, personal hygiene, toilet transfer, and moving from sit to lying. During multiple observations, Resident 6 was lying in bed with the call light on the floor. LVN 2 stated the call light should be within the resident’s reach at all times and not on the floor. The facility’s policy stated that call lights and hand bells are to be placed on the bed at all times and never on the floor or bedside stand.
Failure to Maintain Resident Dignity Through Hygiene and Grooming
Penalty
Summary
The facility failed to promote respect and dignity for Resident 19 by not ensuring she was free from visible food stains on her clothing and dry, crusted discharge on her left eye. Resident 19 was admitted to the facility with diagnoses including depressive disorder, difficulty walking, and osteoarthritis. Her MDS dated 11/15/2025 indicated her cognitive skills for daily decision making were severely impaired and that she was dependent on staff for personal hygiene. Her care plan, revised 12/2/2025, identified an ADL self-care deficit and dependence on staff for personal hygiene, with interventions to work around her needs, respect her dignity and rights, assist with personal hygiene and dressing, ask her preferences, provide grooming, and assist with clean clothes daily as needed. During a concurrent observation and interview on 12/9/2025 at 1:50 PM, Resident 19 was observed sitting in a wheelchair in the hallway with dry, yellowish crusted discharge on her left eye and visible cranberry stains on her white shirt. The Activity Director stated she should have been wearing a shirt without stains and her eyes should have been cleaned and free from discharge. An LVN later stated residents should not have food stains on their clothes and should be well kept for dignity and properly groomed. The ADON reviewed facility policies on grooming, baseline care plans, and dignity, and stated staff have a responsibility to monitor and contribute to residents' grooming and hygiene, residents should be cared for in a manner that promotes dignity and respect, and residents should be clean and well-groomed at all times.
Failure to Monitor Sleep for Trazodone Use
Penalty
Summary
The facility failed to ensure one sampled resident was free from unnecessary use of a psychotropic medication by not monitoring the resident’s hours of sleep for Trazodone use. The resident was admitted and later readmitted to the facility with diagnoses including dementia, major depressive disorder, and anxiety disorder. The Minimum Data Set dated 10/9/2025 showed the resident had moderately impaired cognitive skills for daily decision making, required setup or clean-up assistance with eating, was dependent for multiple activities of daily living, had no mood symptoms, and was taking an antidepressant. The resident’s order summary showed Trazodone 50 mg at bedtime for depression manifested by insomnia, with a later order for Trazodone 25 mg daily for depression manifested by insomnia. During review of the medication regimen review and interviews with the pharmacist consultant and ADON, it was stated that sleep should have been monitored to check the effectiveness of Trazodone and determine whether medication adjustment was needed. The ADON stated the resident had not been monitored for hours of sleep since the initial Trazodone order. Facility policy defined an unnecessary drug as one used without adequate monitoring and without indications for its use, and the psychotropic drug policy stated residents have the right to be free from chemical restraints unless the medication is necessary to treat a specific documented condition.
Care Plan Not Revised to Include Companion Intervention for Behavioral Needs
Penalty
Summary
The facility failed to revise the comprehensive care plan for a resident with dementia, major depressive disorder, and anxiety disorder who had behavioral problems including crying, striking at staff and others, and being a danger to self and others such as kicking. The resident’s care plan, initiated for these behaviors, listed interventions such as behavior monitoring, psychiatric evaluation and follow-up treatment as indicated, anticipating and meeting needs, encouraging attendance at group activities of interest, and explaining the purpose of procedures before starting. The resident’s MDS indicated moderately impaired cognitive skills for daily decision making and dependence for multiple activities of daily living, including oral hygiene, toileting hygiene, showering, dressing, footwear, and personal hygiene. IDT notes documented that the resident had a companion who attended to her needs, but this intervention was not documented in the care plan. During interview, the MDS nurse stated the companion should have been included in the care plan to address the resident’s behavioral problems, and the ADON stated the care plan should have included the presence of a companion at all times or during designated times as agreed upon with the resident’s representative.
Failure to Provide Grooming and Nail Care
Penalty
Summary
Provide care and assistance to perform activities of daily living for any resident who is unable was not met for one resident who was dependent on staff for personal hygiene. The resident had diagnoses including dementia, muscle weakness, and depression. The MDS dated 11/1/2025 indicated the resident’s cognitive skills for daily decision making were severely impaired and that the resident was dependent on personal hygiene. The care plan, initiated on 3/8/2023 and revised on 11/11/2025, directed staff to help with personal hygiene, provide grooming, and check nails daily, with reporting of any brittleness, cracking, splitting, or hang nails to the licensed charge nurse. During observation on 12/10/2025, the resident’s fingernails were noted to be jagged and dirty with yellowish and brownish discoloration. The Activity Director stated the fingernails were dirty and discolored, and an LVN later observed the same condition and stated the nails needed to be trimmed, could possibly cause skin injury, and could harbor bacteria. During record review and interview, the ADON reviewed the facility’s Grooming and Personal Hygiene policy, which stated that nursing and other skilled nursing staff are responsible for monitoring and contributing to residents’ grooming and hygiene, including checking nails daily and referring concerns to the grooming nurse.
PICC External Catheter Length Not Documented After Dressing Change
Penalty
Summary
Failure to provide for the safe, appropriate administration of IV fluids occurred when the facility did not document measurement of the external catheter length for a resident’s PICC line after a dressing change. The resident was admitted with malnutrition, weight loss, and for adjustment and management of a vascular access device. The resident’s record showed a right upper arm double-lumen PICC line inserted for TPN, and the care plan directed staff to measure the external catheter length upon admission and with each dressing change. The IV therapy medication record showed the PICC line dressing, securement device, cap change, and external catheter length measurement were due every 7 days, and the dressing change was signed by RN 1. The record did not show a documented external catheter measurement for the dressing change, and during review the MDS nurse verified there was no measurement documented. The Assistant DON also confirmed there was no documented evidence that the external catheter length was measured after the dressing change and stated RN 1 documented only that the dressing was changed and the site was clean, dry, and intact, with no redness, swelling, or pain. The facility policy titled PICC Dressing Change required the external catheter length to be obtained upon admission and during dressing changes, and to document the date and time, site assessment, and length of external catheter.
Improper PPE Use in Contact Isolation Room
Penalty
Summary
The facility failed to ensure staff donned proper PPE before entering a contact isolation room for two residents. Resident 28 was admitted and readmitted with diagnoses including cerebral ischemia and dementia with anxiety. The resident’s MDS dated 11/23/2025 indicated severe cognitive impairment and dependence for transfers, dressing, footwear, personal hygiene, and eating. Resident 45 was admitted and readmitted with diagnoses including atherosclerotic heart disease and dementia. The resident’s MDS indicated severe cognitive impairment and need for supervision or touching assistance with ambulation and footwear, setup or clean-up assistance with dressing and eating, and independence with transfers, standing, and personal hygiene. An order initiated 12/5/2025 placed Resident 45 on contact isolation due to herpes zoster, and the care plan included an intervention to wear proper PPE. During observation, a CNA was seen inside the room cleaning around Resident 45’s bed, changing linens, and not wearing a gown. The CNA stated he thought a gown was only needed when providing direct care. On another observation, an LVN was seen inside the room picking up an item near Resident 28’s bedside and throwing it away without wearing a gown. The LVN stated she should have been wearing a gown. The IP, ADON, and the facility’s transmission-based precautions policy all stated that staff entering a contact isolation room are expected to wear a gown and gloves upon entry.
Infection Control Deficiencies in PPE Use, Water Management, and Hand Hygiene
Penalty
Summary
The facility failed to adhere to its infection control measures, as evidenced by several observations and interviews. In one instance, a Licensed Vocational Nurse (LVN) did not wear the required Personal Protective Equipment (PPE) while administering medication to a resident via a gastrostomy tube. The resident, who had severe cognitive impairment and was dependent on others for daily activities, did not have an Enhanced Barrier Precaution (EBP) order, despite having an indwelling medical device. The Infection Preventionist confirmed that EBP should have been applied, and the Assistant Director of Nursing acknowledged the oversight, noting the importance of PPE to prevent infections. Another deficiency was noted in the facility's handling of a water main break, which resulted in a loss of water supply for several hours. The facility did not implement its Legionella Water Management Program policy, which required testing the water for contamination after such an incident. The Director of Nursing and the Engineer Assistant both acknowledged that the third-party company responsible for water management should have been contacted to ensure the safety of the water supply. The Infection Preventionist highlighted the potential risks of Legionella contamination due to water stagnation and temperature changes. Additionally, the facility failed to maintain proper infection control practices during meal assistance. Multiple staff members, including a Minimum Data Set Nurse, a Certified Nurse Assistant, and a Restorative Nurse Assistant, were observed assisting residents with feeding without performing hand hygiene between residents. This practice was contrary to the facility's policy, which required hand hygiene to prevent the spread of pathogens. The Director of Nursing confirmed the importance of following hand hygiene protocols to mitigate the risk of infection transmission between residents.
Unsafe Hot Water Temperatures in Resident Bathrooms
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for three residents, as hot water temperatures in their bathrooms were measured above the safe limit of 120 degrees Fahrenheit. This deficiency was identified during observations and interviews, where it was found that the water temperature in the bathrooms of three residents was significantly higher, reaching 128.6 and 127.7 degrees Fahrenheit, respectively. These temperatures pose a risk of scalding and burns to the residents, who were observed attempting to use the facilities without assistance. Resident 37, who has a history of cerebral infarction, aphasia, and hemiplegia, was observed struggling to wash her hands due to the excessively hot water. Similarly, Resident 6, with diagnoses including cerebral infarction and epilepsy, and Resident 10, with Alzheimer's disease and dysphagia, were also at risk due to their inability to independently manage the hot water temperatures. The residents' medical conditions, which include cognitive impairments and physical limitations, further increased their vulnerability to potential harm from the hot water. The facility's failure to monitor and regulate water temperatures in resident areas was highlighted by the Engineer Assistant's admission that only the boiler temperature was checked, and not the individual room temperatures. The facility's policy required weekly measurements and documentation of water temperatures to prevent such risks, but this was not adhered to, leading to the unsafe conditions observed. The lack of proper monitoring and adherence to safety protocols directly contributed to the deficiency identified by the surveyors.
Medication Administration Timing Deficiency
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by nine medication errors out of 27 opportunities, resulting in a 33.3% error rate for one resident. This deficiency was observed during a medication administration for a resident who was scheduled to receive medications at 8 AM but received them after 9 AM, outside the permissible one-hour window. The Licensed Vocational Nurse (LVN) responsible for administering the medications confirmed the late administration. The resident involved had significant medical conditions, including hemiplegia, hemiparesis, and a gastrostomy, and was dependent on assistance for daily activities. The resident's physician's orders included several medications to be administered via a gastrostomy tube, as well as nasal spray and eye drops. The LVN acknowledged the importance of timely medication administration, particularly for blood pressure medications, to prevent adverse effects on the resident's condition. The facility's policy and procedure documents indicated that medications should be administered within one hour of the prescribed time. The Assistant Director of Nursing emphasized the importance of adhering to scheduled medication times to ensure the effectiveness of the medications and prevent complications. Despite these guidelines, the late administration of medications was observed, contributing to the high medication error rate.
Food Safety and Storage Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to ensure proper handling, preparation, and storage of food, which could lead to foodborne illnesses for all 56 residents receiving food from the kitchen. Observations revealed that numerous food items in the kitchen refrigerators, freezer, and dry storage areas were not labeled with open dates, use-by dates, or expiration dates. Additionally, some food items were not sealed after opening, and there were instances of dented canned products and a cracked peanut butter jar in the dry storage area. The facility also failed to maintain cleanliness, as evidenced by a container with a dead fly and dust. Expired food products were not promptly removed and discarded, posing a risk of serving spoiled food to residents. The facility's temperature logs for kitchen refrigerators and dry storage areas were not consistently monitored and documented, with several missing temperature readings and staff initials. This lack of monitoring could result in improper food storage temperatures, further increasing the risk of foodborne illnesses. Interviews with the Kitchen Manager and Food Services Manager confirmed these deficiencies, acknowledging that the lack of proper labeling, expired food items, and inadequate temperature monitoring could lead to residents and staff becoming ill. The facility's policies and procedures were not adequately followed, contributing to these lapses in food safety management.
Improper Garbage Disposal Practices
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, as observed during a survey. On multiple occasions, garbage bins and dumpsters were found uncovered and overfilled with trash, contrary to the facility's policy. Specifically, a garbage bin without a cover was observed in the kitchen area, and several dumpsters outside the facility were overfilled and uncovered. The Food Services Manager (FSM) acknowledged that all garbage bins should have covers, and no trash should be on the floor, as this could attract pests and wildlife. Interviews with the FSM and Engineer Assistant (EA 1) confirmed that the facility's garbage disposal practices were not in compliance with their policy, which requires dumpster lids to be closed at all times and the area around dumpsters to be free of waste. The FSM and EA 1 both stated that the improper disposal of garbage could attract vermin and pose a disease threat to residents and staff. The facility's policy, revised in May 2023, clearly outlines the requirements for garbage disposal, which were not adhered to during the survey period.
Failure to Maintain Resident Dignity During Mealtime Assistance
Penalty
Summary
The facility failed to maintain or enhance a resident's dignity and respect by not ensuring that staff assisted a resident with eating at eye level. The incident involved a resident with multiple diagnoses, including Alzheimer's disease, chronic obstructive pulmonary disease, polyosteoarthritis, major depressive disorder, hypertensive heart disease with heart failure, and was under palliative care. The resident had severely impaired cognitive skills and required supervision or assistance with eating, as well as being dependent on others for personal hygiene and dressing. During a dining observation, a Certified Nurse Assistant (CNA) was seen standing while assisting the resident with eating, despite instructions from the Director of Staff Development (DSD) to sit at eye level with the resident. The CNA refused to comply with the instruction, which was against the facility's policy that promotes dignity and a pleasant environment during mealtime. The facility's policy emphasizes treating residents with dignity and respect, which includes assisting them in maintaining their self-esteem and self-worth.
Failure to Maintain Advance Directives in Resident Charts
Penalty
Summary
The facility failed to ensure that a copy of the advance directive was readily available in the medical charts of two residents, as required by the facility's policy. For Resident 6, who was admitted with serious medical conditions including cerebral infarction and epilepsy, the advance directive was not found in either the physical or electronic medical chart. Despite the resident's severe cognitive impairment and inability to make decisions, the advance directive was missing, which could lead to staff being unaware of the resident's wishes in an emergency. The Social Service Director confirmed the absence of the document and acknowledged its importance for guiding medical decisions when the resident cannot communicate. Similarly, for Resident 108, who was admitted with conditions such as cellulitis and obesity, the advance directive was also missing from both the physical and electronic medical records. Although the resident was independent in cognitive skills, they required substantial assistance for daily activities. The absence of the advance directive was confirmed by a Licensed Vocational Nurse, who emphasized the potential risk of staff acting against the resident's wishes during an emergency. The Social Service Director noted that the resident's husband had promised to provide the document but had not done so, and no follow-up was conducted. The Director of Nursing reiterated the importance of having the advance directive in the resident's medical chart, highlighting that emergencies can occur at any time and that the document is crucial for understanding the resident's preferences. The facility's policy mandates that residents be informed of their rights regarding advance directives upon admission and that any existing directives be documented in their health records. However, this policy was not adhered to in the cases of Residents 6 and 108, leading to the deficiency.
Failure to Conduct Restraint Assessment for Geri Chair Use
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints, specifically a Geri chair, without conducting a proper assessment. The resident, who was admitted with diagnoses including dementia, osteoporosis, and a history of falling, was observed sitting in a Geri chair. The Minimum Data Set (MDS) for the resident indicated severe cognitive impairment and dependency on assistance for daily activities, but did not document the use of a chair that prevents rising. Despite an order allowing the use of a Geri chair for comfort and positioning, there was no documented assessment to justify its use as a restraint. Interviews with facility staff, including a CNA, the Assistant Director of Nursing (ADON), and the Director of Nursing (DON), revealed that the resident had previously used a regular wheelchair and exhibited behaviors such as leaning forward and biting staff. The ADON acknowledged the lack of a restraint assessment and the DON confirmed that an interdisciplinary team assessment should have been conducted prior to using the Geri chair, as it limits movement and is considered a restraint. The facility's policy requires an assessment and attempts of less restrictive measures before using physical restraints, which was not followed in this case.
Failure to Provide Timely Incontinent Care
Penalty
Summary
The facility failed to provide adequate incontinent care and maintain personal hygiene for a resident who was dependent on staff assistance for personal care, toileting hygiene, and showers. The resident, identified as Resident 108, was observed in a state of distress, lying in bed and crying, due to being left soiled for an extended period. The resident reported using the call light during the night for assistance but was told by a nurse that she could wait due to the nurse's workload. The resident remained soiled for two hours before being attended to. Observations and interviews with staff revealed that a Certified Nurse Assistant (CNA) was aware of the resident's soiled condition but did not immediately address it, citing being busy with another resident's shower. The CNA did not seek assistance from other staff members to attend to Resident 108 promptly. Interviews with other staff, including a Licensed Vocational Nurse (LVN) and another CNA, indicated that the resident should have been cleaned immediately to prevent harm, such as skin breakdown and emotional distress. The Director of Nursing (DON) confirmed that leaving a resident soiled for a long period could cause physical and emotional harm. The facility's policies on AM/PM care and dignity emphasize the importance of promptly responding to residents' needs to maintain their dignity and quality of life. However, these policies were not adhered to in the case of Resident 108, leading to the deficiency noted in the report.
Failure to Provide Continuous Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to ensure that a resident on continuous oxygen therapy received oxygen as ordered, which was a deficiency in providing safe and appropriate respiratory care. The resident, who had diagnoses including shortness of breath, dependence on supplemental oxygen, and anemia, was observed with an empty oxygen tank during a dining room observation. The resident's Minimum Data Set indicated severe cognitive impairment and dependence on assistance for daily activities, including continuous oxygen therapy. The deficiency was identified when the oxygen tank's gauge was observed pointing to the red area, indicating it was empty. During an interview, the Assistant Director of Nursing acknowledged the importance of administering oxygen as ordered and ensuring the oxygen tank is not empty. The facility's policy on oxygen administration, formulated in April 2023, required providing oxygen therapy per physician orders, which was not adhered to in this instance.
Late Medication Administration for a Resident
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, identified as Resident 35, by not administering the resident's 8 AM medications on time as per the physician's order. The medications were administered late, at 10:22 AM, which was beyond the one-hour window allowed by the facility's policy. This delay in medication administration was observed during a concurrent observation and interview with LVN 1, who acknowledged the late administration and the potential medical complications that could arise from such delays. Resident 35 had a complex medical history, including hemiplegia, hemiparesis, and a gastrostomy, and was dependent on assistance for daily activities. The resident's prescribed medications included Amlodipine, Aspirin, Carvedilol, Isosorbide, Losartan, multivitamins, Potassium, Fluticasone nasal spray, and Artificial tears, all of which were due at 8 AM. The failure to administer these medications on time was confirmed by both the Assistant Director of Nursing (ADON) and the Director of Nursing (DON), who emphasized the importance of timely medication administration to ensure efficacy and avoid adverse reactions. The facility's policy and procedure for medication administration required that medications be given within one hour of their prescribed time. However, the review of Resident 35's medical records and interviews with the nursing staff revealed that there was no documented justification for the late administration of the medications. The ADON and DON confirmed that the medications were administered late without any documented reason, which constituted a medication error according to the facility's policy.
Failure to Adhere to Medication Administration Parameters
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors by administering medications outside of physician-ordered parameters. The resident, who had diagnoses including bradycardia, hypertension, and angina, was prescribed Amlodipine, Carvedilol, and Losartan with specific instructions to hold the medications if the systolic blood pressure was lower than 100 or the heart rate was lower than 60. During a medication administration observation, it was noted that the resident's heart rate was 59, yet the medications were administered without rechecking the vital signs or notifying the physician. The Licensed Vocational Nurse (LVN) involved stated that there was no order to call for high blood pressure and a heart rate lower than 60, and admitted to not rechecking the resident's blood pressure and heart rate before administering the medications. The Assistant Director of Nursing confirmed that the LVN should have rechecked the vital signs and informed the doctor due to the parameter order to hold the medications for a heart rate less than 60. The facility's policy and procedure required that vital signs be checked and verified before administering medications, which was not adhered to in this instance.
Failure to Post Accurate Nurse Staffing Information
Penalty
Summary
The facility failed to adhere to its policy of posting nurse staffing information in a prominent location accessible to residents and visitors. Observations on multiple occasions revealed that the Daily Report of Nursing Staff was not updated and was not posted in the designated areas, specifically at the East wing nursing station. The report dated 10/20/2024 was observed on 10/22/2024, and the report dated 10/21/2024 was still posted on 10/23/2024, indicating a lack of timely updates. The Director of Staff Development (DSD) confirmed that the staffing information was not updated as required by the facility's policy, which mandates posting within two hours of each shift's start. The DSD admitted to prioritizing floor coverage over updating the staffing information, resulting in outdated postings. The facility's policy, revised in July 2023, requires that the number of licensed and unlicensed nursing personnel responsible for direct resident care be posted daily for each shift in a clear and readable format. The failure to update and post accurate staffing information could potentially mislead residents, visitors, and staff about the actual nursing staff available for direct care.
Failure to Implement Effective Fall Prevention Measures
Penalty
Summary
The facility failed to prevent multiple falls of a resident by not developing and implementing a fall care plan after the resident experienced actual falls on several occasions. The resident, who was at high risk for falls due to impaired cognition and other medical conditions, did not have a care plan that included specific interventions tailored to their needs. The care plans that were in place were generic and did not provide clear guidance on how to monitor or supervise the resident to prevent falls. The resident, who had a history of falls and severe cognitive impairment, experienced multiple falls resulting in significant injuries, including a right hip fracture and dislocation. Despite being identified as high risk for falls, the care plans did not include specific interventions such as constant supervision or the use of a lap belt while the resident was in a wheelchair. The lack of specific interventions and supervision led to the resident sliding from the wheelchair and sustaining injuries that required hospitalization and surgical intervention. Interviews with facility staff revealed a lack of communication and assumption of responsibility for supervising the resident. Staff members assumed that others would monitor the resident, leading to the resident being left unsupervised in the hallway, which contributed to the falls. The facility's policies and procedures required individualized care plans and interventions for high-risk residents, but these were not adequately implemented for the resident in question.
Failure to Document Specific Behavior for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medication, specifically Lorazepam, by not having a specific target behavior documented for its use. The resident, who had diagnoses including anxiety disorder, dementia, and depression, was administered Lorazepam without a clear indication of the behavior it was meant to address. The medication orders for Lorazepam were incomplete, lacking specific behavior manifestations that would justify its administration. Interviews with facility staff, including an LVN and the MDS nurse, confirmed that the Lorazepam order did not specify a target behavior, which is crucial for determining when the medication should be administered. The Director of Nursing also acknowledged that specific behavior manifestations should have been included in the physician's order to ensure the PRN medication was given appropriately. The facility's policy and procedure on psychotropic drugs required that such medications be used only when necessary to treat a diagnosed specific condition documented in the clinical record.
Failure to Conduct Restraint Assessment for Resident
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraints by not conducting a necessary assessment before using a seatbelt as a restraint. The resident, who had diagnoses including anxiety disorder, dementia, and a history of repeated falls, was observed with a seatbelt across her lap while in a wheelchair. The seatbelt was ordered without a prior physical restraint assessment, which is required to determine the necessity and safety of such a restraint. The resident was unable to unbuckle the seatbelt, indicating it restricted her movement. Interviews with facility staff, including a Licensed Vocational Nurse and an MDS Nurse, confirmed that no physical restraint assessment was conducted before the seatbelt's use. The facility's policy requires an interdisciplinary team to complete an assessment and attempt less restrictive measures before using physical restraints. The lack of assessment and documentation for the seatbelt's use was a deviation from this policy, potentially affecting the resident's physical and psychological well-being.
Failure to Implement Comprehensive Fall Care Plan
Penalty
Summary
The facility failed to develop a comprehensive, resident-centered fall care plan for a resident, identified as Resident 1, who was at high risk for falls. Resident 1 had a history of anxiety disorder, dementia, and repeated falls, and was readmitted to the facility with severely impaired cognitive skills and required assistance with daily activities. The resident's Morse scale score indicated a high risk for falling, yet the care plan initiated on 7/30/2024 did not include necessary interventions such as supervision and frequent visual checks, which were crucial to prevent further falls. On 8/2/2024, Resident 1 experienced a fall that resulted in severe pain and required transfer to a General Acute Care Hospital. The fall occurred when a CNA observed the resident slowly slipping from a wheelchair and was unable to prevent the fall completely. Following this incident, additional interventions were added to the care plan, but it was noted that these should have been implemented earlier, as per the facility's Fall Prevention Policy and Procedure. The policy required interventions like constant visual monitoring and offering frequent restroom breaks, which were not initially included. The facility's policy also mandated the use of a color-coded wristband to identify residents at high risk for falls, which was not applied to Resident 1. The failure to include these specific interventions in the care plan was against the facility's policy, which emphasized the need for unique interventions tailored to each resident's needs. This oversight potentially increased the risk of falls for Resident 1, as the care plan did not adequately address the resident's high fall risk status.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 7,104 citations issued within 25 miles in the last 12 months — including the 35 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Los Angeles
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Infinity Care Of East Los Angeles | 0.6 mi | ★★★★★ | 11 | 0 |
| White Memorial Medical Ctr Dp | 0.8 mi | ★★★★★ | 0 | 0 |
| Los Angeles Comm Hospital | 2.2 mi | ★★★★★ | 15 | 1 |
| Kei-ai Los Angeles Healthcare Center | 2.5 mi | ★★★★★ | 37 | 0 |
| East Los Angeles Doctors Hosp | 2.5 mi | ★★★★★ | 7 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.