Below average — CMS composite of the measures below.
A standard survey is most likely before 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 Inland Valley Care And Rehabilitation Center during CMS and state inspections, most recent first.
Failure to Maintain Resident Dignity Through Delayed Care and Inadequate ADL Assistance: A resident with intact cognition and dependence for toileting hygiene was left in a urine-soaked brief and bed linens, with no documented peri care for much of the shift and staff reporting residents should be checked and changed every 2 to 4 hours. Another resident with intact cognition was observed with poor hygiene, body odor, stool odor, and matted hair, and reported long waits for call light response, a wet brief with stool, and no oral care. A third resident with ESRD and impaired cognition reported that CNAs did not assist after dialysis.
A resident with impaired cognition, dependence for toileting hygiene, and diagnoses including HTN urgency, TIA, and DM2 had a call light that did not sound when activated. Staff and maintenance observed that the call light outside the room and the Nurse Station panel produced no audible alert, and maintenance identified a disconnected speaker pushed up into the ceiling, leaving the signal audible only in the attic rather than the hallway.
A resident with DM2, chronic pain, CKD, and moderate cognitive impairment was discharged to an apartment with hospice services, but the facility did not complete a discharge planning review, did not have a DSCA in the chart, and did not provide discharge paperwork to the RP. The RP also stated no caregiver training was provided, and staff confirmed the required discharge planning, discharge instructions, and caregiver training were not completed.
A resident with ESRD and dependence on renal dialysis was receiving in-house hemodialysis under an active order and care plan. The resident was told verbally that Medicare coverage for in-house dialysis was ending and that services would change to outpatient dialysis, but the record contained no written notice of the coverage change or potential liability; the CM and DON confirmed no written notice was provided.
Broken Curtain Left Unrepaired: A resident with DM, ESRD on dialysis, and cellulitis had a window curtain next to the bed that was falling off the rail. The resident used clips to keep the curtain in place and block sunlight, while a CNA confirmed the curtain was broken and the MS stated maintenance was responsible for fixing it to support privacy and a comfortable, homelike environment.
A resident with DM2, chronic pain, and CKD had an MDS that failed to accurately capture a heel pressure injury at discharge. Nursing documentation showed discoloration and then a left heel ulcer, the RP said the resident had a pressure sore at discharge, and the MD stated the heel injury was a pressure wound rather than a diabetic ulcer, yet the discharge MDS still indicated no pressure ulcer/injuries.
A WCS incorrectly diagnosed a resident’s left heel wound as a diabetic foot ulcer instead of a pressure injury. The resident had DM, CKD, and significant functional impairment, and the care plan identified the heel wound as a diabetic ulcer. The WCS stated any foot wound in a diabetic resident would be diagnosed as a diabetic ulcer, while the MD stated the heel location made pressure the primary contributor and that the wound should not have been classified as a diabetic ulcer.
Failure to care plan for pressure injury risk: A resident with DM, CKD, chronic pain, and limited mobility was assessed as high risk for pressure injury after admission, but no care plan was created to address that risk. The resident’s skin was intact on admission, then later developed discoloration and a left heel wound. The MD stated the heel wound was a pressure injury, and the WCS later agreed the wound had been misdiagnosed as a diabetic ulcer.
A resident with ESRD and DM missed two scheduled hemodialysis treatments because transportation did not arrive. The resident had intact cognition and an order for dialysis three times weekly, but the facility’s records showed transportation coverage ended before a new standing request was submitted. The resident, an LVN, SSA, and DON all confirmed the missed treatments were due to transportation issues.
A resident with HTN and heart failure experienced a significant increase in BP from a prior normal reading, but the LVN who obtained the elevated value did not perform a reassessment, repeat the BP, document a change in condition, or notify the physician. Review of the vital signs record and progress notes confirmed the lack of follow-up assessment or provider notification, despite facility policy requiring hypertensive readings to be reported and documented. The ADON verified that the expected practice of assessing and documenting changes in BP was not followed in this instance.
The facility failed to maintain an audible call light system and to respond promptly to call lights, affecting two residents with intact cognition who were dependent on staff for most ADLs. One resident’s call light remained on for extended periods without response while the resident requested assistance for thirst, and another resident reported that staff did not come when the call light was used and felt forgotten by nursing staff. A CNA reported answering a call light only after seeing the blinking light above the door, not hearing it, and an LVN confirmed that call lights should be answered promptly by all staff. Testing of call lights on two units showed that activating call lights did not produce an audible signal at the nurses’ station or in the hallway, despite facility policy and the DON’s expectation that a sound box should beep when a call light is on, and policies required timely response and reporting of defective call lights.
Two residents with intact cognition and dependence on staff for most ADLs did not have bedside water pitchers and reported only receiving small amounts of fluids when requested or only at mealtimes, despite feeling thirsty and having dry mouths. Observations confirmed the absence of water pitchers and cups in their rooms. A CNA not assigned to one resident eventually brought a pitcher after noticing it was missing, while the assigned CNA stated they only provided water upon request. An LVN and the DON both stated that all residents who can swallow and are not on fluid restriction must have bedside water pitchers and that nursing staff are responsible for ensuring this, in line with facility policies on accommodating needs and supporting ADLs.
A resident with dementia and significant ADL dependence was found to have an inoperable, uncovered light fixture above the bed, with no other light source in the room except the roommate’s light. Maintenance staff identified that a repair need had been logged days earlier, but the light remained nonfunctional at the time of surveyor observation, and the Maintenance Supervisor could not produce a corresponding work order. This condition did not meet the facility’s policy requiring comfortable and adequate lighting to support a safe, homelike environment.
A resident with intact decision-making capacity and multiple medical conditions, including a tibia fracture and DM, repeatedly requested to see the Case Manager (CM) to discuss care and discharge planning related to HMO coverage. Nursing staff reported informing the CM of these requests but did not follow up, and the CM did not meet with the resident or document any contact for an extended period after admission, despite a job description requiring monitoring HMO residents and discussing discharge plans. The facility’s social services policy required providing medically related social services, including educating residents about health care options and assisting with psychosocial concerns, yet the resident remained unaware of the discharge plan and experienced mental stress due to the lack of CM involvement.
The facility failed to follow its grievance policies by not ensuring staff could direct complainants on how to file written grievances, and by not thoroughly investigating or documenting grievances submitted by two residents and a representative. One resident’s representative reported multiple care concerns, including hygiene, call light response, food temperature, physician visits, and dental care, but the facility only documented investigation of some issues and did not provide verbal or written findings. Another resident reported waiting two hours for CNA assistance to get into bed, yet no investigation was documented and no follow-up discussion or written report was provided to the resident.
A resident with DM2, dementia, and an anxiety disorder, who required staff assistance with ADLs, was housed in a room where the sliding screen door to an outside patio would not latch or lock. A family member reported the problem to a nurse, who stated it would be entered into the maintenance log. Review of the log showed an entry noting the screen door was not locking, but no completion date, and later observation confirmed the door still did not latch or lock. The maintenance staff confirmed the door needed a new latch and that their policy requires maintaining the building and equipment in a safe and operable manner.
A resident with decision-making capacity and independence in most ADLs yelled at another cognitively impaired, dependent resident and that resident’s family member, and verbally threatened to do something bad to the other resident. A SSA documented the threat and informed the SSD but did not directly notify the ADM or ensure timely reporting as required. The ADM later stated that both the SSA and SSD, as mandated reporters, failed to report the verbal threat as an allegation of abuse in accordance with facility policy, which requires immediate internal notification and reporting to appropriate agencies within two hours.
A resident with DM, dementia, and anxiety, who required staff assistance with hygiene, had a physician order to consult with a podiatrist and had previously been seen for dystrophic and elongated toenails with a recommendation for routine foot care in 60 days. The resident’s family later observed dark brown, peeling toenails and reported this to the DON, who indicated the need for a podiatry visit. However, the resident was not scheduled for the recommended follow-up due to an insurance change and the resident’s name being placed on the wrong podiatry list, contrary to the facility’s foot care policy.
A resident with diabetes, dementia, and anxiety disorder required staff assistance with several ADLs and had documented complaints of abdominal pain in nursing notes. However, over multiple required visits, the NP photocopied the same prior Attending Progress Note, changing only the date, with each note stating there were no complaints and a non-tender abdomen. This resulted in a lack of original, visit-specific physician progress notes as required by OBRA-related policy and had the potential to lead to overlooked changes in the resident’s health status and compromised physician oversight.
A resident with diabetes, dementia, and anxiety, who required staff assistance with oral hygiene, had loose and missing upper teeth and reported needing false teeth. The resident’s family member also reported deteriorating teeth and a need for dental care, stating that no treatment had been provided despite a dental visit. During that visit, the resident refused treatment until the dentist spoke with the family member, but the dental note did not specify the proposed treatment, and there was no evidence the requested discussion occurred. The facility did not ensure timely follow-up or coordination with the dental provider, leaving the resident’s dental deterioration untreated despite a policy stating that routine and emergency dental services are available to meet residents’ oral health needs.
A resident with DM2, dementia, and an anxiety disorder, who had no cognitive impairment per MDS and required assistance with several ADLs, reported that food was sometimes too cold. During a noon meal observation, staff delivered trays from a cart left in the hallway, and the resident’s pureed lunch items were found to be below the facility’s required hot food temperatures, with the pureed chicken at 104°F and cauliflower at 118°F. The resident described the chicken as lukewarm, while the Food Service Manager stated hot foods should be served around 145°F and acknowledged that trays sitting in the hallway can cause temperatures to drop, contrary to the facility’s policy requiring hot foods to meet minimum holding and delivery temperatures.
Two residents who required staff assistance for toileting hygiene were left wet or soiled during nighttime hours due to staffing shortages, despite care plans and facility policies requiring staff to keep them clean and dry. Both residents were dependent on staff for ADLs, and their needs for peri-care were not met as documented in interviews and record reviews.
Two residents with significant care needs were left wet or soiled during nighttime hours due to insufficient CNA staffing, as confirmed by staff interviews and assignment records. CNAs were assigned to care for more residents than outlined in the facility's staffing assessment, resulting in incomplete care tasks and residents being left unkempt by morning.
A resident with severe cognitive and physical impairments developed multiple open wounds and skin breakdown on the right hand after staff failed to correctly apply a palm protector as directed by rehabilitation staff and did not report observed skin issues or bleeding to licensed nursing staff. The resident's care plan and physician orders required monitoring and prompt reporting of skin integrity concerns, but these were not followed, leading to untreated wounds.
Two residents with medical conditions requiring supervision were allowed to smoke on the patio without direct visual oversight, as the assigned staff member was seated inside and unable to monitor them. Both residents had care plans indicating the need for supervision during smoking, and facility policy required staff to maintain visual contact. Staff interviews confirmed that unsupervised smoking was not permitted due to safety concerns, but the required supervision was not provided during the observed incident.
A resident with moderate cognitive impairment and multiple medical conditions was injured after being pushed by her severely cognitively impaired roommate, who had a known history of aggressive behaviors. The incident followed an argument and resulted in the resident sustaining a head laceration and elbow fracture, requiring hospital treatment. Staff responded after the altercation, despite existing care plans and policies addressing aggressive behaviors.
A resident with complex medical needs was discharged to an ICF without the facility communicating the resident's medical conditions or care requirements to the receiving provider. Upon arrival, the ICF determined it could not meet the resident's needs due to unreported conditions, and there was no evidence that the facility had provided the necessary transfer information as required by policy.
A resident and their legal representative were not provided timely access to complete medical records as required by facility policy, despite proper authorization and repeated requests. The facility sent incomplete records and did not adhere to the required timeframe for providing electronic records, as confirmed by the Director of Medical Records.
A resident with end stage renal disease and intact cognition was given four melatonin tablets by an LVN without a physician's order. The LVN administered the supplement upon the resident's request without verifying the order, contrary to facility policy requiring medications to be given as prescribed. The incident was confirmed through interviews and record review, including input from the DON.
Failure to Protect Privacy, Dignity, and Timely Care A resident’s privacy curtain was left open while an LVN checked a GT site, exposing the resident’s body to the roommate and hallway. Multiple residents also reported long waits for toileting, peri-care, and diaper changes, including waits of 20 minutes to several hours. One resident with a stage 3 sacral pressure injury and other serious diagnoses reported waiting more than 4 hours after a BM to be cleaned, while another resident said the resident had gone weeks without the requested shower and felt dirty, embarrassed, and not listened to.
Failure to Accommodate Resident Needs and Preferences: The facility did not provide an appropriate call system for a resident with bilateral arm and hand contractures, left two residents’ call lights out of reach, used a bed that was too short for a resident whose feet rested against the footboard, and did not address a resident’s request for a room change due to a noisy roommate. Care plans for the affected residents directed staff to keep call lights within reach, respect choices, and address safety or psychosocial needs, but observations and interviews showed the residents’ needs and preferences were not accommodated.
Advance Directive forms were not properly discussed, completed, or available for three residents. One resident with anxiety, depression, and bipolar disorder, another with CKD and DM2, and a third with DM and schizoaffective disorder all had records showing impaired cognition or lack of decision-making capacity, yet staff could not locate completed ADA forms in the chart or PCC, and one form was left blank except for basic identifying information. Staff stated the forms should have been completed upon admission so resident wishes would be known and available in an emergency.
Two residents had inaccurate MDS coding. One resident’s record, care plan, and MAR showed ongoing oxygen use, and staff confirmed the resident was on 2 liters via NC, but the MDS did not reflect oxygen therapy. Another resident’s records showed hospice certification and staff confirmed hospice services, but the MDS did not indicate hospice care. The MDS staff described the omissions as miscoding/data entry errors.
Missing Care Plans for Dementia and PICC Line Management: The facility failed to develop a comprehensive, person-centered care plan for two residents. One resident with dementia, encephalopathy, and Parkinsonism had severe cognitive impairment and no dementia care plan was found in the EMR or hospice binder. Another resident with a PICC line had severely impaired cognition and dependence for multiple ADLs, but staff found no clinical documentation that a PICC line care plan had been initiated or implemented.
A facility failed to carry out ordered care for three residents. One resident with dementia, osteoarthritis, and osteoporosis did not have the ordered bolstered mattress in place. Another resident with COPD, DM2, and bipolar disorder reported burning with urination, but staff did not notify the MD despite signs consistent with a UTI. A third resident with pericardial effusion, DM2 with CKD, and COPD had ongoing dysuria and severe pain; ordered UA/C&S were missed, Pyridium was delayed, and the care plan was not revised.
Pressure ulcer prevention measures were not carried out as ordered for multiple residents. A resident with hemiplegia and an ostomy had blisters under the ostomy bag that were not documented in the order summary, while other residents with PUs or skin risk had LAL mattresses observed on static mode or set to 350+ lbs instead of being matched to their actual weight. Staff and the DON acknowledged the mattresses were supposed to be set by resident weight and, for some residents, not left on static mode.
Oxygen Therapy Care Not Provided per Policy: Three residents on oxygen therapy were observed with care issues including tubing not labeled with the change date, tubing touching the floor, missing "no smoking/oxygen in use" signs outside rooms, and one resident lacking an oxygen-focused care plan. Records showed orders for oxygen and diagnoses including COPD, CHF, dyspnea, pulmonary embolism, quadriplegia, and respiratory failure, while staff and the DON confirmed the facility’s expectations for weekly tubing changes, labeling, signage, and care planning.
Failure to Keep Hemodialysis E-Kits at Bedside: Two residents receiving HD did not have an E-kit at bedside even though their care plans directed that a clamp be kept nearby for emergency bleeding at the access site. One resident had ESRD, CHF, and DM with a tunneled catheter in the upper chest, and the other had ESRD, anemia, severe cognitive impairment, and a quinton catheter in the upper thigh. CNAs confirmed the E-kits were not present, and the DON stated all HD residents needed an E-kit at bedside for bleeding control.
Delayed Toileting and Incontinent Care Due to Insufficient CNA Staffing. Two residents did not receive timely toileting and peri-care because morning-shift CNA staffing on Station 1 was stretched to about 10 residents per CNA, which staff said delayed care and call light response. One resident with COPD, DM2, and bipolar disorder reported waiting a long time for a diaper change, and another resident with COPD, pneumonia, morbid obesity, and a sacral pressure injury reported waiting hours after a BM to be cleaned up. Staff, including the DON and DSD, acknowledged that residents were waiting too long and that the assignment load was heavier than the facility’s expected 8 to 9 residents per CNA.
Meals Served Were Unappetizing and Did Not Reflect Resident Preferences: Two residents with intact cognition reported poor food quality, limited variety, and meals that did not look appetizing. One resident with respiratory failure, ventilator dependence, and dialysis dependence received an unidentifiable piece of meat that a DA later called baked chicken and said looked overcooked. Another resident with severe protein-calorie malnutrition and dysphagia received a tray with a ground beef patty that appeared irregular and undercooked to the resident, despite the resident’s stated food preferences and complaints about the lack of variety.
Kitchen sanitization buckets and the sink sanitization compartment used for food prep areas were found at 50 ppm during observation, below the DS-stated 200-400 ppm range and below the manufacturer’s 150-400 ppm testing range. The RD and DS stated the sanitizer concentration is important for patient safety and to prevent cross contamination, and the DS later stated the test strips used to check the buckets had expired.
A facility failed to follow infection control practices for multiple residents. A urine drainage bag and oxygen tubing were observed touching the floor, staff did not perform hand hygiene before and after resident care, and a resident with a PICC line had uncovered ports with IV tubing looped into the same administration set. The residents involved had significant medical conditions including paralysis, respiratory failure, UTI, candidiasis, osteomyelitis, and dependence for ADLs.
A facility failed to give several meds on time for three residents, with repeated late doses of seizure, anemia, pain, supplement, and lipid-lowering meds. An LVN also attempted to give Tylenol to a resident even though the wound had resolved and the resident said there was no wound. In another event, pregabalin given to a resident was documented on the MAR but not on the controlled substance record, and the LVN said she was too busy to sign it.
An LTC facility failed to properly label two residents’ eye drop medications and left a medication cart unlocked and unattended. One resident’s eye drop bottle lacked resident identification, and another resident’s eye drop bottle was unlabeled with only a room number on the box. During a medication pass, an LPN left the med cart in the hallway unlocked and out of view, and the DON stated the cart should be locked whenever it is outside the nurse’s view.
Failure to Obtain Informed Consent for Buspirone: A resident with anxiety, depression, bipolar disorder, and moderately impaired cognition was ordered Buspirone 7.5 mg TID for anxiety. During record review and interview, the LVN and DON stated there was no documented informed consent for the psychotropic medication, despite facility policy requiring physician-obtained informed consent verified by nursing staff.
Failure to notify the physician of a resident’s complaint of burning with urination. A resident with COPD, DM2, and bipolar disorder reported recent UTI treatment and ongoing dysuria, but multiple nurses did not act on the complaint. The LVN notified an RN, yet neither staff member contacted the MD. A later UA showed large leukocyte esterase and positive nitrite, and the RN acknowledged the result indicated a UTI.
A resident's room and two Station 4 shower rooms had black stains and a black-colored substance on the floors and grout. The MS stated the stains were dirt, the areas could be cleaner, and no log was kept for weekly checks. The resident had DM2, acute kidney failure, and was independent for showering/bathing. The facility policy stated residents are to be provided with a safe, clean, comfortable, and homelike environment.
Failure to Revise Fall Care Plan After Resident Fall: A resident with anxiety, depression, bipolar disorder, and moderately impaired cognition sustained a fall and had a history of multiple recent falls, balance problems, and need for assistance with ADLs. The fall care plan included bed positioning and floor mats, but it was not revised after the fall, and both an LVN and the DON stated the plan needed revision to evaluate whether the fall interventions were effective.
Failure to provide timely peri-care and toileting hygiene for two residents. One resident with COPD, DM2, pneumonia, morbid obesity, and a Stage 3 sacral pressure injury reported waiting hours after a BM to be cleaned up, while another resident with ESRD, groin/buttock wounds, necrotizing fasciitis, morbid obesity, DM2, and vulvar/vaginal inflammation said staff did not clean her properly and she felt dirty and upset. Records showed both residents needed assistance with toileting hygiene, and staff interviews confirmed delays, incomplete care, and that residents with wounds require hygiene and repositioning.
Hand Roll Not Maintained in Correct Position: A resident with severely impaired cognition and dependence for ADLs had an order for bilateral hand rolls to support ROM and mobility. During observation, the resident had the left hand roll in place, but the right hand roll was on the bed instead of in the hand. An LVN, RNA, and DON stated the hand rolls should be properly applied and maintained throughout the treatment period.
Failure to Maintain Resident Dignity Through Delayed Care and Inadequate ADL Assistance
Penalty
Summary
The facility failed to maintain dignity for multiple residents by not providing timely peri care, not answering call lights promptly, and not assisting with ADLs as needed. Resident 1 was admitted with diagnoses including UTI, COPD, and anxiety disorder, had intact cognition, and was dependent on staff for toileting hygiene. Resident 3 was admitted with diagnoses including UTI, asthma, and depression, had intact cognition, and required partial/moderate assistance with toileting hygiene. Resident 4 was admitted with diagnoses including ESRD, Type 2 diabetes mellitus, and epilepsy, had moderately impaired cognition, and required substantial/maximal assistance with toilet hygiene. During observation and interview, Resident 1 stated being left to wait one to two hours to be changed, reported not being changed all day since 7:00 a.m., and said the bed became wet while waiting for staff. When observed during a brief change and peri care, Resident 1’s bed was wet up to the lower back area, and the blanket, shirt, bedding, pillow, and mattress were wet with urine. Urine odor was present in the room. CNA 4 stated residents should be checked and changed every two to four hours, and CNA 2 stated Resident 1 could not have been changed in the last two to four hours based on the condition observed. The ADL Flow Sheet showed no peri care since 6:21 a.m. and no documentation that Resident 1 was checked or changed during the 7:00 a.m. to 3:00 p.m. shift. Resident 1 stated the CNAs did not ask if a change was needed and denied refusing care. Resident 3 was observed with unkept, matted hair, noticeable body odor, and stool odor, and stated having to wait two hours for staff to answer the call light. Resident 3 reported a wet brief with stool and said staff had not assisted with oral hygiene, despite sore gums. The DSD stated residents should be checked regularly, oral care should be provided every shift and as needed, and residents should not go an entire shift without being checked, changed, and provided oral care. Resident 4 stated CNAs on the unit did not do anything for residents and did not help after dialysis when the resident felt tired from treatment. The facility’s dignity policy stated residents shall be cared for in a manner that promotes well-being, satisfaction with life, and feelings of self-worth and self-esteem.
Call Light System Not Functioning for Resident Bathroom Area
Penalty
Summary
The facility failed to ensure that the call light system was functioning for one sampled resident in the bathroom and bathing area. Resident 2 was admitted and readmitted with diagnoses including hypertensive urgency, transient ischemic attack, and Type 2 diabetes mellitus. The resident's MDS dated 3/15/2026 indicated moderately impaired cognition, substantial/moderate assistance was needed for personal hygiene and sit-to-stand, and the resident was totally dependent for toileting hygiene. The H&P dated 4/11/2026 stated the resident did not have the capacity to understand and make decisions. During an observation and interview on 5/21/2026, Resident 2's call light was observed on with no audible sound, and the resident stated no one had come to help and the call light did not make a sound. CNA 1 stated staff knew the resident needed help when they passed by the room or through the panel in the Nurse Station. Later observations with maintenance staff showed the resident's call light still did not sound when illuminated outside the room, the Nurse Station panel did not sound, and a small black hole was seen in Station 6 hallway. MAINT 1 stated Resident 2's call light was disconnected in the ceiling, that the hole in the ceiling was the reason there was no sound, and that the sound could not be heard in the hallway. The ceiling mechanism was observed pushed up into an opening, and MAINT 1 stated the speaker was in the ceiling and had to be pushed up manually.
Incomplete discharge planning and missing discharge documents
Penalty
Summary
The facility failed to provide and document sufficient preparation and orientation for the discharge of one resident who was admitted with type 2 diabetes mellitus, chronic pain, and chronic kidney disease. The resident’s MDS showed moderate cognitive impairment and need for assistance with dressing, bathing, toileting, and personal hygiene. The resident was discharged to an apartment with hospice services, and the responsible party stated that no discharge paperwork was provided by the transportation team and that no one from the facility informed them the resident would be discharged that day. The record review showed the facility did not conduct a Discharge Planning Review, as the form was left blank. The facility also did not have a Discharge Summary/Comprehensive Assessment in the resident’s medical record, and the responsible party stated no caregiver training was provided. Staff interviews confirmed that discharge planning, caregiver training, and discharge instructions were part of the discharge process, and the facility’s records and interviews confirmed these steps were not completed for the resident.
Failure to Provide Written Notice for Dialysis Coverage Change
Penalty
Summary
The facility failed to inform one resident in writing why bedside dialysis services would no longer be covered by the resident’s insurance. The resident was admitted with diagnoses including type 2 DM, ESRD, and dependence on renal dialysis, and the H&P documented that the resident had capacity to understand and make decisions. The MDS showed the resident needed assistance with bathing, dressing, and toileting hygiene, and the care plan identified a need for hemodialysis with in-house dialysis scheduled on Monday, Wednesday, and Friday. The resident’s record showed an active order for in-house dialysis, and progress notes documented that the resident was receiving in-house dialysis, was told skilled coverage was ending, and was expected to transition to outpatient dialysis. Another progress note stated the resident’s insurance benefits were exhausted. Review of the medical record found no written notice form for the change from in-house dialysis to outpatient dialysis. The resident stated the change was explained verbally and that no written notice was received, and the CM and DON both confirmed that no written notice was given regarding the change in dialysis services.
Broken Curtain Left Unrepaired
Penalty
Summary
The facility failed to provide a comfortable, homelike environment for one resident when the window curtain next to the resident’s bed was broken and falling off the curtain rail. During observation, four black clips were seen holding the two curtains together so they would stay in place and keep sunlight from coming through and interrupting the resident’s sleep. The resident stated the clips had been purchased by the resident because the curtain kept dropping off the rail, and staff knew about the problem but had not fixed it. The resident involved was admitted with diagnoses including type 2 DM, ESRD with dependence on renal dialysis, and cellulitis of the left lower limb. The resident’s H&P indicated capacity to make medical decisions, and the MDS showed intact cognitive skills with substantial to maximal assistance needed for toileting hygiene, lower body dressing, and showering or bathing, and supervision or touching assistance needed for oral hygiene and upper body dressing. A CNA confirmed the curtain was broken and that clips were being used to prevent it from falling, and the MS stated it was maintenance’s responsibility to fix the curtain and that doing so was important for privacy and a comfortable, homelike environment.
Inaccurate MDS Failed to Reflect Resident’s Heel Pressure Injury
Penalty
Summary
The facility failed to ensure an accurate MDS for one resident when the discharge assessment incorrectly indicated the resident did not have any pressure ulcer/injuries at discharge. The resident was admitted with diagnoses including type 2 diabetes mellitus, chronic pain, and chronic kidney disease, and the admission MDS showed the resident had moderate cognitive impairment and required substantial to maximal assistance for multiple mobility and dressing tasks, as well as partial to moderate assistance for bathing, toileting, and personal hygiene. During the stay, a change in condition evaluation documented discoloration to the left heel and then a diabetic ulcer to the left heel after assessment by nursing staff. The resident’s responsible party stated the resident had a pressure sore on the left heel at discharge. The wound care specialist documented a diabetic ulcer of the left foot, while the physician stated the heel injury was a pressure wound and should not have been diagnosed as a diabetic ulcer. Despite these findings, the resident’s discharge MDS still indicated there were no pressure ulcer/injuries upon discharge.
Incorrect Wound Etiology Diagnosis for Heel Injury
Penalty
Summary
The Wound Care Specialist inaccurately diagnosed Resident 8’s left heel wound as a diabetic foot ulcer instead of a pressure injury. Resident 8 was admitted with diagnoses including type 2 diabetes mellitus and chronic kidney disease, and the Minimum Data Set showed moderate cognitive impairment and substantial to maximal assistance needed for multiple activities, including walking and dressing. The resident’s care plan identified a diabetic ulcer of the left heel and included an intervention to determine and treat the cause of the ulcer. During review of the resident’s change-in-condition documentation, discoloration to the left heel was noted, and the facility arranged for the resident to be seen by the Wound Care Specialist. The Wound Care Specialist documented the wound as a diabetic ulcer of the left foot and stated that if a diabetic resident had a wound on the foot, the wound would always be diagnosed as a diabetic ulcer, even if the cause was pressure. The physician later stated that because the injury was on the heel, pressure would be the primary contributor and that the wound should not have been diagnosed as a diabetic ulcer. After reviewing the CMS RAI Manual definitions with the surveyor, the Wound Care Specialist acknowledged that the left heel wound had been diagnosed incorrectly and stated the wound was a pressure injury. The manual stated that an ulcer caused by pressure on the heel of a diabetic resident is a pressure ulcer and not a diabetic foot ulcer, and that the primary etiology should be considered when determining whether an ulcer or injury is caused by pressure or other factors.
Failure to Care Plan for Pressure Injury Risk
Penalty
Summary
The facility failed to create a care plan for a resident who was identified as high risk for pressure injury development. The resident was admitted with diagnoses including type 2 diabetes mellitus, chronic pain, and chronic kidney disease. Admission records and the body assessment indicated the resident’s skin was intact on admission, and the skin check also showed no skin issues at that time. The resident had moderate cognitive impairment and required substantial to maximal assistance with walking and lower body dressing, and partial to moderate assistance with rolling, bathing, upper body dressing, toileting, and personal hygiene. A Braden Scale assessment completed after admission indicated the resident was at high risk for developing a pressure ulcer, but the care plan report did not include interventions to address that risk. The treatment nurse stated the facility’s practice was to complete weekly Braden Scale assessments for the first four weeks after admission and confirmed that the resident was assessed as high risk, but no care plan was created to address pressure injury prevention. The nurse also stated that if a care plan with interventions to prevent skin breakdown is not created for a resident at high risk, the resident may experience skin breakdown. The resident later developed discoloration to the left heel, and the change in condition form documented the heel wound. The resident’s physician stated that because the injury was on the heel, pressure was the primary contributor and identified the wound as a pressure injury. The wound care specialist initially documented the wound as a diabetic ulcer, but after reviewing the CMS RAI Manual definitions, stated that the left heel wound was incorrectly diagnosed and was actually a pressure injury. The resident was later discharged with a pressure sore on the left heel.
Missed Dialysis Due to Transportation Failure
Penalty
Summary
The facility failed to arrange transportation for a resident who required hemodialysis, resulting in the resident missing two scheduled dialysis treatments. The resident was admitted with diagnoses including type 2 DM, ESRD, dependence on renal dialysis, and cellulitis of the left lower limb. The resident’s H&P indicated the resident had the capacity to make medical decisions, and the MDS indicated intact cognitive skills. The physician’s order specified hemodialysis on Monday, Wednesday, and Friday at 1:50 PM, with dialysis transportation arranged through an outside transportation service for 14 trips. The resident’s CICE forms documented missed dialysis due to transportation issues on two occasions, and the social services progress notes showed the resident’s transportation coverage ended before a new standing request was submitted to the insurance. The resident stated the facility should arrange transportation so dialysis could occur as scheduled. LVN 1, SSA 1, and the DON each confirmed the resident missed dialysis because transportation did not come, and the DON stated it was important for residents to receive dialysis as scheduled to maintain health condition.
Failure to Assess and Report Elevated Blood Pressure
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice and facility policy after an elevated blood pressure reading for one resident. The resident was admitted with diagnoses including hypertension and heart failure and had intact cognitive skills and decision-making capacity. The resident was dependent on staff for several ADLs, including toileting, bathing, and lower body dressing. On review of the Vital Signs Record, the resident’s blood pressure increased from a prior reading of 128/75 mmHg to 168/77 mmHg on 2/27/2026. There was no documentation of any reassessment, repeat blood pressure measurement, or physician notification following this elevated reading. Progress notes contained no change in condition documentation related to the elevated blood pressure. During interview, the LVN who obtained the 168/77 mmHg reading confirmed that the physician was not notified and that no reassessment, repeat blood pressure, or change in condition documentation was completed. The ADON, upon review of the records, confirmed the absence of reassessment, change of condition documentation, and physician notification, and stated that staff were expected to assess residents, monitor vital signs, and notify the physician for changes in condition, and that a change from 128/75 mmHg to 168/77 mmHg required assessment and documentation even if the resident denied symptoms. The facility’s blood pressure policy indicated hypertensive readings should be reported to the physician and that staff should document and evaluate findings, which was not followed in this case.
Failure to Maintain Audible Call Light System and Timely Response to Resident Calls
Penalty
Summary
The deficiency involves the facility’s failure to ensure the call light system was audible and that call lights were answered in a timely manner, resulting in unmet needs for two residents. Resident 1 was admitted with myasthenia gravis and sequelae of cerebral infarction, had intact cognitive skills and decision-making capacity, and was dependent on staff for most ADLs, including transfers. Resident 1 reported that when using the call light, no one came or it took a long time for staff to respond, causing the resident to feel ignored. On one observation outside Resident 1’s room, the call light remained on and unanswered for 25 minutes. In a concurrent observation and interview inside the room, Resident 1 stated the call light had been on for over 30 minutes without response, and that the resident wanted assistance for dry mouth and thirst. Resident 2, admitted with hemiplegia and diabetes mellitus, also had intact cognitive skills and was dependent on staff for most ADLs, including transfers, and was documented as alert and oriented. Resident 2 stated there was no point in using the call light because nursing staff did not answer it, and that whenever the call light was pushed, no one came to see what was needed. Resident 2 reported feeling that staff did not care and had forgotten about the resident, and expressed concern that an emergency could occur without staff awareness. These resident interviews demonstrated that their calls for assistance were not being reliably answered. Staff interviews and observations further showed that the call light system was not functioning audibly as intended. A CNA reported answering Resident 1’s call light only because the blinking light above the door was seen, not because the call light was heard, and the CNA did not know how long the light had been on. An LVN stated that call lights should be answered promptly by all staff and that if the responding staff member could not assist, they should notify someone who could, emphasizing that unanswered call lights could delay care and potentially cause life-threatening situations. During testing of call lights on two units, the LVN demonstrated that activating call lights in random rooms did not produce an audible sound at the nurses’ station or in the hallway, despite the DON’s description that each unit’s nurses’ station should have a call light sound box that beeps when a call light is on. Facility policies on answering call lights and accommodation of needs required timely response to residents’ requests and prompt reporting of defective call lights, but the observations and interviews showed these requirements were not met.
Failure to Provide Bedside Water Pitchers to Maintain Resident Hydration
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents received fluids consistent with their needs and preferences to maintain hydration, specifically for two residents who did not have water pitchers in their rooms. One resident was admitted with myasthenia gravis and sequelae of cerebral infarction, had intact cognitive skills, and was dependent on staff for most ADLs including transfers. This resident reported not having a water pitcher, receiving only small cups of water when requested, and experiencing dry lips and throat. On a subsequent day, the resident’s call light had been on for over 30 minutes while the resident was waiting to request water due to thirst and a dry mouth. Another resident, admitted with hemiplegia and diabetes mellitus, also had intact cognitive skills and was dependent on staff for most ADLs including transfers. This resident reported not being given a water pitcher and stated that water and juices were only provided during mealtimes. Observations confirmed there were no cups and no water pitcher in this resident’s room. Both residents were described in clinical documentation as alert, oriented, and capable of making decisions, yet they lacked ready access to fluids at the bedside. Staff interviews further clarified the circumstances leading to the deficiency. A CNA who was not assigned to one of the residents brought a water pitcher after noticing its absence and stated that all residents should have a water pitcher at the bedside to prevent dehydration. An LVN stated that all residents who can swallow and are not on fluid restriction must have a water pitcher at their bedside and that all staff are responsible for providing water. The CNA assigned to one of the residents stated they only provided water if the resident requested it and had assumed the resident did not need water when the resident answered “no” to a general offer of assistance. The DON stated that all residents who can swallow and are not on fluid restriction must have water pitchers at their bedside, that pitchers should be changed daily and as needed, and that nursing staff are responsible for assuring all residents have a water pitcher, consistent with facility policies on accommodation of needs and supporting ADLs.
Failure to Maintain Operable Bedside Lighting for Dependent Resident
Penalty
Summary
The facility failed to ensure an operable light fixture above one resident's bed, compromising the resident's right to a safe, comfortable, and homelike environment. The resident had been readmitted with diagnoses including cholecystitis and dementia, with documentation indicating capacity to make medical decisions but moderately impaired cognitive skills for daily decision-making. The resident required substantial to maximal assistance with upper body dressing, toileting, and personal hygiene, and was dependent on staff for showering, lower body dressing, footwear, and transfers in and out of bed. During observation, the light fixture above the resident's bed was found to be inoperable and missing its cover, and there was no other light in the room except the roommate's bed light. Maintenance staff reported that a work order had been entered on the day of the observation, but also identified a prior entry in the maintenance log indicating the need for repair two days earlier. The Maintenance Supervisor was unable to provide a work order for the light fixture repair and acknowledged that lighting was important for CNAs to see during care and for safety. The facility's policy on a homelike environment required comfortable and adequate lighting in all areas, emphasizing sufficient general lighting in resident-use areas, which was not met in this resident's room.
Failure to Provide Medically Related Social Services and Discharge Planning Support
Penalty
Summary
The facility failed to provide medically related social services to a resident when the Case Manager (CM) did not meet with the resident despite multiple requests. The resident was admitted with a right tibia fracture, diabetes mellitus, and hypotension, and had HMO insurance. The resident’s History and Physical and MDS documented that the resident had intact cognitive skills for decision-making and required substantial/maximal assistance for most ADLs. During a phone interview, the resident reported making many requests through nursing staff to see the CM and stated being told that the CM, not the facility social workers, was responsible for coordinating care and discharge for HMO residents. RN 1 confirmed remembering the resident’s request and stated that the CM was informed but RN 1 did not follow up. Review of the electronic medical record showed no CM notes indicating any meeting or discussion with the resident until 14 days after admission, although the CM acknowledged they should have seen the resident earlier and did not. The DON reviewed the CM’s job description, which stated that the CM is responsible for monitoring all HMO/managed care residents for care needs and orders, and for discussing discharge plans with residents to ensure the plan and level of care meet their needs and ability to participate. The facility’s Social Services policy stated that medically related social services are provided to help residents attain or maintain their highest practicable physical, mental, or psychosocial well-being, including informing and educating residents about health care options and assisting with factors negatively affecting psychosocial functioning, such as helping residents voice and resolve grievances. The failure of the CM to meet with the resident from 2/10/2026 to 2/23/2026 resulted in the resident being unaware of the discharge plan and experiencing mental stress.
Failure to Investigate and Communicate Resident Grievances as Required
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to voice grievances and to have those grievances promptly and thoroughly investigated and communicated. Staff interviews showed that some RNs did not guide residents or representatives on how to file written grievances, did not know where grievance forms were located, and did not know who the facility’s Grievance Officer was, despite facility policy requiring staff to provide this information. The facility’s written grievance policies required that all grievances be investigated, that the Grievance Officer initiate investigations, and that complainants be informed verbally and in writing of the findings and corrective actions. One affected resident, identified as Resident 6, was admitted with type 2 diabetes mellitus, dementia, and anxiety disorder, and required staff assistance with bathing, dressing, toileting, and personal hygiene. Resident 6’s representative submitted a written grievance on 10/16/2025 alleging that the resident’s clothing and bedding had not been changed for a week, that the resident was not being showered, that call lights were not answered timely, that food was not served warm leading to weight loss, that the physician was not visiting, and that a dental appointment had not been arranged. The grievance form’s investigation section only addressed the concerns about showers and changing clothes and linens, and did not document any investigation into the complaints about call light response, food temperature, weight loss, physician visits, or dental arrangements. The Social Services Director reported only leaving a message for the representative and did not speak with the representative about the investigation results, and no written report of findings was provided to the representative. Another affected resident, identified as Resident 17, had a history of falls, bone density disorder, and osteoarthritis, with moderate cognitive impairment and a need for substantial/maximal assistance with bathing, lower body dressing, and personal and toileting hygiene. This resident filed a grievance on 1/23/2026 stating that they waited two hours for CNA assistance to get into bed after being left in the hallway. The grievance form for this complaint contained no documented investigation report. The resident stated that no one from the facility spoke with them about the grievance after it was filed. The Social Services Director acknowledged not following up with the resident and not providing a written report, and the Director of Staff Development stated they did not investigate the grievance because they were never informed of it. These actions and omissions conflicted with the facility’s grievance policies, which required investigation of all grievances and verbal and written notification of findings to the complainant within five working days.
Failure to Repair Resident Room Sliding Screen Door Lock
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for one resident when the sliding screen door in the resident's room would not latch or lock. The resident had been admitted with type 2 diabetes mellitus, dementia, and an anxiety disorder, and an MDS assessment indicated no cognitive impairment and a need for staff assistance with bathing, dressing, oral care, toileting, and personal hygiene. The resident's family member reported to an unidentified nurse that the sliding screen door handle in the resident's room would not latch and lock, and the nurse stated they would write a maintenance request in the Maintenance Log at the nurses' station. Subsequent observation showed that the sliding screen door to the outside patio, which provided access to the back of the facility, still would not latch closed and the lock/unlock tab would not slide up or down. Review of the Maintenance Log revealed an entry for this resident's room noting that the screen door was not locking, with no completion date documented, indicating the issue had not been fixed or addressed. The Maintenance Assistant confirmed that staff are required to document needed repairs in the Maintenance Log and that maintenance staff sign and date when issues are resolved, and also confirmed that the resident's sliding screen door required a new latch. The facility's maintenance policy stated that the maintenance department is responsible for maintaining the building, grounds, and equipment in a safe and operable manner at all times.
Failure to Report Resident’s Verbal Threat as Alleged Abuse
Penalty
Summary
The deficiency involves the facility’s failure to follow its Abuse Reporting and Investigation policy when a resident verbally threatened harm toward another resident. Resident 1, admitted with essential hypertension and hyperlipidemia and documented as having decision-making capacity and independence with most ADLs, yelled at Resident 2 and Resident 2’s family member in their shared room. Social Services Assistant (SSA) 1 documented in a social services note on 1/28/2026 that Resident 1 stated that if Resident 2’s family ever addressed Resident 1 again, Resident 1 was going to do something bad to Resident 2. SSA 1 reported this statement to the Social Services Director (SSD) and believed the SSD would inform the Administrator (ADM), but SSA 1 did not directly notify the ADM as required by the facility’s abuse policy. Resident 2, who had diagnoses including hyperlipidemia, history of falling, and depression, was documented as having severely impaired cognition and dependence on staff for multiple ADLs. Resident 2’s family member reported that Resident 1 yelled at everyone in the room and threatened Resident 2, stating Resident 1 would show Resident 2 who Resident 1 was. The ADM stated that neither SSA 1 nor the SSD reported Resident 1’s threat to harm Resident 2 to the ADM, despite both being mandated reporters. The DON stated that verbal threats are a form of verbal abuse and should be reported within two hours to appropriate authorities and to the abuse coordinator. The facility’s Abuse Reporting and Investigation policy required all staff to report all allegations of abuse to appropriate agencies within two hours and to notify the Abuse Prevention Coordinator and their supervisor immediately, which did not occur in this incident.
Failure to Provide Timely Podiatry Follow-Up and Foot Care
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate foot care and assist with podiatry appointments for one resident. The resident was admitted with diagnoses including type 2 diabetes mellitus, dementia, and anxiety disorder. An MDS assessment indicated the resident had no cognitive impairment in decision-making but required staff assistance with bathing, dressing, toileting, oral, and personal hygiene. A physician order dated 12/26/2025 authorized the resident to consult with a podiatrist. During an interview, the resident’s family member reported the resident’s toenails were turning dark brown and peeling, and stated that when this was brought to the DON’s attention, the DON said the resident would need to be seen by a podiatrist. Record review showed that during a podiatry visit documented as a Nursing Home Visit on 10/12/2025, the podiatrist noted dystrophic and elongated toenails and recommended routine foot care again in 60 days. The social services assistant confirmed that this was the resident’s last podiatry visit and that the resident was not seen again in 60 days as recommended. The assistant explained this did not occur due to a change in the resident’s insurance and the resident’s name being placed on the wrong podiatry list. The facility’s foot care policy stated that residents receive appropriate care and treatment to maintain mobility and foot health, which was not followed in this case.
Failure to Document Original Physician Progress Notes at Required Visits
Penalty
Summary
The facility failed to ensure that an attending physician or designee wrote, signed, and dated original progress notes at each required visit for one resident. The resident was admitted with diagnoses including type 2 diabetes mellitus, dementia, and anxiety disorder. A Minimum Data Set dated 12/15/2025 documented that the resident had no cognitive impairment in decision-making and required varying levels of staff assistance for bathing, dressing, oral care, toileting, and personal hygiene. Health Status Notes from early August 2025 showed that the resident complained of abdominal pain. During a concurrent interview and record review with the nurse practitioner (NP) on 2/9/2026, Attending Progress Notes dated across multiple months were examined. The notes for 7/3/2025, 8/4/2025, 9/5/2025, 10/6/2025, 11/7/2025, 12/7/2025, and 1/26/2026 were found to be identical in content, each stating that the resident had no complaints and a non-tender abdomen, with only the date at the top changed. The NP acknowledged photocopying the previous month’s progress note because the NP believed there were no changes in the resident’s condition. This practice conflicted with the facility’s Physician Services policy, which required physician orders and progress notes to be maintained in accordance with current OBRA regulations and facility policy. The report stated that this failure had the potential to result in overlooked changes in the resident’s health status and compromised physician oversight of the resident’s total program of care.
Failure to Coordinate Dental Follow-Up After Resident Requested Dentist-Family Discussion
Penalty
Summary
The facility failed to provide routine dental services to meet a resident's oral health needs by not ensuring timely follow-up or coordination after a dental visit. The resident was admitted with diagnoses including type 2 diabetes mellitus, dementia, and anxiety disorder, and the MDS assessment showed no cognitive impairment and a need for staff assistance with oral and personal hygiene. Observation revealed the resident was missing most upper teeth, and both the resident and a family member reported loose and missing teeth and the need for dental care, including false teeth. The family member stated that if the resident had been seen by a dentist, no treatment had been provided to address the deteriorating teeth. The dental progress note from a dentist visit documented that the resident refused treatment and requested that the dentist speak with the resident’s family member before proceeding. The note did not specify what treatment was refused. The social services assistant acknowledged that the dentist should have spoken with the family member as requested and reported calling the dentist’s office to inform them that the family member wanted to speak with the dentist. The regional manager for the dental provider confirmed the dentist saw the resident and that the resident wanted the dentist to talk with the family member before treatment, but the documentation did not indicate that this occurred. As a result, the resident’s dental deterioration remained untreated, contrary to the facility’s policy stating that routine and emergency dental services are available to meet residents’ oral health needs in accordance with their assessment and care plan.
Failure to Serve Hot Foods at Required Temperatures
Penalty
Summary
The facility failed to ensure hot foods were served at a palatable, safe, and appetizing temperature when a resident received a lunch meal that was below the facility’s required hot food temperatures. The resident, who had type 2 diabetes mellitus, dementia, and an anxiety disorder, had an MDS indicating no cognitive impairment and required varying levels of assistance with ADLs such as bathing, dressing, oral care, toileting, and personal hygiene. The resident reported during interview that sometimes the food served was too cold. During a noon meal observation, the meal tray cart was placed in the hallway near a nurses’ station, and staff began delivering trays a few minutes later, with the resident’s tray delivered several minutes after the cart was opened. Upon observation and temperature testing of the resident’s lunch tray, which consisted of pureed chicken with sauce, pureed cauliflower, pureed pasta, and pureed bread, the pureed chicken measured 104°F and the pureed cauliflower measured 118°F. The resident tasted the chicken and stated it was lukewarm and should be hot. The Food Service Manager stated that hot foods should generally be served around 145°F and acknowledged that if trays sit in the hallway too long, food temperatures will drop. The facility’s Meal Service policy required hot food serving temperatures to be at or above a minimum holding temperature of 140°F, with recommended delivery temperatures greater than 120°F for hot entrées, which was not met for the resident’s pureed chicken.
Failure to Provide Peri-Care for Dependent Residents
Penalty
Summary
Facility staff failed to provide necessary peri-care for two residents who required physical assistance with toileting hygiene. For one resident with diagnoses including epilepsy, type 2 diabetes mellitus, and a history of falls, records indicated a care plan goal for daily ADL needs to be met, with interventions for staff to keep the resident clean and dry. Despite this, the resident reported being left wet during nighttime hours due to staffing shortages. Documentation showed the resident had severely impaired cognitive skills and required supervision to extensive assistance for ADLs. Another resident, with diabetes mellitus and hypertension, was also dependent on staff for toileting hygiene according to their care plan and assessment. This resident reported being left soiled for an extended period during nighttime hours, again citing staffing shortages as the cause. The resident expressed concern about prolonged incontinence and potential skin breakdown. Facility policies reviewed indicated that residents unable to perform ADLs independently should receive necessary services to maintain hygiene, and that perineal care is intended to provide cleanliness, comfort, and prevent infection and skin irritation.
Insufficient Staffing Leads to Delayed Incontinent Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, resulting in delays in toileting and incontinent care for two residents. One resident, with diagnoses including epilepsy, type 2 diabetes, and a history of falls, was assessed as having severely impaired cognitive skills and required supervision to extensive assistance for activities of daily living. This resident reported being left wet during nighttime hours due to staffing shortages. Another resident, with diabetes and hypertension and intact cognitive skills, was dependent on staff for toileting hygiene and reported being left soiled for an extended period during the night, also attributing this to insufficient staffing. Staff interviews and assignment sheet reviews confirmed that CNAs were assigned to care for more than 16 residents during the night shift, exceeding the facility's own staffing assessment. CNAs reported being unable to complete all assigned care tasks due to excessive workloads, resulting in residents being left wet and unkempt by morning. The facility's policies indicated that staffing should be based on resident needs and care plans, but actual assignments did not align with these requirements, leading to unmet care needs for residents.
Failure to Properly Apply and Monitor Hand Splint Resulting in Skin Breakdown
Penalty
Summary
The facility failed to provide appropriate care and services to a resident with severe cognitive impairment and significant physical limitations, specifically regarding the use and monitoring of a right hand palm protector. The restorative nursing assistants (RNAs) did not correctly apply the palm protector as instructed by rehabilitation staff. The elastic band of the device was placed between the thumb and index finger, contrary to the occupational therapist's directions, which was observed to be incorrect and contributed to skin breakdown. Additionally, the RNAs did not inform licensed nursing staff when they observed that the resident's right palm and hand were sweaty and had moisture accumulation, nor did they report the presence of open wounds and bleeding on the resident's right thumb and index finger after removing the palm protector. The wound/treatment nurse was not notified of these wounds, and the resident's care plan and physician orders specifically required monitoring for skin integrity and prompt reporting of any skin breakdown or pain. Observations and interviews confirmed that the resident was dependent on staff for all activities of daily living and had a history of severe contractures and muscle atrophy. Despite these vulnerabilities and clear care instructions, the palm protector was not applied as ordered, and significant changes in the resident's skin condition were not communicated to the appropriate nursing staff, resulting in multiple open wounds and skin issues on the resident's right hand.
Failure to Provide Adequate Supervision During Resident Smoking Activities
Penalty
Summary
The facility failed to provide a safe environment and adequate supervision for two residents who wished to smoke, as required by the facility's policy and procedure on resident smoking. On the observed date and time, the Activities Assistant (AA) responsible for supervising the smoking patio was seated inside, facing away from the door and unable to visually monitor the residents who were smoking outside. The AA acknowledged not being able to see the residents from their position and stated that visual supervision was important to ensure resident safety and prevent incidents such as burns or altercations. Resident 4 had a history of peripheral vascular disease and lack of coordination, with care plans and assessments indicating a risk for injury related to smoking and a need for supervision during smoking activities. Resident 5 had diagnoses including peripheral vascular disease, muscle wasting, and nicotine dependence, and was also identified as being at risk for injury from smoking or vaping, requiring staff supervision during scheduled smoking times. Both residents' care plans and assessments documented the need for precautionary measures and supervision, and facility policy specified that residents requiring assistance or monitoring for smoking safety were not to smoke unsupervised. Interviews with staff, including an LVN and the Director of Nursing (DON), confirmed that residents were not permitted to smoke without supervision due to safety concerns such as burns, altercations, or potential fires. The DON emphasized the necessity of maintaining visual contact with residents during smoking activities. Despite these requirements, the observed lack of direct supervision placed the residents at risk and constituted a failure to follow established safety protocols.
Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Injury
Penalty
Summary
A deficiency occurred when a resident with moderate cognitive impairment and multiple medical conditions, including Alzheimer's disease and anxiety disorder, was physically abused by her roommate. The incident took place after an argument between the two residents, during which the roommate, who was severely cognitively impaired and had a documented history of aggressive behaviors, pushed the resident. This resulted in the resident falling to the floor, sustaining a laceration to the back of her head and a fracture to her right elbow, requiring transfer to an acute care hospital for treatment. The roommate involved in the altercation had a care plan in place due to her potential for physical and verbal aggression, including behaviors such as throwing items, yelling, and arguing with other residents. Staff interviews confirmed that the roommate had a pattern of losing her temper and displaying aggressive behaviors toward other residents, both in the room and in common areas. Despite these known risks, the two residents continued to share a room, and staff intervention only occurred after the altercation had already escalated to physical violence. Facility policy required staff to monitor residents for aggressive or inappropriate behaviors and to recognize behaviors that could provoke reactions, such as verbal or physical aggression and invading personal space. In this case, staff responded after hearing the argument and the incident had already resulted in injury. The failure to prevent the altercation and protect the resident from physical abuse constituted a violation of the resident's right to be free from abuse and neglect.
Failure to Communicate Resident Needs Prior to Discharge
Penalty
Summary
The facility failed to arrange for a safe and orderly discharge for one resident when it did not communicate the resident's medical conditions and needs to the receiving Intermediate Care Facility (ICF) prior to transfer. The resident had significant medical diagnoses, including acute kidney failure, malignant melanoma, and dysphagia, and was severely impaired in cognitive skills, requiring substantial to maximal assistance with activities of daily living. Upon arrival at the ICF, staff determined that the resident had bed sores and an infected tumor on the neck, conditions that the ICF was not equipped to manage. The ICF administrator reported not receiving any transfer paperwork or communication regarding the resident's needs before the transfer and stated that the facility was not appropriate for the resident's level of care. The case manager responsible for the discharge confirmed that there was no evidence, such as a fax confirmation or phone call, to show that the resident's medical needs were communicated to the receiving ICF prior to discharge. The facility's policy required comprehensive information to be conveyed to the receiving provider at the time of transfer or discharge, including medical status, care needs, and special instructions, but this was not followed in this instance.
Failure to Provide Timely Access to Resident Medical Records
Penalty
Summary
The facility failed to provide a resident or the resident's legal representative with a copy of the resident's medical record upon request and within the required timeframe, as outlined in the facility's own policy and procedure. The resident, who was admitted with lumbar region stenosis and hypertension and required substantial assistance with activities of daily living, had intact cognitive skills according to the Minimum Data Set. A signed HIPAA-compliant authorization for the release of patient information was present, and a formal request for records was made to the medical records assistant. Despite these requests, the legal assistant reported that the facility continued to send incomplete printed and scanned records instead of the requested electronic format from the Point Click Care system. The facility's policy required electronic access or copies to be provided within 24 to 48 hours, excluding weekends and holidays, when records are maintained electronically. The Director of Medical Records acknowledged that the department did not follow the established policy and procedure, resulting in the resident's representative not receiving the medical records in a timely manner.
Medication Administered Without Physician Order
Penalty
Summary
A medication administration error occurred when a licensed vocational nurse (LVN) gave a resident four tablets of melatonin, totaling 12 milligrams, without a physician's order. The resident, who had end stage renal disease and was dependent on dialysis, was admitted with intact cognition and the ability to make decisions. The error was documented in the resident's records, including the Change in Condition Evaluation and Care Plan Report, which noted the risk for possible adverse reactions and the need for monitoring. The facility's policy and procedure for administering medications requires that medications be given as prescribed, but this was not followed in this instance. The incident was validated through interviews and record reviews, including statements from the resident and the Director of Nursing (DON). The LVN admitted to administering the melatonin upon the resident's request without verifying a physician's order. The facility's policy, reviewed with the DON, clearly states that medications must be administered in accordance with prescriber orders, which was not adhered to in this case.
Failure to Protect Resident Privacy and Provide Timely Personal Care
Penalty
Summary
The facility failed to protect resident privacy and dignity during care and treatment for seven sampled residents. During an observation of a nurse checking Resident 33’s gastrostomy tube site, the privacy curtain was not closed, exposing the resident’s abdominal area to the roommate and the hallway. The nurse stated the curtain needed to be closed before providing care, and the DON stated body parts should not be exposed during care and treatment and that the privacy curtain needed to be closed to protect privacy and dignity. Several residents reported extended waits for assistance with toileting, peri-care, and changing after incontinence episodes. Resident 116 stated that after receiving a laxative, the resident had loose stool in the bed and had to wait one hour or more to be changed, and said this happened on all shifts. Resident 239 stated the resident waited up to 2.5 hours at night to be changed and felt awful. Resident 45 stated the resident waited 30 minutes to one hour for staff assistance and said staff turned off the call light and did not assist, with waits occurring while staff took breaks and lunches. Resident 11 stated the resident pressed the call light earlier in the morning for a diaper change and waited so long that the resident fell asleep. Resident 136, who had diagnoses including COPD, type 2 diabetes, pneumonia, morbid obesity with alveolar hypoventilation, and a stage 3 sacral pressure injury present on admission, stated the resident had a bowel movement at 7:30 a.m. and was still waiting at 11:07 a.m. to be cleaned up, saying the resident was upset and embarrassed and sometimes waited up to three hours to be cleaned. The record also showed recommendations for aggressive offloading, turning every two hours, no sitting beyond two hours, frequent diaper checks and changes, and keeping skin clean and dry. Resident 27, who required substantial to dependent assistance with toileting hygiene, bathing, and dressing, stated the resident had not taken a shower in three weeks, had only received one bed bath in that time, and had been asking for a shower for the past three weeks. The resident said staff did not clean the resident properly after bowel movements and that the resident felt dirty, mad, sad, embarrassed, and not listened to.
Failure to Accommodate Resident Needs and Preferences
Penalty
Summary
The facility failed to accommodate Resident 8’s needs by leaving a push-button call light in place even though the resident had bilateral arm and hand contractures and could not push the button. Resident 8’s care plan identified the resident as being at risk for falls and directed staff to ensure the call light was within reach and to encourage its use for assistance. During observation, Resident 8 was lying in bed, and CNA 2 stated the resident could not use the push-button call light and would benefit from a pad sensor instead. The DON and LVN 2 stated that residents with limited mobility should have an appropriate means to call for assistance that matches their functional capability. The facility also failed to keep the call light within reach for Resident 41 and Resident 163. Resident 41 had diagnoses including acute embolism, thrombosis, diabetes mellitus, chronic kidney disease, and major depressive disorder, and the care plan directed staff to ensure the call light was within reach. During observation, Resident 41 was resting in bed and the call light was hanging down from the side of the bed, and the resident stated it could not be reached. Resident 163 had diagnoses including muscle wasting and atrophy, intermittent confusion, and moderately impaired cognition. Resident 163’s care plan also directed staff to keep the call light within reach, but during observation the resident stated the call button could not be reached, and LVN 1 observed that it was clipped to the upper left side of the bed rather than accessible to the resident. The facility failed to accommodate Resident 165’s physical needs by providing a bed that was too short for the resident. Resident 165 had respiratory failure, traumatic brain injury, and persistent vegetative state, was dependent on staff for all ADLs, and was 72 inches tall. During observation, Resident 165’s feet hung past the foot of the bed, and when the mattress was placed flat, the feet rested against the footboard. The resident’s mother stated she had requested a longer bed in the past and had been told there were no other beds available. The facility also failed to accommodate Resident 218’s request for a room change related to the roommate’s noise. Resident 218 had dysphagia and functional quadriplegia and was dependent on family members to assist in communication of care needs. The care plan addressed social and mental stimulation and respecting the resident’s choices, but it did not include social services interventions for the room-change request or emotional distress. The resident’s family member stated the resident could not sleep well because of the noise from the roommate and had requested a room change months earlier. Social services stated roommates were assigned based on age and health condition and that Resident 218 and the roommate needed to stay in one room due to isolation, although the records reviewed did not show a common infection.
Advance Directive Forms Not Completed or Available for Three Residents
Penalty
Summary
The facility failed to implement its Advance Directive policy for three sampled residents by not ensuring Advance Directive information was discussed, documented, or available in the medical record. For Resident 7, the admission record showed diagnoses including anxiety, depression, and bipolar disorder, and the MDS indicated moderately impaired cognition and assistance needs with dressing, toileting hygiene, showering, upper body dressing, and footwear. During review of the chart, LVN 4 stated there was no Advance Directive Acknowledgement Form in either the physical chart or PCC, and said the form should be accessible to identify the resident’s medical wishes in an emergency. For Resident 16, the admission record showed diagnoses including CKD and type 2 DM, and the MDS indicated moderately impaired cognition with moderate assistance needed for eating and oral hygiene. LVN 4 stated there was no ADA Form in the physical chart or PCC, and the SSD also stated he could not find the form in the chart. Both staff stated the form needed to be in the clinical record upon admission so the resident’s wishes would be known and immediately available in case of emergency. The DON stated the ADAF needed to be initiated and completed upon admission by Social Services to assess whether the resident had executed an AD or wanted to execute one. For Resident 119, the admission record showed diagnoses including DM and schizoaffective disorder, the H&P stated the resident did not have capacity to understand and make decisions, and the MDS indicated moderately impaired cognition. The undated Advance Directive Acknowledgment Form was blank except for the resident’s name, physician, admission date, and medical record name, with no acknowledgement from the resident or responsible party regarding written material, rights to accept or refuse treatment, the right to formulate an AD, whether an AD existed, or whether the resident or RP declined or wished to execute one. SSD 1 stated it was his job to discuss the resident’s rights to formulate an AD with the responsible party and that he was responsible for completing the form upon admission.
MDS Assessments Not Accurately Coded for Oxygen and Hospice
Penalty
Summary
The facility failed to ensure accurate MDS assessments for two residents. For Resident 9, the admission record listed respiratory failure, COPD, and heart failure, and the H&P stated the resident had the capacity to understand and make decisions. The care plan identified oxygen therapy related to heart failure and respiratory illness, and the MAR documented oxygen administration every day from 7/1/2025 through 7/31/2025. However, the MDS dated [DATE] did not indicate oxygen therapy was used in the last 14 days. During interview, the LVN stated Resident 9 was on 2 liters of oxygen via nasal cannula, and the MDS Coordinator stated the resident was on oxygen at the time of assessment and throughout July 2025, and that the omission was a data entry error. For Resident 13, the admission record listed encephalopathy, respiratory failure, and Parkinsonism, and the H&P stated the resident did not have the capacity to make medical decisions. The MDS dated [DATE] indicated severe cognitive impairment and dependence for toileting and personal hygiene, but did not indicate hospice services. The Physician’s Certification for Hospice Services showed hospice certification from 6/20/2025 to 9/17/2025, and a later MDS also did not indicate hospice services. During interview, the MDS Assistant stated the MDS was miscoded and should have been coded as hospice because Resident 13 was on hospice services, and stated the resident was placed on hospice on 6/20/2025.
Missing Care Plans for Dementia and PICC Line Management
Penalty
Summary
The facility failed to develop an individualized, person-centered care plan for Resident 13, who was readmitted with diagnoses including encephalopathy, dementia, and Parkinsonism. The resident’s H&P stated the resident did not have the capacity to make medical decisions, and the MDS indicated severe cognitive impairment with dependence on staff for toileting and personal hygiene. During interview and record review, RN 6 reviewed the EMR and hospice binder and stated there was no care plan for dementia, and that Resident 13 should have had one because of the dementia diagnosis. The facility also failed to include Resident 33’s PICC line in the resident’s care plan. Resident 33 was admitted with diagnoses including encounter for attention to gastrostomy and pneumonia, and the MDS indicated severely impaired cognition for daily decision making and dependence on staff for multiple activities of daily living, including oral hygiene, toileting, bathing, dressing, footwear, and personal hygiene. During interview and record review, RN 1 stated there was no clinical documentation that a care plan had been initiated for management of Resident 33’s PICC line, and stated a care plan should have been initiated and implemented for the PICC line. The DON also stated that Resident 33’s PICC line care plan must be initiated and implemented to provide proper care and interventions.
Failure to Follow Orders and Address Urinary Pain and Mattress Order
Penalty
Summary
The facility failed to provide treatment and care according to physician orders and resident needs for three sampled residents. One resident with dementia, osteoarthritis, osteoporosis, and severe cognitive impairment had an order for a bolstered mattress when in bed for mobility and positioning, but during observation the resident was lying in bed without the bolstered mattress in place. A CNA stated the mattress was not present, and an LVN confirmed the order should have been carried out as soon as it was received. The DON stated all doctor’s orders should be carried out immediately to avoid delay in care and treatment. A second resident with COPD, type 2 diabetes mellitus, and bipolar disorder reported burning pain when urinating and stated multiple nurses had been told about the symptom, but the complaint was not addressed. An LVN confirmed the resident complained of burning with urination but did not notify the physician, and an RN stated the physician was not notified even though burning with urination is a symptom of a UTI. A urinalysis collected the next day showed large leukocyte esterase and positive nitrite, and the RN stated the result indicated a UTI. The resident’s care plan directed staff to notify the healthcare provider immediately for voiding abnormalities and to monitor for signs and symptoms of UTI. A third resident with pericardial effusion, type 2 diabetes mellitus with chronic kidney disease, and COPD reported pain and burning with urination for three weeks and said two antibiotics had not relieved the symptoms. The resident also reported severe back pain with urination. The record showed a physician/FNP assessment with a plan for urinalysis and culture and sensitivity, but the tests were not carried out. The FNP stated the UA and C&S were missed, Pyridium for urinary pain was delayed, and the resident was not referred to urology. An LVN stated the care plan for pain upon urination was not revised, and the EMR did not contain an SBAR for the resident’s complaint of dysuria.
Pressure Ulcer Prevention and Low Air Loss Mattress Settings Not Managed as Ordered
Penalty
Summary
The facility failed to ensure pressure ulcer care and prevention measures were carried out for five sampled residents. Resident 218 had hemiplegia and hemiparesis following a cerebral infarction and functional quadriplegia, and was dependent on staff for personal hygiene. During observation, two blisters were seen on the left lower side of the abdomen under the ostomy bag, but the order summary did not identify blisters in that area. When interviewed, an LVN stated they did not know about the blisters under the ostomy bag and would report it to the treatment nurse. Resident 212 had diagnoses that included pressure ulcer and non-pressure chronic ulcer of the left heel and midfoot, and the MDS showed severely impaired cognition and dependence on staff for multiple activities of daily living. The resident had an order for a low air loss mattress for skin management. During observation, the mattress was set at 320 lbs and the light was switched to ON, indicating static mode. The LVN stated the mattress needed to be set according to the resident’s actual weight and also stated the mattress needed to be on alternating mode rather than static mode. The DON stated the mattress needed to be set up based on the resident’s actual weight and should not be on static mode. Resident 213 had diagnoses including pressure ulcers of the sacral region and left buttock, with history and assessment findings showing severely impaired cognition, dependence for turning and repositioning, high risk for pressure ulcers, and bedbound status with recommendations for aggressive offloading using a low air loss mattress. The resident had an order for a pressure relieving low air loss mattress set to alternating and weight of resident for wound management. During observation, the mattress was on static mode while the resident was in bed. An LVN confirmed the setting, and the treatment nurse stated the mattress was on static to make the bed more stable before turning it off. The DON stated the mattress would not serve its purpose if not on the appropriate setting to offload weight and should not be on static mode. Resident 136 had COPD, type 2 diabetes, pneumonia, morbid obesity with alveolar hypoventilation, and dependent care needs. The care plan listed a low air loss mattress for skin maintenance, and wound recommendations included turning every 2 hours, no sitting beyond 2 hours, frequent diaper checks and changes, and use of a low air loss mattress. The order summary directed staff to monitor pressure settings according to the patient’s weight and comfort every shift, and the resident’s weight was 190 lbs. Resident 41 had acute embolism and thrombosis of the right lower extremity, CKD stage 4, type 2 diabetes, morbid obesity, and generalized edema. The order summary also directed monitoring pressure settings according to the patient’s weight and comfort every shift, and the resident’s weight was 180.2 lbs. During observation, Resident 41’s and Resident 136’s low air loss mattresses were both set at 350+ lbs. Staff interviews stated the mattress settings were to be determined by resident weight and checked every shift, and the DON and other staff stated the settings needed to match the resident’s weight to support wound healing and pressure ulcer prevention.
Oxygen Therapy Care Not Provided per Policy
Penalty
Summary
The facility failed to provide necessary care and services for residents on oxygen therapy in accordance with its policy and procedure on oxygen administration for three sampled residents. Resident 9 had diagnoses including respiratory failure, COPD, and heart failure, and the record showed oxygen could be given at 2-3 liters per minute via nasal cannula to keep oxygen saturation above 93% for shortness of breath. During observation, Resident 9 was receiving oxygen through a nasal cannula that was labeled 8/4/2025, and the tubing was touching the floor. The LVN stated the tubing should not touch the floor because it could contaminate the equipment and that the tubing should be changed weekly to prevent infection. Resident 25 had diagnoses including CHF, dyspnea, and pulmonary embolism, and had an order for oxygen at 2-4 liters via nasal cannula. During observation, Resident 25 was in bed with oxygen at 4 L/NC, but the nasal cannula tubing was not labeled with the date it was changed and there was no “no smoking/oxygen in use” sign posted outside the room. The CNA stated the sign was needed to remind staff, visitors, and other residents that the resident was on oxygen and that there was a fire risk. RN 2 later stated Resident 25 did not have a care plan developed to address chronic oxygen use and to guide staff on resident-specific interventions. Resident 122 had diagnoses including quadriplegia, diabetes mellitus, and COPD, and had an order for oxygen at 2-4 liters per minute via nasal cannula. During observation, Resident 122 was in bed with oxygen at 3.5 L via nasal cannula, but the tubing was not labeled with the date it was changed and there was no “no smoking/oxygen in use” sign posted outside the room. CNA 1 stated the sign was necessary for fire precautions. RN 2 and the DON stated oxygen tubing should be changed weekly and labeled with the date, that the warning sign should be posted outside rooms with oxygen, and that residents on oxygen therapy should have a care plan to guide staff on care and treatment.
Failure to Keep Hemodialysis Emergency Kits at Bedside
Penalty
Summary
The facility failed to provide an emergency kit (E-kit) at the bedside for two residents receiving hemodialysis, Residents 111 and 219, despite each resident’s care plan directing that a clamp be kept at bedside for emergency bleeding at the dialysis access site. Resident 111 had ESRD, CHF, and DM, and his care plan dated 10/2/2024 identified a potential for bleeding at the hemodialysis access site with instructions to place a clamp at bedside for emergency bleeding management. His record also showed a tunneled catheter hemodialysis access site on the right upper chest and a schedule for hemodialysis on Tuesdays, Thursdays, and Saturdays. During observation on 8/19/2025, Resident 111 was in bed with the access site visible, and CNA 1 stated there was no E-kit at bedside and that one was needed in case of bleeding from the dialysis access site. Resident 219 had ESRD, anemia, and dependence on hemodialysis, with severely impaired cognition and dependence on staff for multiple activities of daily living. His record showed a quinton catheter hemodialysis access site on the left upper thigh and a hemodialysis schedule on Mondays, Wednesdays, and Fridays. His care plan dated 8/7/2025 identified a potential for bleeding from the central line site related to hemodialysis and directed that a clamp be placed at bedside for emergency bleeding management. During observation on 8/19/2025, Resident 219 was in bed with the access site visible, and CNA 3 stated there was no E-kit at bedside and that one should be available for emergency bleeding from the hemodialysis access site. The DON stated all hemodialysis residents needed an E-kit at bedside, close and easily accessible to staff, to stop and control bleeding if it occurred from the hemodialysis access site.
Delayed Toileting and Incontinent Care Due to Insufficient CNA Staffing
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet resident needs, and two sampled residents did not receive timely toileting and incontinent care. Resident 11’s record showed diagnoses including COPD, type 2 diabetes mellitus, and bipolar disorder, and the resident was assessed as having no cognitive impairment but needing staff assistance with bathing, dressing, and toileting hygiene. During interview, Resident 11 stated that a call light was pressed earlier in the morning for a diaper change and that the resident waited so long for help that the resident fell asleep. Resident 136’s record showed diagnoses including COPD, pneumonia, and morbid obesity, and the resident was dependent on staff for toileting hygiene, bathing, and footwear. The resident also had a sacral pressure ulcer/injury present on admission, fragile surrounding tissue, and care areas for incontinence management and a mattress with pump. A wound note later documented the sacrococcyx wound as closed and recommended aggressive offloading, turning every two hours, no sitting beyond two hours, frequent diaper checks and changes, and keeping the skin clean and dry. During observation, Resident 136 stated the resident had a bowel movement at 7:30 AM, had been calling staff, and was still waiting at 11:03 AM to be cleaned up. Staff interviews and record review showed repeated delays in response and staffing patterns that contributed to the care delays. RN 4 stated Station 1 was one of the heavier stations and would benefit from another CNA, and residents and family members complained about slow call light responses. CNA 5 and CNA 6 stated Station 1 usually had only three CNAs on the morning shift, that each CNA was often assigned 10 residents, and that this made timely care difficult; CNA 6 stated it sometimes took 20 minutes to respond to Resident 11’s request for diaper changes. The DSD confirmed that CNAs should be assigned 8 to 9 residents on the morning shift and stated that assigning 10 residents would delay care. Facility records and policies also stated that call lights should be answered immediately and that residents should receive care, including perineal care, in a manner that maintains hygiene, comfort, dignity, and cleanliness.
Meals Served Were Unappetizing and Did Not Reflect Resident Preferences
Penalty
Summary
The facility failed to ensure food was palatable, attractive, and served according to resident preferences for two sampled residents. The deficiency was identified through observation, interview, and record review, and involved meals that residents described as unappetizing and of poor quality. The facility’s policy required residents to be provided nourishing, palatable, well-balanced diets that considered resident preferences, and for food service staff to inspect trays to ensure meals appeared palatable and attractive. Resident 244 was admitted with diagnoses including respiratory failure, dependence on a respiratory ventilator, and dependence on renal dialysis. The resident’s MDS indicated intact cognition, and the H&P stated the resident had the capacity to understand and make medical decisions. During interview, Resident 244 stated the food served at the facility was “awful” and did not look appetizing. During lunch observation, the resident’s tray included a piece of meat that the surveyor and resident could not identify, and the resident stated the food did not look appetizing and did not want to eat lunch. A DA later identified the meat as baked chicken and stated it looked overcooked. Resident 70 was admitted with diagnoses including severe protein-calorie malnutrition, dysphagia, and muscle wasting and atrophy. The resident’s OSR indicated a regular diet with regular texture and thin liquids, and the MDS indicated intact cognition and independence with eating. During interview, Resident 70 stated the facility did not have enough food variety, had requested no fish but was served fish, and returned food because it was of bad quality. During meal observation, the resident’s tray contained chopped steamed spinach, grains, a lemon wedge, and a light brown irregular-shaped piece of meat with a bubbled, crater-like texture and a pinkish-red center. The resident stated the meat did not look like a ground beef patty, and the DS identified it as a ground beef patty and stated it was pink when cooked.
Kitchen Sanitizer Concentration Not Maintained
Penalty
Summary
The facility failed to ensure that kitchen sanitization buckets and the sink sanitization compartment used for sanitizing kitchen surfaces and the tray line preparation area were maintained at the required concentration for effective sanitization. During a concurrent observation and interview on 8/19/25 at 9:56 a.m. with the Dietary Supervisor (DS), two of four red sanitization buckets and the third compartment of the kitchen sink were tested and found to be at 50 parts per million (ppm). The DS stated that the red buckets are filled from the third sink compartment and that the red bucket concentration should be between 200-400 ppm. During interviews, the Registered Dietitian stated that maintaining the red bucket efficacy concentration is important because of safety and health issues for patients, cross contamination, and the presence of sick people with compromised immune systems. The DS also stated that patients can get sick. On 8/21/25 at 9:35 a.m., the DS stated the problem with the red sanitization buckets was that the test strips being used to test them had expired. A record review of the manufacturer's guidelines, titled Individual Sanitizer Testing Procedure, indicated the sanitization testing range should be 150-400 ppm.
Infection control failures with drainage bag, oxygen tubing, hand hygiene, and IV access
Penalty
Summary
The facility failed to follow its infection control policy for five sampled residents by allowing a urine drainage bag to touch the floor, allowing oxygen tubing to touch the floor, failing to perform hand hygiene before and after resident care, and leaving IV tubing ports uncovered. The report states these deficient practices had the potential to result in infection for Residents 168, 175, 218, 1, and 105. Resident 168 was admitted with diagnoses including fracture of neck, head injury, quadriplegia, anxiety disorder, and depression. The resident’s H&P indicated the resident had capacity to understand and make decisions, and the MDS showed the resident required dependent care for eating, oral and personal hygiene, bathing, dressing, and footwear. During observation, the resident was resting in bed and the condom catheter drainage bag was hanging from the side of the bed, not covered with a privacy bag, and touching the floor. The privacy bag was observed hanging next to the drainage bag. The IPN and DON both stated the urine drainage bag should not touch the floor, and the DON stated the facility’s infection control policies indicate that if a urine drainage bag touches the floor, germs can enter the system. Resident 175 was readmitted with diagnoses including hemiplegia and hemiparesis, UTI, and hemorrhage of cerebrum. The MDS indicated the resident was moderately cognitively impaired and required substantial to maximal assistance with ADLs and mobility, and the H&P stated the resident did not have capacity to make medical decisions. The resident was receiving 2L oxygen via nasal cannula, and the oxygen tubing was observed on the side of the bed and touching the floor. The LVN stated the tubing touching the floor was an infection control issue and could cause an infection, and the IPN stated the tubing should not be on the floor because germs could be carried to the nose. Resident 1 was admitted with toxic encephalopathy, acute respiratory failure with hypoxia, UTI, and resistance to vancomycin. The care plan directed staff to perform proper hand hygiene prior to oral care to decrease the resident’s risk for ventilator-associated pneumonia. The MDS indicated the resident’s cognition was rarely understood, memory was impaired, daily decision-making skills were severely impaired, the arms and legs were severely impaired, and the resident was totally dependent on staff for self-care. During observation, RT 1 did not perform hand hygiene before putting on gloves to assess the ventilator machine and did not cleanse hands after removing gloves and leaving the room. The RT stated that if hand hygiene is not performed properly, germs can be spread from one resident to another. Resident 218 had a diagnosis of candidiasis and an active order for enhanced barrier precautions for five infectious organisms. During observation, LVN 9 did not perform hand hygiene before putting on gloves to assess the resident’s abdomen, did not perform hand hygiene after removing gloves, and did not perform hand hygiene before putting on another pair of gloves. Resident 105 was admitted with diabetes mellitus, osteomyelitis, and cellulitis, and had an order for IV Zosyn for right heel osteomyelitis. During observation, the resident had a right upper arm PICC line with two uncovered ports. CNA 3 stated the IV tubing was looped and tucked into another port of the same administration set. RN 1 and the ADON stated PICC line ports and IV tubing should be covered when not in use and should not be looped to a port of the same administration set.
Medication Timing, Unnecessary Administration, and Controlled Drug Documentation Failures
Penalty
Summary
The facility failed to administer medications in a timely manner for three sampled residents. Resident 218 had diagnoses including iron deficiency anemia due to chronic blood loss, a Stage IV sacral pressure ulcer, type 2 diabetes, and intractable epilepsy, and the care plan directed that medications be given as ordered and that side effects be monitored and reported. Resident 209 had a Stage 2 pressure ulcer, epilepsy, and hereditary and idiopathic neuropathy, and the care plan directed that pain medications be given as ordered. Resident 89 had end stage renal disease, anemia, and hyperlipidemia, and the care plan directed that anemia medication be given as ordered and that fenofibrate and ezetimibe be administered daily. Record review showed repeated late administration of multiple medications for these residents. For Resident 218, SF Prostat, levetiracetam oral solution, and ferrous sulfate elixir were administered more than one hour after the prescribed 9 a.m. time on multiple dates. For Resident 209, gabapentin, levetiracetam oral tablet, and zinc sulfate were also administered more than one hour late on several occasions. For Resident 89, B-complex with C and folic acid, fenofibrate, and ezetimibe were administered more than one hour after the ordered 11 a.m. time on multiple dates. Facility staff stated that medications were considered late if given one hour or more after the due time, and the facility policy stated medications are to be administered within one hour of the prescribed time unless otherwise specified. The facility also failed during a medication pass observation when LVN 8 attempted to administer two Tylenol 325 mg tablets to Resident 34 even though the resident stated there was no wound and did not want the medication. Resident 34’s record showed an order for Tylenol to be given 30 minutes prior to wound care, but the wound treatment had been discontinued and the wound was resolved. The DON and RN confirmed that the resident no longer had a wound and that the Tylenol should not have been administered after the wound was resolved. In addition, the facility failed to maintain an accurate controlled substance record for Resident 47’s pregabalin. Resident 47 had diagnoses including alcoholic cirrhosis, diabetes mellitus, and insomnia, and had intact cognition and capacity to make decisions. The MAR showed pregabalin 100 mg was given on the morning and afternoon of the observed day, but the controlled substance record did not document those doses. LVN 7 stated she gave the medication but did not document it on the controlled drug record because she was too busy, and the DON stated controlled drugs must be signed off on the record to keep an accurate count and reflect when the medication was given.
Medication Labeling and Cart Security Lapses
Penalty
Summary
Safe storage and labeling of medications was not maintained when eye drop medications for two residents were found without proper resident identification and when a medication cart was left unlocked and unattended. During observation of one resident’s eye drops, an open box of polyvinyl alcohol lubricating eye drops had the resident’s medication label on the box, but the bottle itself had no resident-identifying information. The resident had diagnoses including metabolic encephalopathy and sepsis, and the record showed the resident had an order for artificial tears ophthalmic solution for dry eyes. The LVN stated the bottle should be labeled with the resident’s name to prevent administration to another resident. A second resident’s eye drops were also observed in an open box with only a room number written on the box and the bottle unlabeled with no date of opening. The resident had diagnoses including diabetes mellitus and sepsis, and the record showed the resident had moderately impaired cognition and did not have the capacity to understand and make decisions. The LVN stated the medication should be labeled with the resident’s name and open date on the bottle, and stated room numbers were not used because residents may change rooms and the medication could be given to the wrong resident. During a medication pass observation, an LVN left the medication cart unlocked in the hallway and out of view where residents and staff passed by. The LVN stated the cart was not locked because of nervousness and forgetting, and acknowledged someone might open it and take medications. The DON stated the cart needed to be locked if it was outside the nurse’s view, and the facility policy stated medication compartments are locked when not in use and unlocked medication carts are not left unattended.
Failure to Obtain Informed Consent for Buspirone
Penalty
Summary
The facility failed to obtain written informed consent for the use of Buspirone for one sampled resident. Resident 7 was admitted with diagnoses including anxiety, depression, and bipolar disorder. The resident’s MDS dated 7/5/2025 indicated moderately impaired cognition for daily decision making and need for assistance with multiple activities of daily living, including maximum assistance for lower body dressing and moderate assistance for toileting hygiene, showering, upper body dressing, and footwear. The resident’s OSR dated 7/24/2025 showed an order for Buspirone HCL 7.5 mg by mouth three times daily for anxiety manifested by inability to physically rest or stay still causing distress. During a concurrent record review and interview on 8/19/2025, the LVN stated physician documentation of informed consent for Buspirone was not documented and that there was no other clinical documentation showing consent was obtained. The DON also stated consent was not obtained prior to use of Buspirone. The facility policy titled Psychoactive medication Informed Consent, dated 3/2024, stated informed consent for the specific medication will be obtained by the physician and verified by the nurse, with a signed consent form or telephone verification documented if a signed consent cannot be obtained.
Failure to Notify Physician of Resident’s Burning Urination Complaint
Penalty
Summary
The facility failed to notify Resident 11’s doctor of the resident’s complaint of burning when urinating on 8/19/2025. Resident 11 had diagnoses including COPD, type 2 diabetes mellitus, and bipolar disorder, and the history and physical indicated the resident had the mental capacity to understand and make medical decisions. The MDS indicated no impairment in cognitive skills, and the care plan for risk for impaired urinary elimination directed staff to notify the healthcare provider immediately if the resident had any voiding abnormalities. During interview, Resident 11 stated the resident had recently been treated for a UTI and was again feeling burning pain when urinating, and that multiple nurses had been told about the complaint but said the resident was fine. LVN 9 confirmed the complaint was reported but did not notify the doctor, instead notifying RN 4. RN 4 stated burning when urinating is a symptom of a UTI and that the doctor should be called for such a complaint, but RN 4 also did not notify the doctor. A urinalysis collected on 8/20/2025 showed large leukocyte esterase and positive nitrite, and RN 4 stated the lab report indicated Resident 11 had a UTI.
Unclean Floors in Resident Room and Shower Areas
Penalty
Summary
The facility failed to maintain clean and stain-free floors in Resident 86's room and in two Station 4 shower rooms. During observation with the Maintenance Supervisor, Resident 86's floor was noted to have black stains, and the Maintenance Supervisor stated the stains were dirt. The Maintenance Supervisor also stated that the room and resident areas were checked weekly, but no log was kept. During the same observation, two Station 4 shower rooms were found to have a black-colored substance on the floor and grout. The Maintenance Supervisor stated the shower areas could be cleaner and again stated there was no log kept. Resident 86 was admitted with diagnoses including Type 2 diabetes mellitus and acute kidney failure, had the capacity to make medical decisions, and was independent for showering and bathing. The facility policy stated residents are to be provided with a safe, clean, comfortable, and homelike environment.
Failure to Revise Fall Care Plan After Resident Fall
Penalty
Summary
The facility failed to revise Resident 7’s fall care plan after the resident sustained a fall on 8/15/2025. Resident 7 was admitted with diagnoses including anxiety, depression, and bipolar disorder, and the 7/5/2025 MDS showed moderately impaired cognition for daily decision making, maximum assistance needed for lower body dressing, and moderate assistance needed for toileting hygiene, showering, upper body dressing, and putting on/taking off footwear. The fall care plan, initiated on 7/8/2025, listed interventions such as keeping the bed in the lowest position and placing bilateral floor mats, but it did not reflect the 8/15/2025 fall. The 8/15/2025 FRE identified Resident 7 as having had 3 or more falls in the past 3 months, balance problems while standing and walking, and a risk for falls. The 8/18/2025 IDT conference record documented that Resident 7 had a syncopal episode and laid down on the floor, and noted that the fall care plan was updated. During interview and record review on 8/19/2025, LVN 5 stated the resident had a fall on 8/15/2025 and the fall care plan was not revised, and stated it needed revision to determine whether the nursing interventions were effective. On 8/22/2025, the DON stated the fall care plan needed to be revised to address nursing interventions after the fall and to determine whether the interventions were effective.
Failure to Provide Timely Peri-Care and Toileting Hygiene
Penalty
Summary
Facility staff failed to provide peri-care for two residents who required assistance with toileting hygiene. Resident 136 was admitted with COPD, type 2 diabetes, pneumonia, morbid obesity with alveolar hypoventilation, and had decision-making capacity. The resident’s MDS indicated dependent care for toileting hygiene, showering/bathing, and footwear. The skin check documented a new sacral pressure ulcer/injury present on admission, described as Stage 3 full-thickness skin loss with fragile surrounding tissue, and the care record noted incontinence management and a mattress with pump. Resident 27 was admitted and readmitted with diagnoses including ESRD, a cutaneous abscess of the groin, a laceration with foreign body of the right buttock, necrotizing fasciitis, morbid obesity, type 2 diabetes, and inflammation of the vagina and vulva. The resident’s MDS showed substantial/maximal assistance needed for toileting hygiene and upper body dressing, and dependence for bathing, footwear, and lower body dressing. The resident’s care plan identified potential for infection related to the surgical incision on the right groin extending to the right buttock and indicated keeping the area clean and dry. A later care plan also identified ADL decline and potential for skin breakdown, but no ADL maintenance or repositioning was documented in the record. During observation and interview, Resident 27 stated she wanted to get clean and reported that when staff performed peri-care, she did not feel clean and felt dirty, mad, and sad. Resident 136 stated the resident had a bowel movement since 7:30 AM, had been calling staff all morning, and was still waiting at 11:07 AM; the resident said sometimes they wait up to three hours to be cleaned up and felt upset and embarrassed. Staff interviews confirmed the delay and incomplete care concerns, with the LVN stating Resident 136 should not have been waiting that long after a bowel movement and that it was not sanitary. The CNA assigned to Resident 136 stated the assignment included 10 residents and that staff can feel overworked and burned out, while also stating that residents sometimes report prior staff answered the call light but did not provide the requested care. Additional staff interviews stated residents should receive timely hygiene and peri-care, that it is not acceptable to leave a resident soiled for long periods, and that residents with wounds need repositioning as well. Facility policies stated residents unable to perform ADLs independently should receive necessary services for personal and oral hygiene, peri-care is intended to provide cleanliness and comfort and prevent infection and skin irritation, and staff are expected to treat residents with dignity and promptly respond to toileting assistance.
Hand Roll Not Maintained in Correct Position
Penalty
Summary
Provide appropriate care for a resident to maintain and/or improve ROM, limited ROM, and/or mobility was not ensured for Resident 125 when bilateral hand rolls were not maintained in the correct position. Resident 125 was admitted with diagnoses including traumatic subarachnoid hemorrhage, surgery on the nervous system, and BPH. The MDS dated 7/29/2025 indicated Resident 125 had severely impaired cognition and was dependent on staff for eating, oral hygiene, toileting, showering, upper and lower body dressing, and personal hygiene. The OSR dated 7/29/2025 showed an order for RNA to apply bilateral hand rolls for up to 6 hours, 5 times a week, and to monitor skin integrity, pain, and discomfort during or after splint application. During a concurrent observation and interview on 8/19/2025 at 10:37 a.m., Resident 125 was awake and lying in bed with a hand roll on the left hand, while the right hand roll was on the bed and not in the resident's right hand. LVN 1 stated the RNA should ensure the hand rolls were in place and kept in the resident's right hand throughout the treatment. RNA and the DON both stated residents on RNA services with hand rolls and/or splints should have them properly applied and maintained throughout the duration of the application. The facility policy stated residents with limited mobility will receive appropriate services, equipment, and assistance to maintain or improve mobility unless reduction is unavoidable.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 3,452 citations issued within 25 miles in the last 12 months — including the 8 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 Pomona
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Park Avenue Healthcare & Wellness Center | 0.2 mi | ★★★★★ | 8 | 0 |
| Landmark Medical Center | 0.5 mi | ★★★★★ | 26 | 0 |
| Country Oaks Care Center | 0.9 mi | ★★★★★ | 20 | 0 |
| Pomona Vista Care Center | 0.9 mi | ★★★★★ | 4 | 0 |
| Laurel Park Behavioral Health Center | 1.5 mi | ★★★★★ | 15 | 1 |
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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.