Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Joyce Eisenberg Keefer Medical Center D/p Snf during CMS and state inspections, most recent first.
Failure to Inform Residents of Survey Results Location: The facility did not notify residents of the existence or location of the most recent survey results and CMS-2567. Ten cognitively intact residents with diagnoses including HTN, OA, muscle weakness, hypotension, and anemia stated they were not aware of the survey results or where to find them. Resident council minutes did not show that survey results were shared, and staff interviews confirmed residents had not been told about the survey binder posted near the dining area and nursing station.
A resident with vascular dementia, psychosis, and major depressive disorder was prescribed Seroquel with orders to monitor for side effects, including orthostatic hypotension, and to obtain orthostatic BP weekly. The chart showed no documented orthostatic BP monitoring over several months, and the RN supervisor confirmed there was no documentation explaining why it was not done or communication to the MD. The DON stated the lack of documentation meant the MD would not know whether the resident was having Seroquel side effects.
Incomplete and Non-Individualized Care Plans: Multiple residents had care plans that did not match their assessed needs or agreed interventions. One resident’s wound was reclassified as MASD, but the care plan was not updated; another resident’s fall-prevention plan omitted a concave mattress intervention agreed to by the IDT; a resident’s activity plan did not address a stated preference for music; a resident on TBP for C. diff had no isolation care plan; and a resident on Seroquel lacked an individualized plan for orthostatic BP monitoring. Staff and the DON stated the care plans should have reflected the residents’ actual conditions and interventions.
A resident on contact precautions for C. diff had the wrong isolation sign posted on the door, and the IP confirmed the sign did not direct staff to use soap and water for hand hygiene. In a separate event, an LVN caring for a resident on EBP for a G-tube left the room wearing an isolation gown after removing gloves and approached the medication cart outside the doorway. The DON stated staff should remove gown and gloves before exiting the room, and the facility policies required contact/spore precautions for C. diff and gown-and-glove use for EBP during high-contact care.
A resident with intact cognition was given several medications by an LVN without being told the name or indication of each medication before administration, and the DON stated this limited the resident’s right to be informed about care and medications. In a separate case, another resident with intact cognition had an incomplete bed rail consent form that lacked required signatures and the reason for the side rails, and the DON stated consent was not obtained or explained.
Call Light Not Within Resident's Reach: A resident with sepsis and Parkinson's disease was observed in a wheelchair with the call light left on the bed and out of reach while he gestured for more water. CNA stated she forgot to place the call light next to the resident, and the DON stated call lights should be within each resident's reach so staff can respond to needs timely. The facility policy required the call light to be accessible to the resident.
Failure to Notify Physician of Repeated Insulin Refusals: A resident with DM, diabetic polyneuropathy, and peripheral vascular disease repeatedly refused scheduled Novolog insulin injections, and the MAR documented multiple refusals. The DON stated nurses should have notified the physician of the refusals, but no documentation of physician notification was found.
Unattended medication cart screen exposed resident eMAR. A medication cart computer screen was left open and unattended with a resident’s eMAR visible on the second floor near the nursing station and main dining room. RN 6 observed the open screen, minimized the window because of HIPAA, and stated leaving it open allowed resident information to be seen by others. LVN 8 and the DON both stated that leaving the screen open to resident medical information was a HIPAA concern and compromised privacy and confidentiality.
Damaged Carpet in Shared Resident Room: Two residents with severe cognitive impairment and dependence on staff for all ADLs shared a room where the carpet had a large cut area with old, peeling tape and sections that could be lifted. A family member stated the condition had been present for at least two years and could cause someone to trip; the MM and DON observed and validated the damaged carpet and noted it did not look right.
Failure to process a family grievance about CNA conduct: A resident with dementia, rheumatoid arthritis, and fibromyalgia required extensive assistance with ADLs. A family member emailed the SW about a CNA being unkind and calling the resident lazy, but the concern was not logged as a grievance and there was no follow-up with the resident or family member at the time. Facility leadership later stated the grievance process had not been carried out and the issue and concerns form was completed only after the concern resurfaced.
A resident’s annual MDS assessment was completed but not transmitted to CMS within the required 14-day timeframe. The resident had COPD, major depressive disorder, and an ileostomy, and needed partial assistance with toileting, dressing, shoes, and personal hygiene. The MDSC stated he forgot to validate and submit the assessment, and the DON acknowledged the submission was about 45 days late.
IDT Care Plan Did Not Address Repeated Insulin Refusals: A resident with DM, diabetic polyneuropathy, mild cognitive impairment, and peripheral vascular disease repeatedly refused ordered Novolog insulin injections. The care plan contained only general noncompliance interventions and did not include resident-specific escalation parameters, such as when to notify the MD, how many refusals required notification, or blood glucose thresholds. The DON stated the care plan was not resident specific and the IDT review did not address the repeated insulin refusals.
The facility failed to document a skin reassessment for a resident whose right buttocks wound was later treated as MASD instead of a PI, and failed to clarify the physician basis for a low air loss mattress setting for another resident. An RN stated she re-evaluated the wound and determined it was MASD but did not document the assessment, while the DON stated that without documentation the reassessment was considered not performed. For the mattress issue, staff observed the resident on a low air loss mattress set at 210 lbs even though the resident’s current weight was 171 lbs and the order did not specify the basis for the setting.
A resident with dysphagia, a gastrostomy, severe cognitive impairment, and dependence for transfers was moved from bed to wheelchair using a Sara lift without the required two-person assist. CNA and RN statements conflicted about who assisted, and the DON confirmed the facility policy required a second person for Sara lift use. In a separate event, an LVN left a prepared medication cup unattended on a med cart while she went to another resident’s room, and the DON stated meds should never be left unattended because they must be securely maintained.
Missing AVF Assessment Documentation for a Dialysis Resident: Facility staff failed to document bruit and thrill checks in the HD record for a resident with ESRD and DM2 who received scheduled HD. The LPNs stated AVF assessments are required before and after treatments to confirm patency, monitor for infection, and communicate fistula status to the dialysis provider.
Failure to Post Daily Nurse Staffing Information: The facility did not post required nurse staffing information daily near the lobby nursing station. The posting was outdated and missing the resident census plus the total number and actual hours worked by RNs, LVNs, and CNAs for each shift. RN 2, the EEA, and the DON all confirmed the staffing data should have been updated at the beginning of each shift per facility policy.
A resident with diagnoses including acute respiratory disease, CKD, and COPD had an order for lactobacillus acidophilus 100 mg in capsule form, but during a med pass an LVN administered a tablet instead. The MAR reflected the capsule order, while the LVN stated the facility only had the tablet house supply available; the DON said he was unaware the capsule form was not stocked and noted meds should be given as ordered.
A resident’s discontinued Cipro remained in Medication Cart 2 after the MD had stopped the order, with two bubble packs still stored in the controlled meds drawer. In addition, an OTC box of lozenges in a medication storage room was left unlabeled without the resident’s name or expiration date. The LVN, RN, pharmacist, and DON all acknowledged the labeling and storage issues.
Chicken Served With Quills in Skin: A resident with DM and GERD was observed eating chicken that still had quills in the skin. The resident stated she could not eat it, pulled several quills from the skin, and set the skin aside. A CNA said the kitchen was aware of the issue and that the resident ate less when quills remained in the chicken. The DS said the chicken had to be Kosher and staff used a torch to burn off the quills, but quills were still present.
A resident with dementia and severe cognitive impairment, ordered a fortified soft and bite-sized diet, was observed receiving a krab salad roll with bread crusts still on. The CNA said the bread was moistened to make it easier to chew, but the RD stated IDDSI guidance requires crusts to be removed and the bread soaked with liquid; the facility’s IDDSI guide also states crusts pose a choking risk.
Inaccurate MAR Documentation for Insulin Administration: A resident with DM had MAR entries that incorrectly recorded BG as 0, insulin as 115 units instead of the ordered 8 units, and injection site as 0 on multiple occasions. The DON stated these entries were inaccurate, and the LPN who documented them said they were mistakes; the facility policy required documentation of dosage, route, and injection site if applicable.
A resident with age-related physical debility and moderate cognitive impairment had an arbitration agreement signed by a family member, but the family member later said she was unaware of the document and did not know what an arbitration agreement was. The ADIR said the facility emailed the agreement with a letter stating it was voluntary and separate from admission paperwork, but did not verbally explain it unless asked, and the ADM said the signed letter was treated as proof of understanding.
A resident with impaired mobility and wheelchair use had damaged push rims that were covered with black plastic tape instead of being promptly replaced. The resident reported discomfort and pain when propelling the wheelchair, while the PT order called for two new rim protectors to be installed and the CSS confirmed the parts were in stock but the repair was delayed.
A resident with multiple chronic conditions experienced blood pressure readings both below and above their baseline, but there was no documentation of a recheck or physician notification as required by facility policy. The DON confirmed the absence of nurse-to-physician communication or notes regarding the resident's condition during this period.
The facility failed to document attempts of non-pharmacological interventions before administering PRN opioid pain medications to two residents with chronic pain conditions. Despite care plans outlining non-pharmacological strategies, these were not documented as attempted prior to medication administration. Interviews confirmed the lack of documentation and highlighted the importance of non-pharmacological methods due to opioid side effects.
A LTC facility failed to properly label and store medications, affecting several residents. An insulin pen for a resident lacked an open date, and expired medications, including eyedrops and glucose control solutions, were found in medication carts. These oversights were confirmed by staff and posed risks of administering ineffective treatments.
The facility failed to provide prescribed mechanical soft diets to four residents, leading to potential choking risks. Three residents did not receive chopped squash as required, and one resident was served the wrong meal. The facility's policies for meal identification and therapeutic diets were not followed, resulting in these deficiencies.
A facility failed to document a resident's blood sugar reading after it was taken by an LVN. The resident, diagnosed with diabetes mellitus, required blood sugar monitoring twice daily. The LVN took the reading but did not record it, citing system limitations. The DON confirmed the need for immediate documentation per policy, highlighting a lapse in professional standards.
A resident with a language barrier was not provided with a communication board as required by their care plan. The resident, who only speaks Farsi, was observed without a communication device, which was necessary for effective communication and addressing their needs. The facility's policy indicated that communication boards should be available for residents unable to communicate.
A resident with severely impaired cognition and a sacral pressure injury had their low air loss mattress (LALM) incorrectly set to 400 lbs instead of their actual weight of 94 lbs. This oversight was confirmed by nursing staff and the DON, who acknowledged the importance of correct LALM settings for wound healing. The facility's policy required pressure redistribution devices to be applied based on individual needs, which was not followed.
A resident with dysphagia and dementia was found with a cup of medications left unattended at her bedside. The resident, who required moderate assistance for daily activities, did not have an assessment for self-administration of medications. An LVN admitted to leaving the medications unattended, acknowledging the risk of choking and unauthorized access by other residents. The facility's policy required a physician's order for medications to be left at the bedside.
Two residents receiving oxygen therapy in an LTC facility were not provided care consistent with infection control standards. The facility failed to label and change oxygen tubing as per policy, increasing the risk of infection. Staff confirmed the oversight, which was not in line with the facility's procedures.
Failure to Inform Residents of Survey Results Location
Penalty
Summary
The facility failed to notify residents of the existence and location of the most recent standard survey results, including the Statement of Deficiencies Form CMS-2567, for 10 of 11 sampled residents in the resident council. The affected residents included Resident 189, Resident 30, Resident 51, Resident 59, Resident 62, Resident 65, Resident 83, Resident 203, Resident 219, and Resident 236. Their records showed they were cognitively intact and able to make daily decisions, with diagnoses including hypertension, osteoarthritis, generalized muscle weakness, hypotension, and anemia. Resident council meeting minutes reviewed for 11/26/2025, 12/17/2025, and 1/29/2026 contained no information showing that residents were made aware of the survey results. During the resident council task meeting interview on 3/09/2026, the 10 residents stated they were not aware of survey results for them to review or where the survey results were located, and they stated no one told them about the survey results. An observation on 3/11/2026 found a survey results binder attached to the wall near the first-floor nursing station, and the binder contained the previous recertification survey results dated 12/20/2024. During interviews, the Activities Director stated the survey results were posted near the dining room entrance on every floor and were within reach of residents, but she had not told residents in resident council meetings about the existence of the survey results or where they were located. The DON stated residents should be made aware of the previous year's survey results and their location, and that residents have the right to review the survey results to remain informed. The facility policy reviewed stated that the most recent licensing visit report, complaint investigations, and related follow-up plan of correction visits are to be available for review in prominent and accessible areas of the facility.
Failure to Monitor Orthostatic Blood Pressure for Resident on Seroquel
Penalty
Summary
The facility failed to ensure adequate monitoring of orthostatic blood pressure for a resident receiving Seroquel 12.5 mg at bedtime. The resident was admitted with diagnoses including vascular dementia, psychosis, and major depressive disorder. The MDS dated 12/17/2025 indicated the resident had severely impaired cognition for daily decision-making and was dependent for ADLs. The physician order for Seroquel, dated 8/8/2025, included monitoring for side effects such as orthostatic hypotension, dizziness, hypotension, and tardive dyskinesia, and orthostatic blood pressure was ordered to be taken every Saturday evening. During record review and interview, the resident’s chart did not show documented orthostatic blood pressure monitoring from 8/1/2025 through 3/12/2026. The RN Supervisor stated the CNA or LVN should document why the orthostatic blood pressure could not be taken and communicate that to the physician, but there was no documentation explaining why it was not done and no communication with the physician regarding the inability to monitor blood pressures. The DON stated that inability to obtain orthostatic blood pressures should be documented and communicated to the physician because without that information the physician would not know whether the resident was having side effects from Seroquel and could not make medication adjustments or interventions if needed.
Incomplete and Non-Individualized Care Plans
Penalty
Summary
Resident 1 had a wound initially assessed as a pressure injury on the right buttocks, measuring 1.5 cm x 1.4 cm x 0.2 cm, but the wound was later re-assessed and determined to be moisture associated skin damage (MASD). The resident’s record showed diagnoses including bacterial pneumonia, chronic respiratory failure, and type 2 diabetes mellitus. The resident was able to make her own needs known and make her own medical decisions, and the MDS showed dependence for toileting hygiene and substantial to maximal assistance for personal hygiene, bathing, dressing, and transfers. RN 6 stated that after determining the wound was MASD rather than a pressure injury, she did not make changes to Resident 1’s care plan. RN 6 stated the care plan required revision and that a dedicated care plan addressing MASD should have been established. The DON stated the care plan serves as the guide on how to care for residents and that because the wound was different than what had been care planned, a care plan for MASD should have been created. The DON also stated care plans need to be current and updated to reflect the resident’s actual condition. Resident 180’s care plan for falls did not include the concave mattress intervention that had been agreed upon by the IDT after a fall. The resident had diagnoses including atherosclerotic heart disease, unspecified psychosis, and type 2 diabetes mellitus, and the H&P indicated impaired decision-making capacity. The MDS showed limited ability to express wants, limited understanding of others, substantial to maximum assistance with eating, dependence for all other ADLs, and dependence for all functional mobility. Staff observed the resident using a unique concave mattress, and RN 6 stated the mattress was used to prevent falls and should have been listed in the care plan. The safety event record for the fall indicated the IDT agreed to add the concave mattress as an intervention, but the care plan did not reflect it. Resident 4’s activities care plan did not address the resident’s preferred activity of listening to music. The resident had diagnoses including dementia and seizures, and the MDS showed severely impaired cognitive skills for daily decision-making and total dependence on staff for ADLs. The MDS also identified listening to music as an activity preference. During observation, the resident was awake in bed, the television was off, and no music was playing. LVN 6 stated the care plan should have been resident-specific and should have addressed the resident’s preferred activity of listening to music because the care plan serves as a communication tool for the care team. Resident 72 tested positive for C. diff toxins and required contact isolation and TBP, but there was no care plan addressing TBP. The resident had diagnoses including unspecified severe sepsis and Parkinson’s disease, and the record showed the resident could speak in full sentences, make needs known, and make simple medical decisions. The facility matrix identified the resident as being on TBP. The DON stated that when there is a change of condition such as C. diff requiring TBP, licensed staff must create an individualized care plan, and that the care plan should have been completed when the resident tested positive so staff would know how to care for the resident and prevent spread of infection. Resident 81’s care plan for behavioral symptoms related to Seroquel included monitoring for orthostatic hypotension, but orthostatic blood pressures could not be done as documented. The resident had diagnoses including vascular dementia, psychosis, and major depressive disorder, and the MDS showed severely impaired cognition and dependence for ADLs. RN 3 stated orthostatic blood pressures could be done by placing the resident in a reclining wheelchair, but there was no documentation explaining why they could not be done and no care plan describing how to properly measure them. RN 3 also stated orthostatic blood pressure had only been measured once since the care plan was initiated. The DON stated an individualized care plan for measuring orthostatic blood pressure should have been created and implemented, and repeated inability to measure it should have been reported so the care plan could be individualized.
Incorrect Isolation Sign and PPE Use During EBP
Penalty
Summary
The facility failed to implement its infection control policy when a resident on transmission-based precautions for C. diff had the wrong precaution sign posted on the door. Resident 72 was admitted with diagnoses including unspecified severe sepsis and Parkinson's disease, and records showed the resident was positive for C. diff toxins and required contact isolation. During observation, the Infection Preventionist confirmed the sign on the door was incorrect and stated that C. diff requires handwashing with soap and water because alcohol-based hand rub is not enough to prevent spread of C. diff spores. Resident 72's records showed the resident could speak in full sentences, make needs known, and make simple medical decisions, and the facility matrix identified the resident as being on transmission-based precautions. The facility's policy for isolation precautions stated that residents with C. diff are to be placed on contact and spore precautions and that handwashing with soap and water is required. The DON stated licensed staff are responsible for checking and observing infection control guidelines and confirmed that the sign must include handwashing with soap and water after assisting the resident. The facility also failed to follow its enhanced barrier precautions practice for Resident 40. Resident 40 had diagnoses including dysphagia and a gastrostomy tube, and the MDS showed severe cognitive impairment, dependence for eating, and a G-tube. During medication pass observation, LVN 3 took the resident's blood pressure while wearing an isolation gown and gloves, then removed the gloves and walked toward the medication cart outside the room while still wearing the gown. When asked, LVN 3 stated he was not aware the gown could contact the medication cart. The DON stated staff caring for residents on EBP should remove the gown and gloves before leaving the room, and the facility's EBP policy stated gowns and gloves are used for high-contact resident care activities.
Failure to Inform Resident of Medications and Obtain Bed Rail Consent
Penalty
Summary
The facility failed to ensure that a resident was fully informed of medications before administration. Resident 59 had diagnoses including chronic respiratory failure and age-related osteoporosis, and the MDS indicated intact cognitive skills for daily decision making. During a concurrent observation and interview, an LVN administered midodrine, Senokot-S, Trelegy Ellipta, Miralax, Tylenol, and Systane to the resident, but did not inform the resident of the name of each medication or its indication before giving them. The LVN stated she was not aware this was required per facility policy, and the DON stated that residents have the right to be informed about their care, including medications, and that not providing this information restricts that right. The facility also failed to obtain informed consent for the use of bed siderails for another resident. Resident 101 had diagnoses including hypertension and dysphagia, and the MDS indicated intact cognitive skills for daily decision making. During record review with the DON, the Informed Consent for Bed Rail Use form was reviewed and found incomplete because it did not include the resident’s or representative’s signature, the reason for the side rails, or the licensed nurse’s signature verifying that consent was obtained. The DON stated the resident’s rights were not protected because consent was not obtained and no explanation was provided regarding the reason for the use of side rails.
Call Light Not Within Resident's Reach
Penalty
Summary
The facility failed to ensure that a call light was within reach for one sampled resident, Resident 72, during a random observation. Resident 72 was admitted with diagnoses including unspecified severe sepsis and Parkinson's disease. The resident's H&P indicated he spoke in full sentences and was able to make his own needs known and make simple medical decisions. The MDS dated 2/13/2026 indicated the resident usually made himself understood and usually understood others, but needed substantial assistance with upper body and lower dressing, personal hygiene, and putting on and taking off shoes. During an observation in the resident's room, Resident 72 was up in a wheelchair with a bedside table positioned halfway between the bed and the entrance door. The resident lifted an empty cup and gestured for more, while the call light, located on the bed, was out of reach. In a concurrent interview, CNA 1 stated she forgot to place the call light next to Resident 72 and said it should be next to him so he could communicate with staff, including making requests for water. The DON stated all call lights should be within each resident's reach so staff would be able to attend to their needs timely at all times. The facility policy titled, Answering the Call Light, stated staff must answer timely to the resident's request and needs and ensure the call light is accessible to the resident.
Failure to Notify Physician of Repeated Insulin Refusals
Penalty
Summary
The facility failed to ensure the physician was notified when Resident 94 repeatedly refused scheduled Novolog insulin injections. Resident 94 was admitted and re-admitted to the facility with diagnoses including diabetes mellitus, diabetic polyneuropathy, and peripheral vascular disease. The resident’s H&P stated the resident had the capacity to understand and make decisions on her own, and the MDS indicated intact cognition for daily decision-making. The H&P also documented an HbA1c of 8.9% with a goal of less than 8%. The physician order report showed an order for Novolog 8 units subcutaneously once daily at 7:30 a.m., with instructions to rotate the site and hold if blood sugar was less than 100 mg/dL. The MAR documented refusals of the scheduled insulin on 3/1/2026, 3/4/2026, 3/5/2026, 3/6/2026, 3/7/2026, and 3/9/2026. During interviews and record review, the DON stated licensed nurses should have informed the physician of the refusals and that the physician could adjust the dose to help prevent complications, but the DON could not find documented evidence that the physician was notified. An LVN also confirmed the resident refused the scheduled insulin injections on those dates.
Unattended medication cart screen exposed resident eMAR
Penalty
Summary
The facility failed to safeguard resident confidentiality and privacy when a medication cart computer screen was left open and unattended on Medication Cart 3. During an observation on 3/9/2026 at 9:19 a.m. between the nursing station and the main dining room on the second floor, Team B medication cart was observed unattended with the computer screen open to a resident’s electronic Medication Administration Record (eMAR). RN 6 was observed calling out a name while approaching the cart, then taking steps to remove the eMAR from view on the screen before walking away from the medication cart. During interview, RN 6 stated she saw the computer screen left open displaying resident information and minimized the window because of HIPAA, stating that leaving the window open allowed residents’ information to be seen by others. RN 6 said she left the medication cart after minimizing the screen to notify the charge nurse of the incident. LVN 8 stated RN 6 informed her right away of her mistake of leaving the medication cart computer screen open and that it should not have been left open displaying resident information because of HIPAA. The DON stated that leaving a computer screen open to a resident’s medical record is a HIPAA concern and compromises privacy and confidentiality. Facility policy stated the MAR should be closed or covered when not attended and that electronic devices should not be left open for viewing and unattended.
Damaged Carpet in Shared Resident Room
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for two residents who shared a room when the carpet in their room was in disrepair. Resident 95 had diagnoses including Parkinson's Disease and dementia, and the MDS indicated severely impaired cognitive skills for daily decision making and dependence on staff for all ADLs. Resident 111 had diagnoses including bipolar disorder and Alzheimer's Disease, and the MDS indicated severely impaired cognitive skills for daily decision making and dependence on staff for all ADLs. During a concurrent observation and interview, an area of the carpet in the shared room was seen with a linear cut in a rectangular shape with three cut sides, and tape had been placed over the area but was old and missing in parts. The family member stated the carpet had been this way for at least two years and that someone had previously said it would be replaced. The family member lifted part of the carpet up and stated someone could trip on it. The Maintenance Manager observed and validated that the carpet was cut, the tape was missing over parts of the cut area, and the carpet could be lifted. The Maintenance Manager and DON stated someone could trip in the area and that the carpet did not look like it should.
Failure to Process a Family Grievance About CNA Conduct
Penalty
Summary
The facility failed to implement its grievance policy and procedure for one resident when a family member reported that a CNA had spoken to the resident in an unkind manner and called the resident lazy. The resident had diagnoses including rheumatoid arthritis, fibromyalgia, and dementia, and the MDS indicated moderate cognitive impairment. The resident also required assistance with dressing, toileting, hygiene, oral care, and bathing. A family member emailed the social worker about the concern, but the concern was not logged as a grievance, issue, or concern in the facility’s tracking log. The family member stated no one from the facility followed up after the email, and the family member later sent another email. The resident stated the CNA had spoken to her in ways that were not nice and that the interaction was upsetting and made her feel uncomfortable. During interviews, facility leadership stated the concern had been known to staff, but the social worker was no longer employed and the grievance process had not been carried out when the first email was received. The administrator stated there was no grievance filed at that time and that the best practice would have been to file one. The administrator and director of social services also stated the resident and family member were not interviewed at the time of the initial concern, and the required issues and concerns form was not completed until later.
Late Transmission of Annual MDS Assessment
Penalty
Summary
The facility failed to ensure that one resident’s annual MDS assessment was transmitted to CMS within the required 14-day timeframe. Resident 87 was admitted with diagnoses including COPD, major depressive disorder, and an ileostomy. The resident’s annual MDS dated 1/11/2026 indicated the resident made himself understood and understood others, and required partial assistance with toileting, upper body dressing, lower body dressing, putting on and taking off shoes, and personal hygiene. The MDS was completed on 1/11/2026 but was not transmitted until 3/11/2026, 59 days later. During interview and record review, the MDSC stated that once the annual assessment is complete, it must be transmitted to CMS within 14 days and that he forgot to validate and submit the assessment after it was completed. The DON stated annual assessments must be completed on time and submitted to CMS within 14 days, and acknowledged that Resident 87’s assessment was submitted about 45 days late.
IDT Care Plan Did Not Address Repeated Insulin Refusals
Penalty
Summary
The facility failed to ensure the interdisciplinary team reviewed and revised a resident’s care plan to include appropriate interventions for repeated refusal of prescribed insulin injections. The resident had diagnoses including diabetes mellitus with diabetic polyneuropathy, mild cognitive impairment, and peripheral vascular disease. The resident’s history and physical stated she had the capacity to understand and make decisions on her own, and the MDS indicated her cognition was intact. The resident’s care plan, updated on 1/6/2026 and titled Episodes of non-compliant with medications-insulin, included general interventions such as breaking tasks into small steps, providing explanations, allowing time to review information, involving family as needed, accepting the decision to refuse care, and notifying the primary physician of the decision and reviewing options if available. However, the care plan did not include resident-specific parameters for escalation, such as the number of missed doses requiring notification, the frequency for monitoring refusals, or blood sugar levels that would require physician notification. The section indicating notification of the physician was unchecked. The physician order report showed an order for Novolog 8 units subcutaneously once daily at 7:30 a.m., and the MAR documented multiple refusals of the insulin dose on several days between 3/1/2026 and 3/9/2026. During interviews, the DON stated the resident had a tendency to refuse insulin injections and acknowledged the care plan was not resident specific and did not address the repeated refusals. The DON also stated the IDT care plan review did not address the resident’s repeated refusals of insulin administration. An LVN similarly stated the care plan did not indicate when the physician should be notified, the number of refusals requiring notification, or acceptable blood glucose parameters.
Failure to document skin reassessment and clarify low air loss mattress setting
Penalty
Summary
The facility failed to clarify with the physician the basis for the setting of a low air loss mattress for a resident with dementia and seizures who was totally dependent on staff for activities of daily living. The resident was observed sleeping in bed on a low air loss mattress set at 210 pounds, while the resident’s current weight was documented as 171 pounds. The physician’s order for the mattress was for wound prevention, but it did not specify the basis for determining the mattress setting. During interview, nursing staff stated the mattress setting was not accurate and that the setting is used for skin management and prevention of skin breakdown. The facility also failed to complete a documented skin assessment for another resident when a skin impairment was re-classified from a Stage 2 pressure injury to MASD. The resident had diagnoses including bacterial pneumonia, chronic respiratory failure, and type 2 diabetes mellitus, and was dependent or required substantial assistance with multiple activities of daily living. The resident reported bowel and bladder incontinence, frequent urination, and recent diarrhea, and stated these issues had caused sores on the buttocks. A wound management form later identified a pressure injury to the right buttocks, while physician orders dated 3/3/2026 indicated treatment for MASD to the right buttocks. The MDS coordinator stated that an RN is responsible for performing a comprehensive skin assessment when a resident develops impaired skin integrity, and the RN who re-evaluated the wound stated she determined it was MASD rather than a pressure injury but did not document the reassessment. The DON stated that the reassessing RN was responsible for documenting the findings and that without documentation it is considered as though the reassessment was not performed. The DON also stated that because the reassessment was not recorded, the health care team lacked awareness of the change from the initial evaluation to the later determination of MASD, and the prescribed treatment did not align with the skin assessment.
Improper Sara Lift Transfer and Unattended Medication on Cart
Penalty
Summary
Resident 40 was admitted and later re-admitted with diagnoses that included dysphagia and attention to gastrostomy. The resident’s MDS dated 1/01/2026 indicated severe cognitive impairment and dependence on staff for chair/bed-to-chair transfer. The physician’s orders directed use of a Sara lift with two-person assist on all transfers, and the falls care plan also included Sara lift with two-person assist on all transfers. The resident’s falls risk assessment dated 12/31/2025 identified the resident as high risk for falls. On 3/12/2026 at 7:30 a.m., CNA 4 was observed opening Resident 40’s room door and exiting while pushing a Sara lift. CNA 4 stated she had moved Resident 40 from bed to wheelchair with the Sara lift. When asked whether another staff member assisted with the transfer, CNA 4 stated RN 5 assisted her. During an interview at 7:37 a.m., RN 5 stated she did not help CNA 4 with any task that morning and said she had only walked in the hallway and stopped in front of Resident 40’s room. CNA 4 then stated RN 5 assisted her, and RN 5 stated she did assist CNA 4. When asked again, CNA 4 stated she used the Sara lift by herself without help from any staff. CNA 4 stated she should have asked another staff member to help because someone needs to be standing by to ensure the Sara lift is locked and the wheelchair does not move. RN 5 stated two staff should operate the Sara lift to ensure safety and prevent injury, and that one-person transfer with the Sara lift could place a resident at risk for fall. The DON reviewed the facility policy titled Moving/Positioning a resident/patient, which stated that a second person is needed to assist in the use of Hoyer lifts, and the DON stated this applied to the Sara lift and that two staff members should always be present for resident transfer.
Missing AVF Bruit and Thrill Documentation for Dialysis Resident
Penalty
Summary
Facility staff failed to complete and document the Hemodialysis record for Resident 16 with assessment of the arteriovenous fistula for bruit and thrill. Resident 16 was admitted with diagnoses including end stage renal disease and type 2 diabetes mellitus, and the MDS dated 02/25/2025 indicated severely impaired cognitive skills for daily decision making and need for assistance with several activities of daily living. The physician order directed dialysis every Tuesday, Thursday, and Saturday at 11:30 a.m. A review of the Hemodialysis Record on 03/11/2026 with LVN 6 showed no documented evidence that bruit and thrill assessments were completed on 02/03/2026, 02/05/2026, 02/07/2026, 02/09/2026, 02/12/2026, 02/14/2026, 02/17/2026, 02/19/2026, 02/21/2026, 02/24/2026, 02/26/2026, and 02/28/2026. LVN 6 stated the AVF must be assessed before and after dialysis treatments to ensure the fistula is patent and not clotted and to monitor for signs and symptoms of infection. LVN 4 stated routine pre and post dialysis assessments are necessary to promptly identify concerns and that the hemodialysis record serves as a communication tool between nursing staff and the dialysis provider. The facility policy titled Dialysis Care stated the facility shall facilitate arrangements for ongoing dialysis care as ordered by the physician and that the IDT shall assure the treatment plan includes the resident's renal condition and necessary precautions, including shunt site and observing for signs and symptoms of infection.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was posted daily for two days, including the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift. During an observation on 3/10/2026 at 2:30 p.m., the staffing information posted near the lobby nursing station was dated 3/9/2026 and did not show the resident census or the total number and actual hours worked by RNs, LVNs, and CNAs for the 7 a.m. to 3 p.m., 3 p.m. to 11 p.m., and 11 p.m. to 7 a.m. shifts. RN 2 confirmed that the posting was outdated and missing the required census and staffing hour information. During interview and record review, the Executive Administrative Assistant stated that the staffing information should be posted and updated daily at the beginning of each shift so residents, family members, and staff can see the number of hours available for resident care. The DON also reviewed the facility's Administrative Manual and stated that the nurse staffing data should be posted daily at the beginning of each shift, including resident census and the total number and actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift. The DON stated the facility policy was not followed, and residents, staff, and visitors were unable to determine how many staff worked on 3/9/2026 or who was scheduled to work on 3/10/2026.
Incorrect Medication Form Administered
Penalty
Summary
The facility failed to ensure that one of four sampled residents received the correct form of medication in accordance with the physician's order. Resident 216 had an order for lactobacillus acidophilus 100 mg, one capsule orally once a day, and the Medication Administration Record also reflected administration of lactobacillus acidophilus 100 mg one capsule orally. During a medication pass observation with LVN 1, the nurse removed one tablet from the facility's lactobacillus tablet medication container and administered it to Resident 216 instead of the ordered capsule form. LVN 1 stated the facility only carried house supply lactobacillus in tablet form and did not have the capsule form available. The DON later stated he was not aware the facility did not carry lactobacillus in capsule form and acknowledged that medications should be administered in accordance with the physician's order to ensure proper absorption and patient safety.
Discontinued medication left in cart and OTC medication left unlabeled
Penalty
Summary
The facility failed to remove a discontinued medication from Medication Cart 2 after the physician discontinued Resident 72’s Cipro 500 mg order. Resident 72’s record showed diagnoses including sepsis, chronic kidney disease, and hypertension, and the resident’s H&P indicated the resident was able to make simple medical decisions while the MDS indicated severely impaired cognition. During observation of the controlled medications drawer in Medication Cart 2, two medication bubble packs of Cipro 500 mg, each containing 5 doses, were still present even though the order had been discontinued. During interview, an LVN stated the discontinued non-controlled medication should be placed in the medication room in the designated container and, if not used, returned to the pharmacy, and that discontinued medications should be removed from the medication cart to prevent medication error. The DON also stated that when a non-controlled medication is discontinued, it should be removed from the medication cart and placed in a secured medication room in the designated containers for disposition, and that discontinued medications should not be placed in the controlled medication drawer. The facility also failed to label an OTC medication in Medication Storage Room C. During observation, a 36-count box of lozenges was stored without a resident name or expiration date. RN 2 stated the box did not have an expiration date or resident name, and the pharmacist stated it was an OTC box provided by a resident’s family and the manufacturer did not provide an expiration date. RN 2 stated the lozenges should have had the resident’s name written on the box, and the DON stated all medications in the medication storage rooms should be labeled, including resident-owned and OTC medications with the resident’s name and room number.
Chicken Served With Quills in Skin
Penalty
Summary
Food was not prepared in a way that conserved appearance and flavor when chicken was served with some of the quills still in the skin for one resident during lunch observation. The resident had diagnoses including type 2 DM and GERD, could speak in full sentences, make needs known, and make medical decisions, and required supervision for eating and oral hygiene along with substantial assistance for several other activities of daily living. During an interview, the resident stated she had been a caterer, that presentation was important to her, and that she loved chicken on the bone but could not eat the facility’s chicken because it was served with quills in the skin. During the lunch observation, the resident ate a leg and thigh quarter of chicken and pulled out several small quills from the skin, stating she was disgusted and removing all of the skin to set it aside. A CNA stated she had seen quills in the chicken skin before and that the kitchen was aware, and also stated the resident enjoyed her food less and did not finish her meal when quills remained in the chicken. The Dietary Supervisor stated the chicken source had to be Kosher and that the kitchen staff used a torch to burn the quills, but quills were still present in the chicken skin. Facility policies stated meals should be presented in an attractive, appetizing, and sanitary manner and delivered to meet diets, consistency, and personal preferences.
Improper Food Texture Preparation for a Resident on Soft and Bite-Sized Diet
Penalty
Summary
The facility failed to prepare food in a form designed to meet individual needs for one resident who was observed during lunch receiving a krab salad roll while on a fortified soft and bite-sized diet. The resident’s record showed diagnoses including chronic atrial fibrillation and dementia, and the MDS indicated severe cognitive impairment, dependence for toileting, bathing, and personal hygiene, and substantial assistance needed with eating, oral hygiene, and dressing. The physician order specified a soft and bite-sized diet, and the facility’s diet manual described this diet as following IDDSI Level 6 guidelines for soft foods that are easy to chew and swallow. During the dining observation, the sandwich was served with the bread crusts still on, although the bread had been moistened. The CNA stated the crust was left on but softened so the resident could chew it more easily. The RD later stated that, under IDDSI standards, the crusts should be removed and the bread soaked with liquid, and the facility’s IDDSI guidance stated to avoid any crust formed during cooking or heating because it poses a choking risk.
Inaccurate MAR Documentation for Insulin Administration
Penalty
Summary
The facility failed to accurately document the blood glucose level, insulin dose, and injection site in the MAR for one sampled resident with diabetes mellitus, diabetic polyneuropathy, mild cognitive impairment, and peripheral vascular disease. The resident’s H&P stated she had the capacity to understand and make decisions on her own, and the MDS indicated her cognition was intact. The physician orders included Novolog 8 units subcutaneously at 7:30 a.m. and 11:30 a.m., with instructions to rotate the site and hold the medication if blood sugar was less than 100 mg/dL. A review of the MAR showed that for the 7:30 a.m. Novolog order, the injection site was documented as 0 on multiple dates. For the 11:30 a.m. Novolog order, one entry showed the units field documented as 115 and the BG result documented as 0. During interview, the DON stated nurses should document the injection site, and if the medication is not administered they should enter N/A rather than 0. The DON also stated that documenting a BG of 0 was inaccurate and that documenting 115 units was not possible because the order was for 8 units. During a concurrent interview and record review, the LVN who cared for the resident on the date in question stated she was the one who documented 115 units and a BG level of 0 for the 11:30 a.m. medication pass, and that these entries were mistakes. She also stated she documented the injection site as 0 on several dates for the 7:30 a.m. medication pass, and that N/A should have been used instead of 0 when no insulin was given. The facility’s Medication Administration policy required documentation of the date and time, dosage, route, injection site if applicable, and other required medication administration details.
Arbitration Agreement Not Explained to Resident Representative
Penalty
Summary
The facility failed to ensure that the binding arbitration agreement was explained to a resident’s representative in a form and manner that he or she understood for Resident 34. Resident 34’s face sheet showed admission to the facility with diagnoses including age-related physical debility, and the MDS dated 2/19/2026 indicated the resident was moderately cognitively impaired with skills required for daily decision making and needed setup or clean-up assistance with eating. Resident 34’s arbitration agreement showed a family member signed the document on 2/06/2026. During a telephone interview, the family member stated she was unaware of the document, was not sure what an arbitration agreement was, and did not recall signing one with the admission paperwork. The Admissions Director stated the facility had been emailing the arbitration agreement with a letter saying it was voluntary and separate from admission paperwork, but did not verbally explain it unless families asked questions. The Administrator stated the facility recently had been emailing the agreement with a letter and believed the signed letter meant the family understood the document, while also acknowledging it was important for residents and families to know the agreement was voluntary, not required for admission, could be rescinded within 30 days, and that they could consult an attorney.
Wheelchair Push Rims Not Repaired Promptly
Penalty
Summary
The facility failed to ensure patient care equipment was maintained in safe, comfortable operating condition for one sampled resident whose wheelchair push rims were damaged. Resident 78 was admitted and re-admitted with diagnoses including cellulitis of the right upper limb, right elbow bursitis, and abnormalities of gait and mobility. The resident’s MDS indicated intact cognition, need for supervision with ADLs, and use of a wheelchair for mobility. During observation, the resident’s wheelchair push rims were covered with black plastic tape around the entire rims, and the resident stated the wheelchair was uncomfortable to use because she could not effectively propel herself and had pain when touching the taped push rims. Record review and staff interviews showed that the resident’s PT evaluation and order on 2/20/2026 requested two wheelchair rim protectors to be installed because the original push rim protectors were damaged and no longer latching properly. The CSS stated he placed black plastic tape around the rim instead of installing new protectors, and the DOR confirmed the resident had continued discomfort and that the issue had not been fully corrected until later. The facility’s request form showed the replacement request was made, and the CSS acknowledged the rim protectors were in stock and that requests were expected to be fulfilled within 24 hours.
Failure to Notify Physician of Abnormal Blood Pressure Readings
Penalty
Summary
The facility failed to notify a resident's physician when the resident's blood pressure readings were outside of their baseline range. Specifically, the resident, who had a medical history including COPD, depression, lymphoma, and lung and bladder cancer, had blood pressure readings that were both below and above their baseline. On one occasion, the resident's blood pressure dropped to 89/62 mmHg, and on the following day, it rose to 172/94 mmHg. There was no documentation of a recheck of the blood pressure during the 12-hour interval between these readings, nor was there any record of communication with the physician regarding these abnormal values. During interviews and record reviews, the DON confirmed that there was no nurse-to-physician communication note or any documentation addressing the resident's condition related to these blood pressure readings. The facility's policy required physician notification when vital signs were out of range from the resident's baseline for two or more consecutive episodes, but this protocol was not followed in this instance.
Failure to Document Non-Pharmacological Interventions Before PRN Opioid Use
Penalty
Summary
The facility failed to document evidence of attempting non-pharmacological interventions before administering PRN opioid pain medications to two residents, which was a requirement according to the facility's pain management policy. Resident 126, who was admitted with conditions such as hereditary neuropathies, ankylosing spondylitis, and chronic pain syndrome, received PRN tramadol on multiple occasions without documented attempts of non-pharmacological interventions. The resident's care plan included strategies like positioning, diversional activities, and massage for pain relief, but these were not documented as attempted before administering the opioid. Similarly, Resident 65, diagnosed with cervical spinal stenosis, polyneuropathy, and chronic pain syndrome, received PRN hydrocodone-acetaminophen without documented attempts of non-pharmacological interventions. The care plan for this resident also included non-pharmacological strategies such as positioning and walking for pain relief, which were not documented as attempted prior to medication administration. Both residents had intact cognition and required assistance with activities of daily living. Interviews with the MDS Nurse and the Director of Nursing confirmed the absence of documentation for non-pharmacological interventions and emphasized the importance of attempting these methods first due to the adverse side effects associated with opioids. The facility's policy, last reviewed and revised in October 2024, clearly stated that non-pharmacological interventions must be tried and documented before administering PRN opioid medications.
Improper Drug Labeling and Storage in LTC Facility
Penalty
Summary
The facility failed to ensure proper labeling and storage of drugs and biologicals, affecting six out of eight sampled residents. For Resident 219, an opened Lantus-100 insulin pen was found without an open date, which is necessary to determine its beyond-use date. This oversight was confirmed by LVN 6, who acknowledged that the pen should be labeled to prevent the administration of potentially expired medication. Similarly, Resident 36's Olopatadine HCl solution was not discarded after its beyond-use date, posing a risk of reduced efficacy in treating the resident's condition. Further deficiencies were observed with the Even Care Glucose Control Solution, which had an illegible open date, making it impossible to determine its beyond-use date. This issue was confirmed by LVN 6 and the facility pharmacist, highlighting the potential for ineffective diabetes management. Additionally, expired medications such as Opti-Fiber for Resident 4, Ativan for Resident 51, and Simethicone tablets were found in the medication cart, despite their expiration dates having passed. These medications should have been removed to prevent the administration of ineffective drugs. The facility also failed to remove expired eyedrops for Residents 214 and 111. Netarsudil and Latanoprost eyedrops were found in the medication cart beyond their use-by dates, as confirmed by LVN 2 and the facility pharmacist. The Director of Nursing emphasized the importance of not using medications past their expiration dates to avoid ineffective treatment. The facility's policy on drug storage and inventory inspection, which mandates the removal of unusable drugs, was not adhered to, leading to these deficiencies.
Failure to Provide Prescribed Mechanical Soft Diets
Penalty
Summary
The facility failed to meet the nutritional needs of four residents by not providing a mechanical soft diet as ordered by their physicians. For three residents, the kitchen staff did not place chopped squash on the tray table for those on mechanical soft and dysphagia diets. This oversight was observed during a review of the residents' tray cards, which indicated that chopped roasted squash was required. The Registered Dietician and Food Services Director confirmed that the squash was not chopped as per the menu, and the cooks did not want to chop it because it would become mushy. This failure to follow the menu placed the residents at risk for choking. Additionally, one resident was accidentally served the incorrect diet during lunch. The resident's lunch menu ticket indicated a no added salt mechanical soft diet with nectar thick liquids, but the resident received a regular diet instead. The Speech-Language Pathologist confirmed that the resident was served his wife's tray, which was not a mechanical soft diet. This mistake was acknowledged by the facility's Registered Dietician, who stated that the staff served the wrong tray, increasing the risk of choking for the resident. The facility's policies and procedures for meal identification and therapeutic diets were not followed, leading to these deficiencies. The policies indicated that dietary services should use appropriate identification to ensure residents receive their prescribed diets. However, the failure to adhere to these procedures resulted in residents not receiving the correct diet, which could lead to potential health risks such as choking and weight loss.
Failure to Document Blood Sugar Reading
Penalty
Summary
The facility failed to adhere to professional standards of practice when a Licensed Vocational Nurse (LVN 4) did not document a resident's blood sugar after taking it. This incident involved a resident who was admitted with a diagnosis of diabetes mellitus and required blood sugar monitoring twice daily as per physician's orders. On the day of the observation, LVN 4 took the resident's blood sugar at 3:25 p.m. but did not record the value, citing that the computer system only allowed documentation one hour before the scheduled time. Consequently, the resident's blood sugar was not documented before they began eating dinner at 5:32 p.m. During an interview, LVN 4 acknowledged the importance of documenting the blood sugar value to avoid confusion and admitted to not writing it down for later entry. The Director of Nursing confirmed that the blood sugar should have been documented immediately after it was taken, in line with the facility's Medication Administration policy. This policy requires that any medication or related procedure be documented before proceeding to the next resident's medication administration. The failure to document the blood sugar reading placed the resident at risk for complications related to their diabetes management.
Failure to Provide Communication Device for Non-English Speaking Resident
Penalty
Summary
The facility failed to provide a communication device for a resident who only speaks Farsi, which is a language barrier that was documented in the resident's care plan. The resident, who was admitted with conditions including benign prostatic hyperplasia, major depressive disorder, and chronic kidney disease, was observed in a wheelchair without a communication board in their room or attached to their wheelchair. This lack of a communication device was confirmed by a Certified Nursing Assistant who stated that the resident only speaks Farsi and had never seen a communication board in the resident's room. The Minimum Data Set Nurse reviewed the resident's care plan, which had been revised to address the language barrier by providing a communication board. However, the communication board was not in place, which the Director of Nursing acknowledged was necessary according to the care plan interventions. The facility's policy on Interpreter Services also indicated that communication boards should be available for residents unable to communicate, highlighting the deficiency in meeting the resident's communication needs.
Incorrect LALM Setting for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to ensure that a resident's low air loss mattress (LALM) was set to the correct setting, which is crucial for preventing skin breakdown and aiding in the healing of pressure ulcers. The resident, who was admitted with pressure-induced deep tissue damage in the sacral region, had severely impaired cognition and required maximal assistance for daily activities. The resident's care plan included the use of an LALM for wound management, but during an observation, it was found that the mattress was set to 400 pounds, despite the resident weighing only 94 pounds. Interviews with the nursing staff, including a Registered Nurse (RN) and a Licensed Vocational Nurse (LVN), confirmed that the LALM should have been set according to the resident's weight. The Director of Nursing (DON) also acknowledged the importance of setting the LALM correctly to facilitate wound healing. The facility's policy on wound and skin management emphasized the need for pressure redistribution devices to be applied based on the resident's individual needs, which was not adhered to in this case.
Unattended Medications at Resident's Bedside
Penalty
Summary
The facility failed to ensure a licensed nurse did not leave a cup of medications unattended at a resident's bedside, which was identified during an observation of a resident in a wheelchair with a cup containing eight medications on the table. The resident, who had been admitted with diagnoses including dysphagia and dementia, stated she takes her medications by herself all the time. However, the resident had moderately impaired cognition and required moderate assistance for most activities of daily living, as indicated in her Minimum Data Set. Licensed Vocational Nurse 2 admitted to leaving the medications unattended and acknowledged that the resident was at risk for choking and should have been supervised while taking her medications. The resident did not have an assessment for self-administration of medications, which was confirmed by the MDS Nurse. The Director of Nursing emphasized the importance of not leaving medications unattended, as it could lead to residents not taking their medications or other residents accessing them. The facility's policy stated that medications could only be left at the bedside with a specific physician's order and must not be accessible to other residents.
Infection Control Deficiencies in Oxygen Therapy Management
Penalty
Summary
The facility failed to adhere to professional standards of infection control practice for two residents, Resident 114 and Resident 222, who were receiving oxygen therapy. For Resident 222, the facility did not label the oxygen tubing with the date and time it was last changed, as required by the facility's policy. The resident, who was admitted with chronic obstructive pulmonary disease (COPD) and other conditions, was observed receiving oxygen therapy without the necessary labeling on the tubing. Both a registered nurse and the facility's Infection Preventionist confirmed that the tubing was not labeled, which is a requirement to prevent respiratory infections. Resident 114, who had a history of hypertensive chronic kidney disease, Alzheimer's disease, and COVID-19, also experienced a lapse in infection control practices. The facility failed to change and label the resident's oxygen tubing and nasal cannula every seven days as per the facility's policy. During an observation, it was noted that the tubing had not been changed on the scheduled date, and both a licensed vocational nurse and the Infection Preventionist acknowledged this oversight. The Director of Nursing also confirmed the requirement for weekly changes and labeling to prevent respiratory infections. The facility's policy, last reviewed in October 2024, mandates that oxygen cannulas, masks, and tubing be dated and changed every seven days. The failure to comply with this policy for both residents placed them at an increased risk of infection. The observations and interviews conducted with the facility staff highlighted these deficiencies in infection control practices, which were not in line with the established procedures for managing oxygen therapy equipment.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Reseda
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Grancell Village Of The Jewish Homes For The Aging | 0 mi | — | 5 | 0 |
| Woodland Care Center | 0.6 mi | ★★★★★ | 19 | 0 |
| Park View Nursing And Subacute | 0.6 mi | ★★★★★ | 7 | 0 |
| Northridge Care Center | 1.1 mi | ★★★★★ | 44 | 0 |
| Eisenberg Village | 1.1 mi | ★★★★★ | 22 | 0 |
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