Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Huntington Healthcare Center during CMS and state inspections, most recent first.
The facility failed to follow therapeutic diet menus and recipes by serving double portions of mashed potatoes to residents on a CCHO diet and by preparing Szechuan pork and fried rice with regular high-sodium ingredients instead of the specified low-sodium products. Kitchen staff used a #8 scoop instead of the required #16 scoop for mashed potatoes, and the cook substituted regular soy sauce, hoisin sauce, bouillon, and chicken broth when low-sodium versions were not available, resulting in noticeably salty food. The Dietary Supervisor and cook confirmed these deviations from the written menus and recipes, and the RD noted that excessive carbohydrates and sodium intake can adversely affect residents with diabetes and renal conditions.
A resident with type 2 DM, ESRD, and dependence for oral hygiene and most ADLs was not scheduled for routine dental care despite facility policy requiring assistance in obtaining such services. The resident reported never seeing a dentist since admission and complained of poor dental condition. An LVN noted decomposed teeth and bad breath, and an RD at the HD center observed rotten lower teeth and foul breath, with the resident again stating no dental visit had occurred. The SSD acknowledged that the on-site dentist could not see the resident because HD appointments conflicted with dental clinic days and admitted she had not arranged a visit on a non-dialysis day, resulting in the resident not receiving needed dental services.
A resident with type 2 DM and ESRD, who required extensive assistance with ADLs but could communicate needs, reported that facility food was very salty and sometimes hard to eat. Surveyors reviewed the menu and recipe for a meal of Szechuan pork and fried rice, which specified low-sodium broth, soy sauce, and hoisin sauce, but observed that only regular, higher-sodium versions were available and used. A test tray confirmed the meal tasted salty. The cook stated she substituted regular ingredients when low-sodium items were unavailable, despite the facility policy requiring nutritionally adequate, palatable meals that meet residents’ special dietary needs.
A resident with DM and end-stage renal disease, whose physician-ordered diet specified a renal CCHO diet with soft and bite-sized texture, regular/thin liquids, and no salt, was served double portions of meat and rice without a corresponding physician order. The dietary staff provided these double portions based on the resident’s request, and the meal ticket reflected double portions contrary to the order. An LPN reported the resident’s blood glucose readings were elevated, and the facility’s own policy required diets to be served exactly as ordered by the physician.
Unsanitary Kitchen Conditions and Improper Food Storage: The facility failed to maintain safe and sanitary kitchen practices when the handwashing sink lacked hot water and was clogged, the can opener and surrounding areas were covered with dried residue, the air-drying area for food service items was dusty and unsanitary, and raw beef was stored in a way that allowed blood to leak onto a box below it. Surveyors also observed meal service plates with dried food particles that were still wet, and the DS stated the items had not been properly washed, rinsed, or air-dried before storage.
Incomplete Resident Personal Inventory Record: A resident with PVD, HTN, diabetes, and moderately impaired cognitive skills had an incomplete personal inventory sheet because staff did not obtain the resident's signature and did not document why it was missing. The CNA and ADON signed the form, but the resident's signature line and reason-for-absence line were blank. During observation, the resident accused staff of stealing belongings and reported missing purses and underwear. The SSD confirmed the inventory record was incomplete and that nursing staff were responsible for obtaining the resident's or RP's signature.
A facility completed inaccurate MDS assessments for four residents by misreporting hearing, vision, and oral/dental status. One resident with documented visual deficits and hard-of-hearing concerns was coded as having adequate hearing and vision, two residents without natural teeth were coded as having no oral/dental issues, and another resident with bilateral hearing loss was also coded as having adequate hearing. Staff observations, resident statements, and the MDSN’s own review showed the assessments did not match the residents’ actual conditions.
A facility failed to develop individualized care plans for six residents with identified needs. Two residents had hearing loss, two had dementia, and two had missing natural teeth, yet their records showed no care plans addressing those conditions. Staff observations and interviews confirmed the hearing impairment, cognitive impairment, and chewing difficulty, and the DON and MDSN acknowledged the missing care plans.
Failure to provide routine nail care affected two residents who required staff assistance with ADLs. One resident with dementia and severe cognitive impairment was observed with black substance under all fingernails and toenails that were long, irregular, and curled over the toes. Another resident with DM and cellulitis was also observed with black substance under all fingernails and stated no one had helped clean or cut the nails yet. Staff and the IP stated nail care was part of CNA or nursing duties and should be assessed daily.
Incomplete clinical documentation after a resident’s fall and decline: A resident with DM, dementia, HTN, pneumonia, and other diagnoses had missing and incomplete nursing notes after a fall, after return from the hospital, during hospice referral, and before death. The chart lacked the fall details, immediate assessment, change-of-condition documentation, physician communication, and the reason for hospice evaluation, while SBAR forms were left in progress and unsigned.
A staff member was observed wearing a surgical face mask below the nose while providing care to a resident with multiple medical conditions, in violation of facility policy requiring proper mask use. The staff member acknowledged the error, and the infection preventionist confirmed that masks must cover both nose and mouth to comply with infection control procedures.
A resident with severe cognitive impairment and mobility issues experienced a fall resulting in injury. The LTC facility failed to update the resident's fall care plan promptly, as required by their policies, leaving staff unaware of necessary interventions to prevent further falls. The care plan was not revised until several weeks after the incident.
The facility failed to account for controlled substances and non-controlled medications, leading to deficiencies in medication management. A dose of diazepam was unaccounted for due to an LVN not signing the accountability log. Additionally, six logs lacked necessary signatures for medications awaiting disposal, and the Medication Disposition log for 16 non-controlled medications lacked witness signatures and quantities. These practices indicate a lack of adherence to procedures, increasing the risk of medication errors.
The facility failed to ensure safe food preparation practices for 89 residents. Dietary staff did not perform proper hand hygiene or change gloves when leaving and returning to the tray line. Additionally, staff did not wear N-95 masks correctly while preparing food, as observed during lunch service. These practices were against the facility's policies, which emphasize hand hygiene and proper mask usage to prevent infection.
A facility failed to notify a resident's responsible party (RP) of a change in condition in the RP's preferred language, Korean. The resident, with multiple mental health diagnoses, was unable to make decisions, and the RP did not understand English. Notifications were left in English, delaying the RP's awareness of the resident's condition and care plan. Staff interviews revealed that language translation services were not utilized, despite facility policies requiring communication in the RP's preferred language.
The facility failed to develop care plans for three residents, addressing hearing difficulties and denture issues. A resident with hearing loss had no care plan to guide staff in communication, while two residents with denture problems lacked plans to address discomfort and usage, potentially delaying necessary care. Interviews with staff confirmed the absence of these care plans.
A resident with right-sided hemiplegia and hemiparesis did not receive the prescribed wrist hand finger orthosis (WHFO) and elbow splint as ordered by the physician. Despite the physician's order for daily application, the devices were not observed on the resident during multiple checks. RNA 1 admitted to not monitoring the devices due to being busy with other residents and failed to document or report the resident's removal or refusal of the devices. This oversight placed the resident at risk for further decline in mobility and increased contracture risk.
A facility failed to enforce its smoking policy and mitigate fire hazards by not being aware that a resident kept a lighter and cigarettes at the bedside. Despite the resident's intact cognitive ability and a care plan indicating a risk for smoking-related injuries, staff did not monitor or document unsafe smoking behaviors. Interviews revealed that staff were unaware of the resident's possession of these items, and the facility's policy requiring secure storage of cigarettes and lighters was not enforced.
A resident with severe weight loss and other health issues did not receive a fortified diet as prescribed by the physician. The facility staff failed to verify the meal tray against the physician's orders, resulting in the resident not receiving the necessary nutritional intake. This oversight was confirmed by the Dietary Supervisor and an LVN, highlighting a lapse in following the facility's policy for meal delivery verification.
A facility failed to store and discard an expired insulin vial for a resident according to manufacturer and facility guidelines. The opened Novolin R vial was improperly stored in the refrigerator, increasing the risk of ineffective medication use. Interviews with RN 2 and the DON confirmed the error, highlighting a deviation from the facility's policy and procedures.
A resident with specific dietary needs and preferences was not provided with alternative food choices, despite expressing dissatisfaction with the blandness of meals. The resident, who had conditions such as CHF and diabetes, often requested an alternative menu and extra portions but did not receive them. Staff interviews revealed a lack of awareness and implementation of the facility's policy to offer suitable meal alternatives, resulting in a deficiency.
Failure to Follow Therapeutic Diet Portions and Low-Sodium Recipes
Penalty
Summary
The facility failed to ensure menus and recipes for therapeutic diets were followed, resulting in incorrect portioning for a Consistent Carbohydrate (CCHO) diet and failure to use required low-sodium ingredients for menu items. During an observation with the Dietary Supervisor, kitchen staff were seen using a #8 scoop (4 oz/½ cup) to serve mashed potatoes, even though the Spring 2026 menu spreadsheet directed use of a #16 scoop (2 oz/¼ cup) for small and regular CCHO servings. The Dietary Supervisor confirmed that using the larger scoop doubled the carbohydrate portion for residents on CCHO diets and acknowledged this could lead to increased blood sugar levels. The facility’s policy on Diet/Special Diets/Therapeutic Diets required that diets be served as ordered and based on residents’ assessed needs and practitioner orders. In a separate observation and record review involving the cook, Dietary Supervisor, and Lead Assistant, the lunch menu titled “The Good for You Health” listed Szechuan pork and fried rice, with the standardized recipe specifying low sodium chicken broth, soy sauce, and hoisin sauce for the Szechuan pork sauce and low sodium soy sauce for the fried rice. The kitchen did not have low sodium soy sauce, chicken broth, or hoisin sauce available. The cook reported that she routinely followed recipes but, when the correct ingredients were unavailable, she used whatever was on hand. For this meal, she used regular (salted) soy sauce, hoisin sauce, chicken bouillon, and chicken broth instead of the low-sodium versions. She identified substantial differences in sodium content between the regular and low-sodium products. A food test tray confirmed the pork sauce and fried rice tasted salty. In a subsequent phone interview, the Registered Dietitian stated that sodium amounts ordered for renal diets must be followed and that high sodium diets could lead to hypertension, fluid overload, and edema, and that excessive carbohydrates could lead to elevated blood sugar levels.
Failure to Arrange Routine Dental Services for Dependent Resident
Penalty
Summary
The facility failed to ensure that a resident received routine dental services as required by its policy. The resident was admitted with diagnoses including type 2 diabetes mellitus and end-stage renal disease and had fluctuating capacity to understand and make decisions per the History and Physical. The MDS assessment showed the resident could understand and be understood, but required maximal assistance for eating and was dependent for oral hygiene and most activities of daily living, including personal hygiene. Despite these needs, the resident reported not having seen a dentist since admission, and staff interviews and record review did not show that a dental visit had been arranged. During interviews, the resident stated he had not seen a dentist since admission and that his teeth were in bad condition. An LVN reported that the resident came to the facility with decomposed teeth and bad breath and did not know if the resident had been seen by a dentist while in the facility. A renal RD who saw the resident at the hemodialysis center observed rotten lower teeth and foul breath and was told by the resident that he had not seen a dentist since admission. The Social Services Director acknowledged that the dentist could not see the resident during on-site visits because the resident was out for hemodialysis and admitted she should have scheduled the dental visit on a non-dialysis day. The facility’s dental services policy stated that every resident would receive or refuse necessary dental services, including routine care, and that the facility would assist residents in obtaining routine dental care from a licensed dentist, which did not occur for this resident.
Failure to Provide Palatable, Low-Sodium Meals as Ordered
Penalty
Summary
The facility failed to ensure food was palatable and prepared according to the ordered menu and recipes for a resident with significant medical conditions. The resident, who had type 2 diabetes mellitus and end-stage renal disease and required maximal assistance with eating and was dependent for most ADLs, reported that the food was very salty and sometimes difficult to eat. The resident’s MDS indicated that he was able to understand and be understood by others, and his history and physical noted fluctuating capacity to understand and make decisions. During a surveyor interview, the resident specifically stated that the food was very salty. Surveyors reviewed the menu and recipe for a scheduled meal of Szechuan pork and fried rice, which required low sodium chicken broth, soy sauce, and hoisin sauce, as well as low sodium soy sauce for the fried rice. Observation of the kitchen showed that no low sodium soy sauce, chicken broth, or hoisin sauce were available. A test tray conducted by surveyors found the pork sauce and fried rice to be salty. The cook stated she always followed the recipe but, when the correct ingredients were not available, she used whatever was on hand, and on that day she used regular, higher-sodium ingredients instead of the specified low sodium products. The cook acknowledged that the difference in sodium content between the regular and low sodium products was substantial and stated that if food was too salty, residents would not enjoy it and might lose weight. The facility’s policy on Menu Planning & Implementation required provision of nutritionally adequate, palatable, well-balanced meals that meet residents’ nutritional and special dietary needs in accordance with physician orders, resident preferences, and current standards of practice.
Failure to Follow Physician-Ordered Therapeutic Diet for Diabetic Resident
Penalty
Summary
The facility failed to provide a therapeutic diet as ordered by the physician for a resident with diabetes mellitus and end-stage renal disease. The resident’s care plan and physician’s order specified a renal diet with consistent carbohydrate (CCHO), soft and bite-sized texture, regular/thin liquids, and no salt placed on the tray, with no order for double portions. Despite this, observations on the lunch meal service showed the resident received double portions of meatloaf and rice, along with a single portion of green beans and apple juice. The meal ticket for that lunch also reflected double portions, which did not match the physician’s order. During interviews, the Dietary Supervisor acknowledged that the resident did not have an order for double portions and stated that double portions were provided because the resident requested them. The Dietary Supervisor also stated that giving double portions of rice could lead to high blood sugars. A review of blood sugar monitoring for the resident showed readings ranging from 177 mg/dL to 343 mg/dL before dinner during the month, and an LVN reported that normal blood sugar ranges were 70 to 99 mg/dL and that he was unaware the resident was receiving double portions. The facility’s policy on therapeutic diets required that diets be provided consistent with physician orders and served as ordered, but the resident’s diet was not served according to those orders.
Unsanitary Kitchen Conditions and Improper Food Storage
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and preparation practices in the kitchen. During an observation in the kitchen with the Dietary Supervisor, the handwashing sink did not have hot water and was clogged, the surface of the can opener was blackened and covered with black stains and dried residue, and the area around the can opener blade and gear was stained with dark, hardened food debris. The air-drying area for food service equipment, including water pinchers, plates, cutting boards, cups, and spoons, was dusty and unsanitary. During the same observation, a large piece of raw beef was found not fully frozen and leaking blood onto a box stored directly underneath it in the freezer. During a later tray line observation, multiple meal service plates were observed with brownish-yellow dried food particles and were still wet. The Dietary Supervisor stated the sink conditions prevented proper hand hygiene, the unclean equipment and unsanitary storage created a risk of re-contamination, the raw beef should have been stored separately and fully frozen, and the plates had not been properly washed, rinsed, or air-dried before storage. Facility policies reviewed by surveyors required sanitary kitchen practices, safe food storage, raw meats stored on lower shelves, and kitchen equipment cleaned and sanitized daily or after each use.
Incomplete Resident Personal Inventory Record
Penalty
Summary
The facility failed to ensure a resident's personal inventory list was completed when staff did not obtain the resident's signature and did not document a valid reason for the missing signature on the inventory sheet for one of six sampled residents. Resident 3 was admitted and later readmitted to the facility, and diagnoses included PVD, HTN, and diabetes. The resident's MDS dated 10/16/2025 indicated moderately impaired cognitive skills for daily decision making and that the resident required supervision or touching assistance with ADLs. A prior H&P dated 8/18/2025 indicated the resident had the capacity to understand and make decisions. During observation and interview on 12/3/2025, Resident 3 was seen yelling at staff and accusing them of lying and stealing belongings, stating that three purses and several pairs of underwear were missing. Review of the resident's Inventory Sheet dated 8/18/2025 showed signatures from a CNA and the ADON, but the resident's signature line was blank and the reason for the missing signature was also blank. The ADON stated the process was to itemize belongings with the resident, obtain the resident's or RP's signature, and have the RN sign to confirm completion. The SSD stated nursing staff were responsible for obtaining the resident's or RP's signature and notifying her if the form could not be completed, and she confirmed the Inventory Sheet was incomplete because it lacked the resident's signature. The facility policy required a complete and current inventory of each resident's personal items from admission through discharge.
Inaccurate MDS Coding for Hearing, Vision, and Oral/Dental Status
Penalty
Summary
The facility failed to complete accurate MDS assessments for four sampled residents by incorrectly coding hearing, vision, and oral/dental status. For Resident 91, the MDS dated 8/26/2025 and 11/26/2025 indicated hearing was adequate and vision was adequate, even though the resident had diagnoses including functional quadriplegia and adult failure to thrive, was severely cognitively impaired, and had documented visual deficits in the baseline care plan. An eye exam dated 10/22/2025 documented decreased vision, difficulty watching television, eating, and recognition, along with dense cataracts, optic pallor, and glaucoma suspect. Social services documentation also described the resident as hard of hearing and having decreased vision that affected communication and recognition of staff. During observation and interview, Resident 91 was seen with an opaque white film over both eyes, stared at the wall, did not make direct eye contact, and stated she could not hear well and needed staff to speak louder into her right ear. A CNA later observed that the resident did not respond when approached from either side and stated the resident was hard of hearing and had poor vision. The MDSN stated she assessed hearing by asking one question and waiting for a response, did not observe the resident’s verbal interactions throughout the day, and did not consult direct care staff. The MDSN also stated she assessed vision by asking whether the resident could read her name badge and did not use the standardized vision testing tool, and acknowledged the latest MDS submission was not accurate. For Resident 61 and Resident 70, the MDSs indicated no oral and/or dental issues even though both residents had diagnoses including dementia and dysphagia and required staff assistance with ADLs. Resident 61 was observed eating breakfast and stated it was hard to chew because he did not have his teeth. Resident 70 was observed without upper or bottom teeth, and the MDSN stated the resident did not have natural teeth and that the assessment should have been coded to reflect edentulous status. The MDSN stated the oral/dental status for both residents was coded incorrectly and did not reflect their actual condition. For Resident 20, the MDS indicated adequate hearing despite diagnoses including unspecified hearing loss in both ears, dementia, quadriplegia, and encephalopathy. During observation, the resident did not respond when called by name, and a CNA stated the resident was hard of hearing and would not hear unless spoken to very close to the ear. An LVN also stated staff were aware of the hearing impairment and that the MDS was incorrect. The DON stated that if the resident had a diagnosis of hearing impairment, the MDS should have reflected the hearing loss, and that nursing staff did not know the MDS process and required additional education.
Failure to Develop Care Plans for Hearing Loss, Dementia, and Missing Teeth
Penalty
Summary
The facility failed to develop individualized, resident-centered care plans for six sampled residents when their identified needs were not addressed in the care planning process. The report states that Residents 91 and 20 had hearing impairments, Residents 42 and 55 had dementia, and Residents 61 and 70 had missing natural teeth, yet no care plans were developed for those conditions. The facility’s policy required a comprehensive, person-centered care plan for each resident based on interdisciplinary assessment and including measurable objectives, timeframes, and specific interventions. Resident 91’s record showed diagnoses including history of falling, functional quadriplegia, adult failure to thrive, and hypertensive heart disease. The MDS indicated severely impaired cognitive skills for daily decision making, and a social services note stated the resident was hard of hearing and had difficulty engaging in communication. During interview, the resident stated she could not hear well and asked that staff speak louder into her right ear. CNA observation showed the resident did not respond when staff attempted to communicate, and LVN staff confirmed the hearing impairment. Review of the care plans showed no plan addressing hearing loss, and the LVN stated such a plan was important so staff would know how to care for and perform ADLs with the resident. Resident 20’s record showed diagnoses including bilateral hearing loss, dementia, quadriplegia, and encephalopathy. The H&P stated the resident did not have the capacity to understand and make decisions, and the MDS showed moderately impaired cognition and need for assistance with eating, toileting, bathing, oral care, personal hygiene, and wheelchair mobility. During observation, the resident did not respond when called by name, and CNA staff stated the resident was hard of hearing and needed staff to be very close to her ear to hear. LVN staff and the DON acknowledged that no hearing-loss care plan had been initiated, and the DON stated nursing staff should have initiated one when hearing loss was identified. Residents 42 and 55 each had dementia, impaired cognition, and lacked capacity to understand and make decisions, but the medical record showed no care plan developed for dementia. Residents 61 and 70 each had dysphagia and dementia; Resident 61 stated it was hard to chew because he did not have teeth, and the MDSN confirmed Resident 70 had no upper or lower natural teeth. Neither resident had a care plan addressing missing teeth, and the MDSN stated care plans were used to communicate the problem, goal, and interventions needed for proper care.
Failure to Provide Routine Nail Care
Penalty
Summary
Provide care and assistance to perform activities of daily living for any resident who is unable was not ensured when the facility failed to provide routine fingernail and toenail care for two residents. Resident 61 was admitted and readmitted to the facility with diagnoses including dysphagia, dementia, and major depressive disorder. His MDS dated 6/28/2025 indicated severely impaired cognition and that he required staff supervision for ADLs. During observation on 12/1/2025, Resident 61 was found with black substance under all ten fingernails, and his toenails were long, irregular, and curled over the tips of the toes. A CNA observed the nails and stated they were dirty and required cleaning and trimming, and that CNAs were responsible for clipping, trimming, and cleaning residents’ nails. Resident 5 was admitted and readmitted to the facility with diagnoses including cellulitis, major depressive disorder, and diabetes mellitus. The MDS indicated Resident 5 had intact cognition and required staff supervision for ADLs. During observation on 12/1/2025, Resident 5 was found with black substance under all ten fingernails and stated that no one had helped clean or cut the nails yet. The Infection Preventionist stated nail care should be assessed daily and that residents needing help with cleaning or trimming nails should be assisted by CNAs or licensed nurses. The facility policy titled Nail Care- Fingernails and Toenails stated staff would perform fingernail and toenail care as part of daily grooming to promote hygiene, comfort, and dignity.
Incomplete Clinical Documentation After Fall and Decline
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for one resident after a change in condition. The resident had multiple diagnoses including DM, dementia, tachycardia, HTN, pneumonia, hyperlipidemia, age-related physical disability, unspecified fall, and gastric ulcer. The resident’s MDS indicated moderately impaired cognitive skills for daily decision making, short-term memory problems, and dependence on staff for eating, toileting, bathing, dressing, oral hygiene, and personal hygiene. The H&P also noted fluctuating capacity to understand and make decisions, and described fever, increased agitation, aggressive behavior, and deterioration in mental status after a fall that led to transfer to a GACH and later return to the facility. The nursing progress notes did not document the date of the fall, the circumstances of the fall, or the resident’s assessment immediately after the fall. The notes from the period after the resident returned from the hospital documented antibiotic administration, monitoring, and the resident’s condition, but did not include documentation of the resident’s change in condition or any clinical concerns. The hospice evaluation note did not state why hospice was requested or what condition led to the referral. The note describing the resident as transitioning with irregular breathing did not include the decline that occurred before that point, what assessments were completed, or communication with the physician regarding the worsening condition. The final progress note stated the resident had irregular breathing throughout the night and was confirmed deceased by the RN, with the physician notified, but it did not describe the resident’s condition leading up to death or the assessments completed. During interviews, the ADON stated the resident fell when she slipped from her wheelchair and that the fall details, investigation, witness statements, SBAR, and IDT documentation were kept in the incident report binder in the DON’s office rather than in the medical record. The ADON also stated she did not document the resident’s decline after antibiotic monitoring ended, did not chart the hospice discussion or the resident’s worsening condition, and acknowledged she did not document on the resident for four days. The MRD and DON confirmed that SBAR forms were left in progress and unsigned, and the DON stated nurses should have documented what was occurring with the resident. The facility policy required nursing documentation to be accurate, timely, complete, and to reflect assessments, interventions, resident responses, and clinical decision-making.
Staff Failed to Wear Surgical Face Mask Correctly in Resident Care Area
Penalty
Summary
A deficiency occurred when a restorative nurse assistant (RNA) was observed in a resident's room wearing a surgical face mask below her nose, leaving both nasal openings exposed. The RNA acknowledged that the mask was applied incorrectly and stated that improper use could increase the potential to spread the COVID-19 virus to residents. This observation was made during a concurrent interview and was in direct violation of the facility's policy and procedure, which requires that face masks cover both the nose and mouth while staff are inside the facility and performing treatment or services. The resident involved had a medical history including cerebral infarction, cellulitis, and hypertension, and required partial to moderate assistance with oral hygiene, toileting, and personal hygiene. The infection preventionist nurse confirmed during an interview that all staff are expected to wear surgical face masks correctly, as outlined in the facility's policy. The failure to adhere to these protocols was identified through observation, interview, and record review.
Failure to Revise Fall Care Plan After Resident's Injury
Penalty
Summary
The facility failed to revise the fall care plan for Resident 64 after the resident experienced a fall with an injury on 6/20/2024. Resident 64, who was admitted with diagnoses including muscle wasting, gait abnormalities, weakness, and dementia, had severely impaired cognition and required assistance for activities of daily living. Despite the fall resulting in a wound to the left upper eye, the care plan was not reviewed or updated until 8/8/2024, leaving a gap in the documentation of necessary interventions to prevent further falls. The facility's policy and procedure for fall risk assessment and care plans required collaboration to address fall risk factors and update care plans with any significant changes in a resident's condition. However, the interdisciplinary team did not review or update Resident 64's care plan following the fall, as confirmed by interviews with RN 2 and the DON. This oversight increased the potential for staff to be unaware of the necessary interventions to prevent additional falls and injuries for Resident 64.
Deficiencies in Medication Management and Accountability
Penalty
Summary
The facility failed to properly account for controlled substances and non-controlled medications, leading to deficiencies in medication management. Specifically, one dose of a controlled substance, diazepam, was unaccounted for in the medication cart for Resident 23. The discrepancy arose because the Licensed Vocational Nurse (LVN) administering the medication did not sign the Controlled Drug accountability log after giving the dose, which is against the facility's policy. This oversight was confirmed during an interview with LVN 3, who acknowledged the failure to document the administration of the medication. Additionally, the facility did not include the necessary verifying signatures on the Controlled Drug accountability logs for medications awaiting disposal. Six logs lacked signatures from either the Director of Nursing (DON) or a Registered Nurse (RN), alongside the LVN, as required by the facility's procedures. The DON admitted to not consistently signing and dating the logs upon receipt of controlled substances, which is crucial for maintaining accountability and preventing medication diversion. Furthermore, the Medication Disposition log for 16 non-controlled medications disposed of on a specific date did not contain witness signatures or the quantity of medication destroyed. The DON sometimes disposed of these medications without a witness, which is contrary to the facility's policy. These practices indicate a lack of adherence to established procedures for medication management, increasing the risk of medication errors and potential harm to residents.
Deficient Food Preparation Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food preparation practices for all 89 residents. During observations of the tray line service for lunch, it was noted that dietary staff did not adhere to proper hand hygiene and glove-changing protocols. Specifically, Dietary Aide 1 was observed leaving the tray line to retrieve supplies without changing gloves or performing hand hygiene upon returning. Similarly, Dietary Aide 2 left the tray line to retrieve a pan and returned without changing gloves or washing hands. These actions were confirmed during interviews with the dietary aides, who acknowledged the importance of hand hygiene and glove changes to prevent contamination. Additionally, the dietary staff did not wear N-95 masks appropriately while preparing food. Dietary Aide 1 was observed with a mask that did not fully cover her nose and mouth, which was against the facility's policy requiring masks to be worn correctly to prevent infection. The Dietary Supervisor confirmed that the facility's policy mandates the use of N-95 masks to protect residents from illness and emphasized the importance of proper hand hygiene to prevent the spread of infections. The facility's policies on hand hygiene and food handling were reviewed, highlighting the requirement for staff to wash hands before handling food and maintain cleanliness throughout the tray line process.
Failure to Notify Resident's Responsible Party in Preferred Language
Penalty
Summary
The facility failed to notify the responsible party (RP) of a change in condition for a resident in the RP's preferred language of Korean. This deficiency was identified during a review of the resident's records and interviews with staff and the RP. The resident, who had diagnoses including major depressive disorder, anxiety disorder, dementia, and schizophrenia, was unable to understand or make decisions. The RP, who preferred communication in Korean, was not informed of the resident's change in condition and subsequent hospitalization in a language she could understand. Instead, notifications were left in English, which the RP could not comprehend, delaying her awareness of the resident's condition and care plan. Interviews with facility staff, including the Director of Nursing (DON) and Licensed Vocational Nurse (LVN) 1, revealed that the RP was notified of the resident's change in condition via a voice message in English, without the use of a language translator. The facility's policy required that updates to the plan of care or changes in a resident's condition be communicated in the RP's preferred language. Despite having a Korean-speaking RN available, she was not always present to assist with translation, leading to communication in English. The facility's policies emphasized the importance of accommodating residents' needs and preferences, including language, to ensure effective communication and maintain dignity.
Failure to Develop Care Plans for Residents' Specific Needs
Penalty
Summary
The facility failed to develop care plans for three residents, addressing specific needs related to hearing difficulties and denture issues. Resident 72, who was admitted with a history of falling, dementia, and hearing loss, did not have a care plan addressing her hearing difficulties. Despite being hard of hearing and requiring staff to speak loudly or closely, there was no care plan in place to ensure all staff were aware of these needs. This oversight was confirmed during interviews with facility staff, who acknowledged the absence of a care plan for Resident 72's hearing loss. Resident 37, admitted with conditions including weakness, anemia, diabetes, and dementia, experienced discomfort with her dentures, which affected her ability to eat. Despite this, there was no care plan addressing her denture discomfort, which could potentially delay necessary care and affect her oral intake. Interviews with the Director of Social Services revealed that a care plan should have been created to address this issue, but it was not documented. Resident 74, who had no natural teeth and was at risk of weight loss and pressure ulcers, also lacked a care plan for denture usage. Although Resident 74's dentures were missing, and she had been seen by a dentist, there was no care plan to address the situation. Interviews with facility staff confirmed that a care plan should have been in place to ensure proper care and prevent delays in addressing the resident's needs.
Failure to Apply Prescribed Orthotic Devices
Penalty
Summary
The facility failed to provide appropriate treatment for a resident, identified as Resident 31, by not applying a wrist hand finger orthosis (WHFO) and an elbow splint as ordered by the physician. Observations on multiple occasions revealed that Resident 31's right arm elbow and wrist were without the prescribed splint and WHFO. The resident, who has a history of right-sided hemiplegia, hemiparesis, diabetes, muscle weakness, and dysphagia, expressed an inability to straighten his right arm and hand and acknowledged the need for a splint. The physician's order required the application of the WHFO and elbow splint five times a week for four to six hours daily, with skin checks every one to two hours. RNA 1 admitted to applying the splint and WHFO but failed to check the resident's skin or ensure the devices remained in place due to being occupied with other residents' care. RNA 1 acknowledged the responsibility to monitor and reapply the devices if removed by the resident, but there was no documentation of reporting the resident's removal or refusal of the devices to the rehabilitation team. The Certified Occupational Therapy Assistant confirmed that not following the physician's orders placed the resident at risk for further decline in mobility and increased contracture risk. The facility's policies emphasized the importance of following physician's orders and providing appropriate services to maintain or improve resident mobility.
Failure to Enforce Smoking Policy and Mitigate Fire Hazards
Penalty
Summary
The facility failed to identify and mitigate fire hazard risks for a resident by not being aware that the resident kept a lighter and cigarettes at the bedside. During observations and interviews, it was found that the resident had a pack of cigarettes and a lighter on the nightstand and carried them while wheeling through the hallway. The resident confirmed that no staff had discussed the storage of these items with him. The resident's medical history included chronic obstructive pulmonary disease, generalized muscle weakness, schizophrenia, anxiety, and nicotine dependence. Despite having an intact cognitive ability for daily decision-making, the resident's care plan indicated a risk for smoking-related injuries, yet staff failed to monitor and document unsafe smoking behaviors. Interviews with staff, including an LVN and the DON, revealed that the facility's policy prohibited residents from keeping lighters and cigarettes in their rooms due to safety concerns. However, the staff was unaware of the resident's possession of these items, and there was no documentation of the resident's refusal to relinquish them. The facility's smoking policy required that cigarettes and lighters be stored securely by the patio monitor, but this was not enforced in the case of the resident. The lack of adherence to the facility's policy and inadequate supervision increased the risk of fire hazards, as staff did not confiscate the lighter and cigarettes or document the resident's non-compliance with the policy.
Failure to Provide Prescribed Fortified Diet
Penalty
Summary
The facility failed to ensure that a resident received a meal tray as prescribed by the physician, which was necessary to maintain the resident's health. The resident, who was admitted with diagnoses including failure to thrive, muscle wasting, dehydration, and anemia, required a fortified diet to address severe weight loss. Despite the physician's order for a fortified diet, the resident did not receive the appropriate meal tray during an observation, as confirmed by the meal tray ticket. Interviews with the Dietary Supervisor and a Licensed Vocational Nurse revealed that the staff did not verify the meal tray against the physician's orders before delivery, resulting in the resident not receiving the fortified tray. The facility's policy required staff to confirm the correct meal delivery, but this procedure was not followed, leading to the deficiency. The failure to provide the prescribed fortified diet placed the resident at risk of not meeting nutritional requirements and experiencing further weight loss.
Improper Storage and Expiration Management of Insulin
Penalty
Summary
The facility failed to properly store and discard an expired insulin vial for a resident, which was found during an inspection of Medication Room Nursing Station 2. The opened Novolin R vial was stored in the refrigerator, contrary to the manufacturer's guidelines that require opened vials to be stored at room temperature and used or discarded within 42 days. This improper storage increased the risk of the resident receiving ineffective or potentially toxic medication. During interviews, both RN 2 and the Director of Nursing acknowledged the error, with RN 2 noting that the expired insulin could be mistakenly used, leading to ineffective blood sugar management for the resident. The facility's policy and procedures, as well as the Insulin Storage Requirements guide, were reviewed and indicated that opened insulin should be stored at room temperature. The facility's failure to adhere to these guidelines resulted in the deficiency.
Failure to Provide Alternative Food Choices
Penalty
Summary
The facility failed to honor the food choices and offer alternative menu options for a resident, identified as Resident 15, which had the potential to impact the resident's nutritional status and quality of life. Resident 15, who was admitted with diagnoses including congestive heart failure, failure to thrive, and diabetes mellitus, was cognitively intact and capable of making decisions. Despite having no food allergies and being able to eat independently, Resident 15 expressed dissatisfaction with the blandness of the food and reported that his requests for more enjoyable meals were not fulfilled. During interviews and observations, Resident 15 stated that he had repeatedly requested an alternative menu but had not received it. He often resorted to eating two servings of oatmeal for breakfast to avoid hunger, as he disliked the meals served. On some occasions, he was only provided with one serving of oatmeal, with staff citing a lack of availability. The Licensed Vocational Nurse (LVN) acknowledged that the facility should feel like home for the residents and that Resident 15 should have access to alternative food choices and extra portions if requested. The Dietary Supervisor confirmed awareness of Resident 15's desire for alternative food choices and stated that the resident should be able to choose from an alternative menu and receive extra portions if requested. The facility's policy indicated that residents should be provided with a suitable nourishing alternate meal if the planned meal was refused, and that residents have the right to meal choices. However, these policies were not effectively implemented for Resident 15, leading to the deficiency.
What surveyors are citing around you — mapped
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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 6,631 citations issued within 25 miles in the last 12 months — including the 42 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Los Angeles
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Kei-ai Los Angeles Healthcare Center | 1.1 mi | ★★★★★ | 39 | 0 |
| Montecito Heights Healthcare & Wellness Centre, Lp | 1.5 mi | ★★★★★ | 0 | 0 |
| Highland Park Skilled Nursing And Wellness Center | 1.7 mi | ★★★★★ | 22 | 0 |
| York Healthcare & Wellness Centre | 2.3 mi | ★★★★★ | 0 | 0 |
| Royal Gardens Healthcare | 2.3 mi | ★★★★★ | 35 | 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 June 2026) and official state health department websites.