Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Kei-ai Los Angeles Healthcare Center during CMS and state inspections, most recent first.
Two residents with intact decision-making capacity reported that a contracted phlebotomist entered their shared room in the early morning without properly identifying himself, used a rough, stabbing technique during venipuncture, ignored one resident’s verbal requests to stop, and caused significant pain and bruising. One resident, recovering from joint replacement, stated the phlebotomist continued inserting the needle despite her yelling for him to stop, while the roommate, who has spinal stenosis and prior phlebotomy experience, described previous and repeated rough blood draws, arm bruising, and the phlebotomist holding her arm down and telling her to “cool off” despite her complaints of pain. Both residents reported the conduct to nursing staff; however, although an RN supervisor, CN, CM, and DSD became aware of the complaints, there was no documented immediate action to protect residents, no identification of the phlebotomist, and no investigation or notification of the contracted lab, contrary to facility policies on resident rights and refusal of treatment.
Two residents with intact cognition reported that a contracted phlebotomist entered their room in the early morning without proper identification, used a rough, stabbing technique during venipuncture, ignored a resident’s verbal requests to stop, and caused significant pain and bruising, leading one resident to leave AMA and the other to refuse further blood draws, delaying needed labs and treatment. Multiple staff, including an RN supervisor, CM, CN, and DSD, were informed of the complaints and documented awareness of the concerns, but they did not initiate or document an abuse investigation, did not promptly identify or report the phlebotomist to the lab vendor, and did not implement measures to prevent further incidents, contrary to the facility’s abuse and neglect policy requiring investigation of alleged abuse.
A resident with chronic kidney disease and decision-making capacity repeatedly requested discharge home and participated in an IDT meeting where the team documented that the resident would remain until full recovery and that the MD would be notified to determine discharge safety. Despite a care plan calling for evaluation of prognosis, pre-discharge planning, and monitoring for distress, staff did not notify the physician, obtain MD orders or progress notes regarding discharge appropriateness, or document specific safety concerns preventing discharge. The resident reported not seeing a doctor since admission and feeling distressed and uninformed about discharge goals, while SS and the DON acknowledged that discharge goals, rationale, and required physician notification were not documented or completed.
A resident with chronic kidney disease and decision-making capacity repeatedly expressed a desire to return home, but the facility failed to develop and document specific discharge goals or a clear rationale for why discharge was not feasible. Although the care plan contained general language about evaluating discharge potential and arranging community resources, the record lacked resident-specific discharge planning interventions, measurable objectives, or exploration of community supports. Progress notes referenced an IDT meeting that concluded the resident would remain until deemed safe by the MD, yet there was no documented assessment of discharge needs, no ongoing communication with the resident about next steps, and no physician documentation explaining why community discharge was not possible, contrary to facility policy.
A resident’s CHF medication was unavailable and the nurse did not notify the pharmacy or prescriber, while two residents received medications without observed identity verification. The facility also did not keep copies of Ekit usage logs and did not consistently have incoming and outgoing nurses count and sign controlled drug inventories together during shift change. The DON and ADON confirmed the documentation and counting processes were not followed as required.
Medication Administration Without Required BP and HR Checks: An LVN gave BP meds to multiple residents without verifying BP and/or HR at the time of administration, despite ordered hold parameters. The nurse relied on undated, untimed vitals taken earlier by a CNA, and the MAR showed BP meds were administered without reassessment for a resident with HTN, A-fib, and CVA history.
Safe food storage practices were not maintained when seven packages of previously frozen turkey breast were found in the walk-in refrigerator without proper labeling or use-by dates, and the Dietary Supervisor and Dietary Lead stated the food had been thawed and should have been discarded. In addition, the resident refrigerator near the nurse's station was observed at 45 degrees F with resident food items inside, and the temperature log showed repeated out-of-range readings with no documented corrective actions. The DON stated the refrigerator was not working, and the Dietary Lead stated dietary staff were responsible for checking unit refrigerator temperatures.
Failure to Renew Psychotropic Medication Consents: A resident with schizophrenia and bipolar disorder had psychotropic medication consents for lamotrigine, trazodone, and aripiprazole that were not renewed as required. During survey review, the LVN could not locate the lamotrigine consent in the chart and noted the other consents were also not renewed. The DON and ADON stated psychotropic consents needed to be updated every six months, and the DON stated the resident could have been deprived of the opportunity to give consent and participate in the plan of care.
Inaccurate MDS Documentation for Diagnosis and Discharge Status: The facility failed to ensure the MDS was accurate for two residents. One resident’s MDS did not include bipolar disorder even though the admission record and progress note documented that diagnosis, and the MDSRN, MDSLVN, and DON stated the assessment was not accurate and affected CMS submission and reimbursement. Another resident’s MDS incorrectly listed discharge to a short-term general hospital even though the order summary, discharge instructions, and nurses’ notes showed discharge home with family; the MDSLVN and ADM confirmed the discharge status was wrong.
Failure to care plan low air loss mattress use: A resident with DM, dementia, severe cognitive impairment, weakness, and dependence for multiple ADLs was identified as at risk for pressure injuries and using a pressure-reducing bed device. However, the record review and staff interviews confirmed there were no orders and no individualized care plan for the LALM, and the DON and LVN stated the mattress use should have been included in a person-centered plan with specific indications and settings.
Unupdated ROM Care Plan for Resident Refusing Lower Extremity Exercises. A resident with bipolar disorder, dementia, an above-the-knee amputation, and a lower extremity contracture had a care plan that still addressed ROM for both upper and lower extremities even after the resident refused lower extremity ROM and the service was discontinued. RNA staff reported they only performed ROM to the upper extremities, and the DON confirmed the care plan had not been revised and was no longer pertinent.
Incorrect LALM Settings for Two Residents: Two residents with significant mobility, cognitive, and skin-risk issues had Drive/low air loss mattresses set to weights far above their actual body weights. One resident weighed 79 lbs. but the LALM was set at 250 lbs. while the other weighed 118 lbs. but the LALM was set between 320 and 350 lbs. Staff and the DON confirmed the settings were incorrect and not based on the residents’ weights, and one resident already had buttocks/ischial skin damage.
High Bed Position for High-Fall-Risk Resident: A resident with vascular dementia, weakness, gait instability, and a history of falls was observed with the bed in a high position instead of the lowest position. CNA, LVN, RN, and the DON all stated the elevated bed created fall risk, and the resident's record showed significant mobility impairment, confusion, 2-person transfer needs, and other fall-risk interventions already in place.
Oxygen Tubing Left on Floor During Use: A resident with dementia, dysphagia, weakness, repeated falls, and impaired respiratory function was observed using O2 while the nasal cannula tubing touched the floor. An LVN stated the tubing could cause infection and needed to be changed right away, while a CNA noted it was also a tripping hazard. The resident had recent pneumonia treatment and an order to change the cannula tubing every 2 weeks and as needed for soilage.
Medication error rate exceeded 5% when an LVN administered Labetalol and Lisinopril to a resident with HTN without verifying BP or HR immediately before administration. The resident had orders to hold Labetalol for low SBP or HR and Lisinopril for low SBP, but the LVN relied on undated, untimed vitals reportedly taken by a CNA about 2.5 hours earlier. Two errors were identified during med pass observation, resulting in a 7.69% error rate.
An open box of Advair Diskus for a resident with COPD was found in a med cart without an open date. An LVN stated staff could not accurately know when the inhaler would expire without that date, and an RN confirmed the manufacturer’s instructions require the open date and use-by date to be written on the label.
An LVN administered medications to a resident without performing hand hygiene before entering the room, and a CNA changed another resident’s incontinent brief while on EBP without wearing a gown. The residents had significant medical needs, including diabetes, bed confinement, and a chronic foot ulcer, and facility leaders confirmed that hand hygiene and gown use were required by policy for these care activities.
A resident with encephalopathy, epilepsy, dysphagia post-CVA, severe cognitive impairment, and high ADL dependence was admitted for rehab with a documented goal to discharge home with family. After becoming combative and being placed on 1:1, the resident was transferred to a GACH on a 5150 hold. Over subsequent months, the hospital CM repeatedly faxed referrals and updated clinicals and reported the resident was calm, off restraints, and ready for discharge, but the facility’s admissions staff and DON declined readmission based on the prior 5150 and did not contact the hospital to clarify current status. Despite policies requiring priority readmission of hospitalized residents and comprehensive discharge planning focused on discharge goals and transition to post-discharge care, the facility did not revise or implement an effective discharge plan or facilitate the resident’s return or alternative placement, resulting in the resident remaining in the hospital long after being cleared for discharge.
A resident with intact cognition and multiple medical conditions repeatedly complained of inadequate assistance from CNAs, housekeeping, and nursing staff, as well as unresolved diarrhea and confusion about his medications. Staff, including an LVN, ADON, and social worker, acknowledged that the resident frequently voiced complaints about care and staff behavior, but no grievance form was completed, no grievance was formally filed, and no documentation was produced to show that his concerns were recorded or resolved. This conflicted with the facility’s grievance policy, which requires grievances to be documented, logged, and followed up by the grievance official while keeping the resident informed.
A resident with severe cognitive impairment and high risk for pressure ulcers was found with new MASD and skin tears. An LVN assessed the area and applied zinc oxide ointment without obtaining a physician's order, following a common practice in the facility. Review of facility policies confirmed that a physician's order is required for such topical treatments, and this protocol was not followed.
Two residents with complex medical conditions were discharged to other facilities without documentation of required nurse-to-nurse reports in their medical records, despite physician orders and staff confirmation that the reports were given. This resulted in incomplete and inaccurate records, contrary to facility policy.
A CNA wrapped a sheet around a resident's legs and tied it to the bedframe, restricting movement without a physician's order or care plan authorization. The resident, who had severe cognitive impairment and was fully dependent on staff, was found by multiple staff members with his legs immobilized. Facility policy prohibits such restraints, and the action was confirmed as unauthorized and not in line with professional standards.
A resident with severe cognitive impairment and multiple medical conditions was found with a sheet tied around their legs and bedframe by a CNA, constituting an unauthorized restraint. Multiple staff recognized this as abuse and removed the restraint, but the administrator did not report the incident to CDPH and the ombudsman within the required two-hour window, citing the absence of serious bodily injury. This delay violated mandated reporting requirements.
During a COVID-19 outbreak, staff failed to consistently wear N95 masks as required, with some not wearing them at all and one LVN wearing an N95 over a surgical mask, compromising its effectiveness. A CNA was observed not removing gloves between tasks, and the facility did not follow local health department guidelines such as social distancing, separating laundry, and keeping doors closed for exposed residents. These actions were not in accordance with the facility's infection control policies.
A resident's discharge was delayed due to transportation issues, but the responsible party was not notified of the changes and was unable to reach staff despite leaving multiple voicemails. Staff interviews revealed that no one was assigned to check or knew how to retrieve voicemail messages, resulting in the responsible party waiting and becoming worried, and the resident feeling anxious.
A resident with anxiety and other health conditions had their care plan include Alprazolam administration and monitoring. After a physician discontinued the Alprazolam, the care plan was not updated to reflect this change, resulting in an inaccurate care plan that did not match the resident's current treatment.
Five used oxygen concentrators were found unsanitized and uncovered in the supply room alongside clean supplies. Staff confirmed the devices had not been disinfected after resident use and were awaiting hospice pickup, in violation of facility policy requiring cleaning, disinfection, and separate storage of reusable equipment.
A medication cup with pills was left unattended on the bedside table of a resident who required moderate assistance, after an LVN failed to remain with the resident to ensure medication was taken, contrary to facility policy and professional standards. Staff interviews and policy review confirmed that medications should not be left at the bedside and that staff are required to observe residents take their medications.
A resident with chronic kidney disease, heart failure, and dementia had a care plan requiring intake and output monitoring to prevent renal complications. Despite this, staff were unable to provide documentation that intake and output were monitored, as confirmed by both an LVN and an RN supervisor. The resident was totally dependent, incontinent, and received nutrition via a gastrostomy tube, yet the care plan intervention was not implemented as required.
A resident with multiple complex medical conditions had a physician's order for GT feeding and water flush to be administered over 16 hours, but the order and MAR documented a 12-hour administration period instead. Both a registered dietitian and an LVN confirmed the documentation was incorrect, resulting in inaccurate medical records.
A call light system malfunction occurred when staff failed to properly reset a bathroom call light switch, causing the entire second floor's call system to become nonfunctional. This affected 71 residents, including a resident with significant care needs who was unable to use the call light and had to rely on a hand bell to request assistance. The deficiency was confirmed by staff interviews and review of facility records.
A resident with dementia and a history of falls did not have a floor mat placed as required by their care plan, increasing the risk of injury. Staff confirmed the absence of the mat, which was necessary to prevent injury, despite the facility's policy to implement comprehensive care plans.
The facility failed to ensure a CNA maintained current BLS certification, as required by the facility's policy. The CNA's BLS certificate had expired, and the DSD stated that only licensed staff were required to have BLS certification. This deficiency had the potential for the CNA not to recognize residents needing immediate emergency intervention.
A resident with dementia and a history of falls experienced multiple unwitnessed falls due to the facility's failure to ensure the sensor pad alarm was monitored and functioning. Staff interviews revealed inconsistencies in checking the alarm's placement and responding promptly when triggered, despite the resident's high fall risk and facility policies emphasizing safety and supervision.
A resident with chronic kidney disease stage five did not receive the required weekly blood tests as ordered by the physician. The facility failed to conduct the tests on a specified date, and there was no documentation explaining the omission. The oversight was confirmed by the registered nurse supervisor and the director of nursing, who noted the absence of records indicating a refusal by the resident.
A facility failed to provide adequate supervision and care for a cognitively impaired resident with a history of falls. Despite physician orders for 30-minute visual checks, these were not consistently implemented, and the care plan was not updated after multiple falls. The resident, with multiple health issues, experienced a third fall resulting in hospitalization for a hematoma and shoulder fracture. Staff interviews revealed lapses in supervision, contributing to the resident's repeated falls and injuries.
A resident was discharged without a proper order from their primary physician, leading to inaccurate documentation. Despite the resident's need for assistance with daily activities, the facility failed to confirm the discharge order source, violating professional standards.
A resident was administered psychotropic medications without obtaining informed consent, as required by the facility's policy. The resident, who was cognitively intact, did not sign the consent forms, nor did a responsible party. The forms were only signed by the physician, and the facility's policy required either the resident or a responsible party to sign, with two nurses witnessing the consent if the resident was unable to sign. The oversight was confirmed by the registered nurse supervisor and the director of nursing.
A resident in an LTC facility, who was frequently incontinent and dependent on assistance for daily activities, consistently refused personal and toileting hygiene. The facility failed to involve the resident's responsible party or notify the physician about the refusals, despite care plans indicating the need for such actions. Interviews with staff revealed the resident often refused care, leading to poor hygiene and potential health risks.
The facility failed to ensure call lights were within reach for five residents, preventing them from calling for assistance. Observations confirmed that residents with various impairments had their call lights out of reach, contrary to their care plans and facility policy. Staff acknowledged the oversight and the importance of accessible call lights.
A resident with limited mobility experienced a significant change in condition, but the facility failed to notify the physician directly. The resident's RNA services were discontinued based on hospice company orders without direct physician communication, potentially leading to a sacro-coccyx wound. Facility staff did not document or communicate the change of condition as required by policy.
A resident was prescribed psychotropic medications without proper diagnoses documented in their medical record, leading to an increased risk of unnecessary medication administration. Despite having a history of dementia, alcohol dependency, and opioid dependency, the resident had not seen a psychiatrist since readmission, and the facility failed to conduct a necessary psych consult. Facility staff acknowledged the oversight, which was against the facility's policy requiring diagnoses for psychotropic medication orders.
A facility failed to implement person-centered care plans for three residents, leading to a deficiency. One resident's care plan did not include their preferred activities like reading, another resident's request to listen to music was not updated in their care plan, and a third resident lacked an activity care plan altogether, resulting in isolation. The Activities Director and DON acknowledged these oversights, highlighting the importance of updating care plans to reflect residents' preferences.
The facility failed to provide consistent activities for three residents, impacting their physical, cognitive, and emotional health. One resident with dementia was observed without activity engagement, another with depression reported inconsistent staff visits, and a third with schizophrenia had limited access to preferred activities like bingo and religious services. The facility's policy required sufficient staffing for activities, but this was not met.
The facility failed to provide prescribed range of motion (ROM) and mobility services to several residents, as per physician orders. Residents did not receive active or passive ROM exercises, nor the application of prescribed splints and orthotic devices. Documentation was incomplete, and residents reported not receiving the necessary care. The Director of Staff Development confirmed the deficiencies, which could lead to a decline in ROM and mobility.
A resident with mobility concerns did not receive prescribed OT and PT services for 20 days due to the facility waiting for insurance authorization, despite having physician orders. This delay potentially contributed to further ROM limitations. Observations showed the resident's condition had deteriorated, with bent hips and knees and complaints of pain during repositioning.
A facility failed to complete therapy discharge summaries for several residents, impacting their follow-up care. Residents with conditions like schizophrenia, Alzheimer's, and B-cell lymphoma did not have their PT and OT discharge summaries completed, as confirmed by therapists and the Director of Rehabilitation. The facility's policy emphasized the importance of these summaries for ensuring continued care.
A resident with severe cognitive impairment and a preference for Mandarin was not provided with adequate translation services, despite the facility's policy and care plan interventions. Instead, an LVN used a personal phone to communicate, contrary to the facility's procedures, potentially affecting the resident's psychosocial wellbeing.
A resident's care plan for 'Alteration in Comfort' was not updated quarterly as required, despite the facility's policy. Staff interviews revealed that the care plan, last revised several months ago, was not reviewed to assess its effectiveness or the resident's progress, contrary to the facility's procedures.
A resident at risk for seizures did not have the physician-ordered bilateral padded side rails on their bed, as confirmed by staff. The resident, with severe cognitive impairment and dependency on staff, was admitted with epilepsy and other conditions. Despite the care plan and physician's order, only one padded side rail was present, increasing the risk of injury during seizures.
Failure to Honor Residents’ Right to Refuse Rough Phlebotomy and Ensure Respectful Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were treated with respect and dignity and that their right to refuse care from a contracted phlebotomist was honored during early-morning blood draws at the bedside. On the date in question at approximately 4:00 AM, a male phlebotomist from an outside laboratory company entered the shared room of two cognitively intact residents without introducing himself, wearing a visible name badge, or adequately responding when asked for his name. One resident, admitted with a left artificial knee joint following joint replacement surgery and assessed on the MDS as having cognitive skills for daily decision-making and needing varying levels of assistance with ADLs, reported that the phlebotomist stated he was going to draw her blood but did not explain who he was or why the blood draw was needed. She stated he proceeded to insert the needle in a forceful, stabbing manner without using a tourniquet, causing significant pain. According to the resident’s account and nursing progress notes, she verbally told the phlebotomist to stop the procedure and yelled at him to stop, but he continued to re-insert the needle to draw her blood. She reported feeling that her rights were violated and that the incident caused her anguish and anxiety, contributing to her desire to leave the facility against medical advice. Her roommate, who also had cognitive skills for daily decision-making and was admitted with spinal stenosis requiring extensive assistance with ADLs, corroborated hearing the interaction, including the resident’s repeated requests for the phlebotomist to stop and her screams of pain. The roommate stated that the phlebotomist did not knock, did not identify himself, and pulled the curtain open when entering the room. The second resident also reported having previously experienced rough and unprofessional blood draws by the same phlebotomist, including an earlier incident after which her arm was bruised for a week. She stated that he held her arm down despite her telling him it hurt, told her to “cool off,” and used a stabbing technique that caused significant pain, despite her informing him she had small veins and was a hard stick. On the later date, when he again entered around 4:00 AM without identifying himself, she told him to get out and refused to allow him to draw her blood, even when a male nurse accompanied him and asked her to permit the blood draw. Nursing progress notes documented that she adamantly refused the blood draw and that the CN attempted to convince her to proceed, but there was no documentation of honoring her refusal through appropriate follow-up per policy. Facility staff were aware of both residents’ complaints about the phlebotomist’s rude, harsh, and rough conduct, as reflected in nursing progress notes and staff interviews. The RN Supervisor, CN, Case Manager, and Director of Staff Development all acknowledged being informed of concerns about the phlebotomist’s behavior and the residents’ reports that he did not identify himself and caused pain. Despite this, there was no documented evidence that the facility took immediate action to ensure resident safety, to prevent the phlebotomist from continuing to provide services to other residents, or to initiate an investigation to identify the phlebotomist and notify the contracted laboratory company. The RN Supervisor stated she attempted but was unable to reach the core lab to identify the phlebotomist and did not document or thoroughly follow up, and the CN did not report or investigate the incident after hearing the second resident’s complaint. As of the survey date, no investigation or interventions had been implemented, despite facility policies stating that residents are to be treated with respect, be free from abuse, be informed of and participate in treatment decisions, and that refusals of care must be assessed and addressed by the CN or DON without coercion or intimidation.
Failure to Investigate and Act on Abuse Allegations Against Contracted Phlebotomist
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from abuse and to report, investigate, and act on allegations of abusive conduct by a contracted phlebotomist. On the date in question, a cognitively intact resident with a left artificial knee joint following joint replacement surgery reported that a male phlebotomist entered her room around 4 a.m. without introducing himself, without a name badge or identification, and proceeded to draw blood despite her questions about who he was and why the blood draw was needed. She stated he did not use a tourniquet and inserted the needle in a forceful, stabbing manner that caused significant pain. According to nursing progress notes and her interview, she verbally told him to stop, yelled at him to stop the procedure, and felt her rights were violated when he continued to re‑insert the needle, causing her anguish and anxiety and contributing to her decision to leave the facility against medical advice. A second cognitively intact resident with spinal stenosis also reported rough, unprofessional conduct by the same phlebotomist on more than one occasion. She stated that during a prior blood draw, he did not identify himself, did not knock, pulled the curtain open, held her arm down despite her telling him she had small veins and that it hurt, and told her to “cool off.” She reported that his technique was poor, that he used a stabbing technique, and that her arm was bruised for a week after the first encounter. When he returned early in the morning on the same date as the first resident’s incident, again without acknowledging himself, she told him to get out and refused to allow him to draw her blood. She reported these concerns to nursing staff, including that she had been a certified phlebotomist for 25 years and believed his technique inflicted unnecessary pain. Multiple staff members were aware of the residents’ complaints but did not ensure that the allegations were treated and processed as potential abuse in accordance with the facility’s abuse and neglect policy. Nursing progress notes documented that staff were aware of the first resident’s complaints and told her the phlebotomist would be reported to the core lab company administrator, but there was no documented evidence of immediate action to ensure resident safety or to prevent the phlebotomist from continuing to provide services. The registered nurse supervisor, case manager, charge nurse, and director of staff development all acknowledged receiving complaints or hearing about the phlebotomist being rude, harsh, or having “heavy hands,” yet the charge nurse did not report or further investigate, and the case manager only provided limited information to the administrator. The registered nurse supervisor stated she attempted to call the core lab to identify the phlebotomist but did not document or follow up thoroughly. As of the survey date, there was no record that the facility had identified the phlebotomist, investigated the concerns of the two residents, or notified the contracted laboratory company, and no interventions had been implemented to prevent further incidents, despite the facility’s written policy requiring investigation of alleged abuse and neglect to clarify what happened and identify possible causes. The second resident’s refusal to allow further blood draws from the phlebotomist led to a delay in necessary lab work, treatment, and diagnosis. Staff interviews confirmed that the phlebotomist typically arrived before the start of the morning shift, that some staff were unfamiliar with his identity, and that communication with the vendor was acknowledged as an area needing improvement. The director of nursing stated he was unaware of any issues with the contracted phlebotomist and emphasized that residents can refuse blood draws and that poor service or delays in blood draws may risk delayed care. Despite these acknowledgments and the facility’s abuse and neglect policy defining abuse as the willful infliction of injury, intimidation, or punishment resulting in physical harm, pain, or mental anguish, and neglect as failure to provide necessary services to avoid physical harm, pain, mental anguish, or emotional distress, the facility did not initiate or document an abuse investigation into the phlebotomist’s conduct toward the two residents.
Failure to Notify Physician and Document Discharge Planning for Resident Requesting Return Home
Penalty
Summary
The deficiency involves the facility’s failure to notify the physician and to follow through on discharge planning as documented in an Interdisciplinary Team (IDT) meeting for one resident. The resident was admitted with chronic kidney disease and, per a recent MDS, had decision-making capacity and required varying levels of assistance with ADLs, including cleanup assistance for eating and oral hygiene, maximal assistance for toileting, showering, lower body dressing, and footwear, and partial or supervisory assistance for transfers and upper body care. The resident’s care plan, initiated months earlier, included interventions to evaluate and discuss prognosis for independent or assisted living, identify and address limitations and risks, establish and revise a pre-discharge plan, arrange community resources, and monitor for anxiety, fear, and distress. Record review showed that an IDT meeting was held to discuss the resident’s ongoing desire to discharge home, which the resident had been expressing since the prior year. The IDT documented that the resident would remain in the facility until full recovery and that discharge home would occur once deemed safe by the MD, and the IDT notes stated that the physician would be notified regarding the resident’s request and the team’s determination that discharge was not safe. However, as of the survey date, there was no documentation that the physician had been notified, no physician progress note addressing discharge appropriateness, no physician orders related to discharge planning or safety concerns, and no follow-up documentation indicating that any consultation occurred. Interviews confirmed these documentation gaps and failures in communication. The resident reported not having seen a doctor since arrival at the facility and described emotional distress, frustration, and feeling uninformed about discharge goals, discharge planning, and the steps needed to return home. The resident stated that a meeting about going home had occurred but that nothing further was done. The social services staff, who participated in the IDT, stated that the resident was not deemed safe to discharge but could not provide documentation of the specific clinical, functional, or safety factors supporting that conclusion, acknowledged that the resident had decision-making capacity, and admitted she had not updated the resident on discharge goals or notified the physician as indicated in the IDT summary. The DON stated that the resident remained without documented discharge goals or a documented rationale for why discharge home was not feasible and that someone from the team should have notified the MD to evaluate the resident for discharge goals, consistent with the facility’s policy requiring communication of marked physical or psychological changes to the physician for proper management.
Failure to Develop and Document Resident-Centered Discharge Goals and Rationale
Penalty
Summary
The deficiency involves the facility’s failure to develop and document discharge goals and to provide a documented rationale for determining that discharge was not feasible for a resident who wished to return home. The resident was admitted with chronic kidney disease and, per the MDS, had decision-making capacity and required varying levels of assistance with ADLs, including maximal assistance for toileting, showering, and lower body dressing, and partial assistance for transfers. Progress notes documented that an IDT meeting was held to discuss the resident’s desire to discharge home, and the IDT concluded the resident would remain in the facility until deemed safe for discharge by the MD. However, despite the resident expressing a desire to go home since a prior date, there was no documentation of specific discharge goals or a clear explanation in the record as to why discharge home was not feasible. The resident’s care plan contained general statements about evaluating and discussing prognosis for independent or assisted living, identifying limitations and needs for maximum independence, establishing a pre-discharge plan, arranging community resources, and monitoring for anxiety, fear, and distress. However, the record lacked evidence that these care plan elements were implemented in a resident-specific, measurable way. There was no documented assessment of the resident’s discharge needs, no documented exploration of community supports or alternative discharge options, and no measurable discharge planning interventions or objectives. The record also did not reflect ongoing communication with the resident about next steps in the discharge process. Interviews further supported the lack of documented discharge planning. The resident reported feeling emotionally distressed, uninformed about the discharge process, and believed the facility was not allowing discharge, stating he felt captured and had not seen a doctor since arrival. The SS, who was part of the IDT, stated the resident was not deemed safe to discharge and had decision-making capacity, but could not provide documentation outlining the specific clinical, functional, or safety factors that made discharge not feasible and acknowledged not updating the resident on discharge goals after the IDT meeting. The DON confirmed that the resident remained in the facility without documented discharge goals or a documented rationale for why discharge home was not feasible, despite facility policies requiring weekly IDT reevaluation of discharge potential, documentation of changes in the medical record, updating the care plan with the discharge plan, and documenting when returning to the community is not feasible and why.
Medication administration, emergency kit, and controlled substance record failures
Penalty
Summary
The facility failed to notify Resident 262’s physician when Spironolactone, an active order for CHF, was unavailable on 02/16/2026. Resident 262 had diagnoses including hypertensive heart disease, and the record also showed the resident’s cognitive skills were intact on the MDS, while the H&P stated the resident did not have the capacity to make healthcare decisions. The MAR for 02/16/2026 showed the scheduled 9:00 AM dose was marked with code 4, and nursing documentation indicated the medication was not available. LVN 3 stated she did not notify the pharmacy on 02/16/2026, did not notify the prescriber, and did not document that the resident missed the dose. The DON reviewed the MAR and progress notes and stated there was no documentation explaining why the medication was held and no documentation that the physician was notified. The facility also failed to positively identify residents before administering medications. During a medication pass, LVN 3 administered Apixaban, Escitalopram, and Benztropine to Resident 262 after stating the resident’s name, but she was not observed verifying identity before administration. LVN 3 stated she already knew the resident and that she asked the resident’s name, but the resident could not hear her and was complaining of hearing difficulty. During another medication pass, LVN 6 administered seven medications to Resident 260, including Labetalol, Lisinopril, Vitamin C, Cranberry, Vitamin B12, Magnesium Oxide, and Ferrous Gluconate, without being observed checking the resident’s identification band. LVN 6 later stated she should have checked the resident’s identification band and that nurses were supposed to verify resident identification before giving medications. The facility did not maintain accurate Ekit usage records for all residents. During inspection, RN 1 stated the facility did not keep a copy of the Ekit usage log; instead, the log was faxed to the pharmacy and then placed back inside the Ekit and sent with the kit to the pharmacy. RN 1 stated this applied to controlled Ekits, injectable Ekits, and non-controlled Ekits. The DON stated the facility did not have a process to monitor or track Ekit usage. The facility also failed to ensure controlled drugs were counted and signed for together during shift change. One controlled drugs inventory form had blank incoming and outgoing signatures for a shift change, and an LVN stated both nurses counted the controlled medications but forgot to sign. Another LVN stated she signed the form ahead of time before the next nurse arrived. The ADON stated both incoming and outgoing nurses were required to count and sign together, and that failing to do so could result in uncertainty about the accuracy of the controlled medications.
Medication Administration Without Required BP and HR Checks
Penalty
Summary
The facility failed to ensure four residents were free from significant medication errors when blood pressure medications were administered without checking systolic blood pressure and/or heart rate in accordance with physician orders, medication parameters, manufacturer information, and the facility’s medication administration policy. The deficiency involved Residents 260, 129, 8, and 83, all of whom had diagnoses that included hypertension and other cardiovascular or cerebrovascular conditions, and whose care plans directed staff to administer prescribed medications and monitor apical pulse and blood pressure as indicated by medication parameters. For Resident 260, the record showed orders for Labetalol 100 mg twice daily with instructions to hold for SBP less than 110 or HR less than 60, and Lisinopril 40 mg daily with instructions to hold for SBP less than 110. During medication pass observation, an LVN prepared and administered these blood pressure medications without being observed checking the resident’s BP or HR first. The LVN later stated she relied on vital signs taken by a CNA earlier that morning, but the handwritten vital sign sheet had no date or time, and the LVN acknowledged she could not verify when the readings were taken. The CNA confirmed the readings were taken earlier and provided them to the LVN, but they were not contemporaneous with medication administration. For Resident 129, the record showed orders for Amlodipine 10 mg daily with hold parameters for SBP less than 110 or HR less than 60, Lisinopril 40 mg daily with hold for SBP less than 110, and Metoprolol 50 mg twice daily with hold for SBP less than 110 or HR less than 60 and to give with food/snack. The MAR showed these medications were administered without reassessing BP and HR. The resident’s care plan identified risk for cardiac distress related to atrial fibrillation, CVA, hyperlipidemia, and HTN, and directed staff to monitor apical pulse and blood pressure as indicated in the medication parameters. The report also noted similar concerns for Residents 8 and 83, whose vital signs were documented on the same undated and untimed handwritten sheet used by the LVN to decide whether to give blood pressure medications, without verification at the time of administration.
Food Storage and Refrigerator Temperature Lapses
Penalty
Summary
Safe and sanitary food storage practices were not maintained when seven packages of previously frozen turkey breast were found stored in the walk-in refrigerator with facility dates of 2/8/2026 to 2/9/2026. The turkey breast had been removed from the original box, and the individual packages did not have any marking or manufacturer use-by date. The turkey was stored inside a large plastic container labeled by the facility with the same dates, and the Dietary Supervisor and Dietary Lead stated the product had been thawed from the freezer and should have been discarded because it was not labeled and dated correctly. During the observation, the Dietary Supervisor and Dietary Lead stated the turkey had been removed from the freezer to thaw on 2/8/2026 and that staff did not label and date it correctly. The Dietary Lead stated the food had been thawed for 3 days and then cooked or used, and that the portion not used should have been discarded. The Dietary Supervisor removed the turkey from storage to discard it and stated the packages were not labeled correctly and could have been a potential for residents to get sick. Facility policy required foods stored in the refrigerator or freezer to be covered, labeled, and dated. The resident refrigerator next to the nurse's station on the first floor was observed at 45 degrees Fahrenheit with a facility-prepared lunch sandwich, snacks, juices, and high-calorie nutrition shakes inside. The Nurse Supervisor stated the normal temperature for the food refrigerator was 41 degrees Fahrenheit and below, and that the perishable sandwich, snacks, and juices had to be discarded because they were not stored at the right temperature. The temperature log for February 2026 showed the refrigerator was above 41 degrees Fahrenheit eight times, and no corrective actions were documented. The Dietary Lead stated dietary staff were responsible for checking the temperature of the resident refrigerators, and the DON stated the refrigerator was not working and would be replaced immediately.
Failure to Renew Psychotropic Medication Consents
Penalty
Summary
The facility failed to renew psychotropic medication consents for one resident who was admitted with diagnoses including schizophrenia and bipolar disorder. The resident had a Verification of Informed Consent for Psychotropic Medication dated 1/31/2023 for lamotrigine, but the consent had not been renewed since 2023. The resident also had a consent dated 2/21/2024 for trazodone and a consent dated 12/10/2024 for aripiprazole, and during the survey review on 2/19/2026, the LVN could not locate the lamotrigine consent in the electronic chart and noted that the trazodone and aripiprazole consents had not been renewed. The resident’s MDS dated 1/9/2026 indicated the resident was alert and oriented with good recall and had bipolar disorder and schizophrenia. During interviews, the LVN stated consents were needed and that the resident would not be informed of the risks and benefits of the medication without them. The ADON and DON stated psychotropic medication consents needed to be updated every six months, and the DON stated the resident could have been deprived of the opportunity to give consent and participate in the plan of care and be informed of the medications. The facility policies reviewed did not specify a time frame for renewing psychotropic consents, while an AFL dated 2/3/2026 stated facilities had to renew the informed consent form every six months during which the resident received a psychotherapeutic drug.
Inaccurate MDS Documentation for Diagnosis and Discharge Status
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was accurate for two sampled residents. For one resident, the admission record showed diagnoses including bipolar disorder, type 2 diabetes mellitus, muscle weakness, and aftercare following joint replacement surgery. The resident’s H&P dated 1/22/2026 indicated the resident had the capacity to make healthcare decisions, and the MDS showed the resident could understand others and make herself understood. However, the MDS dated [DATE] did not check the box for bipolar disorder in Section I, Active Diagnoses. During interview and record review, the MDSRN stated the MDS was not accurate, and the MDSLVN and DON stated the MDS had to be accurate because it was submitted to CMS and affected reimbursement. For the second resident, the admission record showed the resident was readmitted with diagnoses including dysphagia, acute gastric ulcer, and iron deficiency anemia. The H&P dated 11/17/2025 indicated the resident had the capacity to understand and make decisions. The order summary report dated 1/2/2026 indicated discharge to home with family, and the discharge instructions and nurses’ notes also documented discharge home, including discharge by gurney and instructions given to the daughter. During interview and record review, the MDSLVN and ADM reviewed the MDS and confirmed it incorrectly documented the discharge status as discharged to a short-term general hospital instead of discharged to home. The facility’s policy titled, Certify Accuracy of the Resident Assessment, stated that anyone completing a portion of the MDS must sign and certify the accuracy of that portion, and that the information captured reflects the resident’s status during the observation period. The ADM stated the MDS needed to be accurate, reflected the resident’s clinical status, and that the inaccurate discharge status potentially affected financial reimbursement and accurate assessment.
Failure to Care Plan Low Air Loss Mattress Use
Penalty
Summary
The facility failed to develop an individualized, person-centered care plan for Resident 193’s low air loss mattress (LALM), a pressure-relieving mattress used to prevent and treat pressure injuries. Resident 193 was admitted with multiple diagnoses including DM type 2 with circulatory complications, osteoporosis, osteoarthritis, generalized muscle weakness, dysphagia, and left-sided monoplegia following a nontraumatic subarachnoid hemorrhage. A physician progress note documented that the resident was wheelchair and bedbound, weakness prevented ambulation, and the resident had dementia. The MDS indicated severe cognitive impairment, dependence on staff for toileting hygiene, lower body dressing, bed mobility, and transfers, and that the resident was at risk for pressure ulcers/injuries and used a pressure reducing device for bed. During a concurrent interview and record review, LVN 7 confirmed there were no orders and no care plan for Resident 193’s LALM. LVN 7 stated a care plan should have included focused goals and specific interventions, and that the LALM should have been part of a personalized care plan with orders specifying the indication and settings. The DON also confirmed Resident 193 should have had a care plan for the LALM and orders specifying the indication for its use, such as weight. The facility policy on support surface guidelines directed staff to review the resident’s care plan for special needs, and the care plan policy required a comprehensive, person-centered care plan with measurable objectives and timetables developed within seven days of the comprehensive assessment and revised as the resident’s condition changed.
Unupdated ROM Care Plan for Resident Refusing Lower Extremity Exercises
Penalty
Summary
The facility failed to update and revise Resident 12’s ROM care plan after the resident stopped participating in lower extremity ROM. Resident 12 was admitted with diagnoses including bipolar disorder, acquired absence of the right leg above the knee, unspecified dementia, and neuralgia/neuritis. The baseline admission screen noted a left lower extremity contracture, and the history and physical later documented a lower extremity contracture and that the resident did not have the mental capacity to understand or make decisions. The MDS indicated the resident sometimes could make himself understood and sometimes could understand others. The care plan titled high risk for further decline in ROM related to impaired mobility and decreased strength for both upper and lower extremities, dated 11/23/2022, still directed staff to observe and document response to ROM exercises for both upper and lower extremities and to observe for changes in ROM. However, RNA 1 stated she only performed ROM on the upper extremities because Resident 12 did not allow her to touch the lower extremities. LVN 1 and RN 3 reviewed the order history and stated there was only a physician order for RNA to perform ROM on the upper extremities, and that Resident 12 did not allow staff to touch the left lower extremity. A PT progress note documented that Resident 12 had been refusing to participate with RNA for left lower extremity ROM and recommended discontinuing RNA for the left lower extremity; the nurse practitioner agreed and discontinued that service. PT 1 stated the resident had been refusing lower extremity therapy since 10/10/2023 and it was discontinued in 2023 per the resident’s request. The DON confirmed the facility did not update the care plan and stated that if the resident was refusing lower extremity exercises, the care plan should have been revised and updated because the current care plan was no longer pertinent to Resident 12.
Incorrect LALM Settings for Two Residents
Penalty
Summary
The facility failed to maintain appropriate Low Air Loss Mattress (LALM) settings for two residents who were at risk for pressure injuries. Resident 42 had diagnoses including rheumatoid arthritis, bilateral primary osteoarthritis of the hip, peripheral vascular disease, muscle weakness, unsteadiness on feet, congestive heart failure, repeated falls, dementia, and neuralgia/neuritis. Her assessments showed she needed substantial to maximal assistance with multiple activities of daily living, was dependent on staff for bathing, had a weight of 79 pounds, and had a Braden score of 12. Her skin status included left buttocks scar tissue, right ischium excoriation, and left buttocks MASD. Although the care plan addressed use of a LALM for pressure redistribution and skin management, the order review history did not show a physician order for a LALM. During observation, Resident 42’s LALM was set for 250 pounds. The WCN stated the mattress should have been set according to the resident’s 79-pound weight and that the setting could cause the wound on the ischium and buttocks to worsen. RN 2 reviewed the resident’s weight in the EMR and stated the 250-pound setting was too high and could cause the wounds to get worse. The DON stated that if the mattress was set to 250 pounds for a resident weighing 79 pounds, the resident would not get the therapeutic benefit of the LALM and that it should have been based on the resident’s weight. Resident 193 had diagnoses including type 2 DM with circulatory complications, osteoporosis, osteoarthritis, muscle weakness, dysphagia, and monoplegia of the upper limb following nontraumatic subarachnoid hemorrhage. A physician progress note described the resident as wheelchair and bedbound, with weakness preventing ambulation, and having dementia. The MDS showed severe cognitive impairment, dependence on staff for toileting hygiene, lower body dressing, lying to sitting, and chair/bed transfers, and identified the resident as at risk for pressure ulcers/injuries with use of a pressure reducing device for bed. The resident’s weight was 118 pounds, but during observation the Drive LALM was set between 320 and 350 pounds. LVN 1 confirmed the setting and stated it was based on another resident’s weight. LVN 1 then verified the resident’s current weight and stated the mattress could have been too hard for the resident, and the DON stated LALMs were set based on resident weight to provide appropriate pressure.
High Bed Position for High-Fall-Risk Resident
Penalty
Summary
The facility failed to ensure one of five sampled residents, Resident 79, who was identified as high risk for falls, was kept free from an accident hazard when the resident's bed was not placed in the lowest position. During observation in the resident's room, the bed was seen in a high position. CNA 5 stated the bed was high and that Resident 79 could fall out of bed. LVN 11 stated that if the bed position was set too high, the resident could be at risk for a fall, and RN 2 stated the resident could fall and have an injury if the bed was not in a low position. Resident 79's record showed multiple fall-risk factors and mobility limitations. The admission record listed diagnoses including vascular dementia, bilateral hip pain, a collapsed vertebra in the thoracolumbar region, prostate cancer, and ankle and foot pain. The care plan identified the resident as high risk for falls and injury, with interventions including a yellow nameplate and fall risk arm band. The H&P described the resident as mostly wheelchair and bedbound with weakness and gait instability that prevented safe ambulation. The MDS indicated the resident could make himself understood and understand others, and the Morse Fall Risk Screen showed a score of 55 with a history of falling. Additional records showed ongoing concerns with mobility and supervision needs. The care plan documented difficulty with bed mobility, inability to stand for transfer and gait, and impaired balance with bilateral lower extremity weakness, with skilled PT ordered five times a week. Weekly nursing notes described the resident as forgetful and confused and requiring 2-person transfer assistance. The order review history included a Wander guard on the wheelchair for wandering and exit-seeking behavior and orthostatic hypotension checks. The DON stated the bed should have been positioned to the lowest position, and facility policies identified bed safety as a risk factor and directed staff to identify interventions to prevent falls and reduce resident-specific fall risks.
Oxygen Tubing Left on Floor During Use
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not met for Resident 120. Resident 120 was admitted on 8/2/2021 and readmitted on 3/7/2022 with diagnoses including personal history of COVID-19, dementia, unspecified head injury, dysphagia, muscle weakness, and repeated falls. The MDS dated 12/10/2025 indicated Resident 120 rarely or never could make herself understood or understand others, and the H&P dated 10/17/2025 stated she was oriented only to person due to dementia. The care plan dated 1/18/2026 identified impaired respiratory function related to desaturation, tachycardia, fever, and pneumonia per x-ray result, with an intervention to change tubing and the oxygen humidifier bottle when in use per facility protocol. Nurses notes dated 2/3/2026 indicated Resident 120 was status post antibiotic for pneumonia, and an order review history report dated 2/20/2026 showed a physician order to change the oxygen cannula tubing every 2 weeks on Sundays and as needed for soilage. During a concurrent observation and interview on 2/17/2026 at 2:47 PM, Resident 120's oxygen nasal cannula tubing was observed touching the floor while she was using oxygen. CNA 1 stated the tubing on the floor could cause a tripping hazard, and LVN 6 stated Resident 120 could get an infection from the tubing touching the floor and that the tubing would need to be changed right away. The facility's Oxygen Administration policy dated 1/2026 stated oxygen tubing would be changed every 2 weeks or as needed, the Quality of Life - Homelike Environment policy dated 4/2025 stated residents would be provided a clean, sanitary, and orderly environment, and the Infection Prevention and Control Program policy dated 3/27/2025 stated the facility maintained an IPCP to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.
Medication Error Rate Exceeded 5% Due to Unverified BP Medication Administration
Penalty
Summary
The facility failed to keep the medication error rate below 5 percent. During a medication pass observation, two medication errors were identified out of 26 opportunities, resulting in an overall medication error rate of 7.69 percent and affecting one of four sampled residents observed during medication administration. The resident involved had diagnoses that included HTN and hyperlipidemia and was assessed by MDS as having moderately impaired cognitive skills. The resident had active orders for Labetalol 100 mg twice daily for HTN, to be held for SBP less than 110 mmHg or HR less than 60 bpm, and Lisinopril 40 mg daily for HTN, to be held for SBP less than 110. The care plan identified the resident as at risk for cardiac distress and included interventions to administer Labetalol and Lisinopril as ordered and to monitor apical pulse and BP as indicated in the medication parameter. During the med pass, the LVN prepared and administered Labetalol and Lisinopril along with five other medications, but was not observed checking the resident's BP or HR before giving the two BP medications. The LVN stated she normally relied on vitals taken by CNAs and provided a handwritten paper with the resident's BP and HR, but the paper did not include the date or time the vitals were taken. The LVN and CNA stated the vitals had been taken about two and one-half hours earlier, and the LVN acknowledged she could not verify when they were taken. The DON stated BP should be checked as close as possible to medication administration time and that if vitals were taken two hours earlier, the nurse had to recheck them immediately before giving BP medication when ordered parameters were present.
Unlabeled Open Advair Diskus
Penalty
Summary
The facility failed to ensure proper storage, labeling, and/or disposal of medications when an open box of Advair Diskus for one sampled resident did not have an open date. During observation and interview, an oral inhaler for Advair 250/50 mcg was found inside MedCart C on Nursing Station 3 without an open date. The LVN stated there was no open date on the Advair labeled for the resident and acknowledged that without an open date staff would not accurately know when the medication was due to expire. The resident involved had diagnoses including COPD and was admitted and later readmitted to the facility. The resident’s MDS indicated intact cognitive skills, while the H&P stated the resident did not have the capacity to make healthcare decisions. The resident had an order for Advair Diskus 250/50 mcg, one inhalation orally twice a day for COPD, and the RN supervisor reviewed the manufacturer’s labeling stating the medication expires one month after opening the foil pouch or when the counter reads zero, whichever comes first. The LVN also stated she administered a dose of Advair to the resident on the date of interview.
Hand Hygiene and EBP PPE Not Followed
Penalty
Summary
Infection control measures were not maintained for a resident with diabetes mellitus, schizophrenia, hypertension, hyperlipidemia, and bed confinement status when an LVN administered morning medications without performing hand hygiene first. The resident’s record showed intact cognitive skills on the MDS, but the H&P stated the resident did not have the capacity to make healthcare decisions. During a medication pass observation, the LVN prepared apixaban, benztropine mesylate, and escitalopram, then entered the resident’s room and gave the medications by mouth without washing or sanitizing hands before contact. The LVN later confirmed she had not performed hand hygiene before entering the room. A second infection control failure occurred with a resident on Enhanced Barrier Precautions for infection risk and chronic left foot ulcer. The resident’s care plan included EBP, and a sticker next to the resident’s name indicated the precaution was in place. During an observation, a CNA performed an incontinent brief change while wearing gloves and a mask, but no gown. The CNA confirmed that staff were required to wear PPE including a gown for residents on EBP and stated she should have worn one during the brief change. Facility interviews and record review showed that the DON stated nurses were expected to perform hand hygiene before preparing medications and before entering a resident’s room to administer them. The Infection Preventionist and Administrator reviewed the EBP policy and confirmed that gown and gloves were required for high-contact care activities, including changing briefs or assisting with toileting. The facility policies also stated hand hygiene was required before and after direct contact with residents and before preparing or handling medications.
Failure to Develop and Implement Appropriate Discharge Planning and Readmission for Hospitalized Resident
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement an appropriate discharge plan and readmission process for a resident who had been transferred to a general acute care hospital (GACH) for psychiatric evaluation and was not permitted to return. The resident was initially admitted with encephalopathy, epilepsy, dysphagia following a CVA, and severe cognitive impairment, and was largely dependent on staff for ADLs. The admission record did not show a psychiatric diagnosis, but the resident had an order for PRN quetiapine for agitation and was documented as lacking capacity to understand and make decisions. The care plan and an IDT conference shortly after admission identified a discharge goal of returning home with family when able, with the facility offering to assist with home health and DME arrangements or alternative placement options once the MD cleared discharge. After admission, the resident became physically combative with staff, including kicking, punching, and disrobing, and was placed on 1:1 observation. This escalation led to a physician order to transfer the resident to GACH on a 5150 hold. The facility considered this transfer a proper discharge due to the change in condition. The facility’s policies on readmission and transfers/bedholds stated that residents discharged to the hospital would be given priority for readmission and that the facility would develop discharge planning procedures focusing on discharge goals and preparation for transition to post-discharge care. However, following the transfer, the facility did not complete or revise a discharge plan addressing the resident’s post-hospital needs or potential return, despite the previously documented goal of discharge home with family and the facility’s stated role in coordinating services and placement. GACH case management notes documented that the resident had been decannulated and was ready for discharge for at least three months, and that multiple referral packets and updated clinical information were faxed to the facility and other SNFs over several months. On at least one follow-up call, the facility’s admissions coordinator confirmed receipt of the referral and stated the resident was not appropriate for readmission because of the prior 5150 transfer, even after being informed by the GACH case manager that the resident was calm, not on restraints, and did not require a sitter. The DON acknowledged awareness of a referral in mid-December, stated that the information indicated the resident was still restrained, and confirmed he did not contact GACH to verify the resident’s current status. The DON maintained that the facility would not readmit the resident and did not address whether hospitalization was an appropriate long-term disposition, despite facility policies requiring priority readmission and comprehensive discharge planning. These actions and inactions resulted in the resident remaining in the hospital for months after being cleared for discharge. The facility’s own policies titled “Readmission to the Facility” and “TRANSFERS / BEDHOLDS AND DISCHARGES – OUT OF FACILITY” required that residents discharged to the hospital be given priority for readmission upon bed availability and that discharge planning procedures focus on the resident’s discharge goals and preparation for transition to post-discharge care. Despite these policies, the facility did not reassess or update the resident’s discharge plan after the psychiatric transfer, did not engage in documented IDT discharge planning with the hospital’s input, and did not coordinate or facilitate the resident’s return or alternative placement once the resident was clinically ready for discharge. Instead, the facility relied on the fact of the prior 5150 transfer as the basis for refusing readmission, without documented individualized assessment of the resident’s current condition or needs, and without documented communication with GACH to clarify the resident’s status. This lack of effective discharge planning and refusal to readmit contrary to policy formed the basis of the cited deficiency.
Failure to Document and Address Resident Grievances About Care and Assistance
Penalty
Summary
The deficiency involves the facility’s failure to promptly address and document a cognitively intact resident’s repeated grievances about inadequate assistance and nursing care. The resident was admitted with esophagitis, duodenal ulcer, and generalized muscle weakness, and assessments showed he used a walker and wheelchair, was independent with several ADLs, and required assistance with toileting hygiene and bathing. A later history and physical documented that the resident had capacity to make medical decisions and had expressed dissatisfaction with staff and the facility, specifically reporting inadequate assistance and communication issues. During an interview conducted with a translation hotline, the resident reported ongoing diarrhea, stated he did not understand why his medications were not working, and complained that CNAs, housekeeping, and licensed nurses were not providing the assistance he needed. Staff interviews confirmed that the resident voiced many complaints about charge nurses, housekeeping, and CNAs, and that he repeated these complaints. The ADON reported that the last IDT meeting with the resident, used to discuss the plan of care and any concerns, occurred on 11/11/25, despite the resident’s ongoing complaints. The social worker stated that no grievance had been filed for this resident and that his multiple complaints were addressed immediately, but the facility could not provide any documentation to support that the complaints were recorded or resolved. This was inconsistent with the facility’s written grievance policy, which requires staff to record the nature and specifics of grievances on a designated form, for the grievance official to log and document actions taken, and to keep the resident informed of progress toward resolution.
Topical Medication Applied Without Physician Order
Penalty
Summary
The facility failed to obtain a physician's order prior to the application of a topical medication for a resident with severe cognitive impairment and high risk for pressure ulcers. During an observation, a Certified Nurse Assistant and a Restorative Nurse Assistant identified bloody drainage, redness, and small skin tears in the resident's buttock skin folds and notified the Licensed Vocational Nurse (LVN). The LVN assessed the area, identified new Moisture Associated Skin Damage (MASD) with bloody discharge, cleansed the area with normal saline solution, and applied zinc oxide ointment without a physician's order. The LVN stated it was common practice to follow the skin treatment protocol by cleansing and applying zinc oxide ointment before reporting the condition to the physician. Review of facility policies and procedures confirmed that the application of zinc oxide ointment requires a physician's order and that medications should only be administered upon a clear, complete, and signed order from an authorized prescriber. The Director of Nursing and Director of Staff Development both confirmed that the facility's protocols do not allow for the application of topical agents such as zinc oxide without a physician's order. This practice was not in accordance with professional standards or the facility's own policies.
Failure to Document Nurse-to-Nurse Reports at Discharge
Penalty
Summary
The facility failed to ensure that residents' medical records were complete and accurate for two residents who were discharged to other facilities. For both residents, physician orders required that a nurse-to-nurse report be given to the receiving facility at the time of discharge. However, there was no documentation in either resident's medical record indicating that this report was provided, despite staff interviews confirming that the reports were given verbally. The absence of this documentation resulted in incomplete and inaccurate medical records for both residents. One resident, admitted with diagnoses including cerebral infarction, diabetes mellitus, and generalized muscle weakness, was discharged to another facility with a physician order specifying a nurse-to-nurse report. Another resident, with spinal stenosis, diabetes mellitus, and a history of falls, was also discharged under similar orders. In both cases, staff acknowledged during interviews that the nurse-to-nurse reports were not documented in the residents' records. Facility policy required that all services provided, including communication with other staff or facilities, be documented in the medical record to ensure completeness and accuracy.
Unauthorized Use of Physical Restraint on Resident
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) wrapped a linen sheet around a resident's legs and tied it to the bedframe, restricting the resident's movement. The resident, who had severe cognitive impairment and was dependent on staff for all activities of daily living, was found with his legs immobilized by the sheet. Multiple staff members, including registered nurses and other CNAs, observed the resident in this state and confirmed that the sheet was tied tightly enough to prevent movement. The CNA responsible stated that the action was intended to prevent the resident from sliding out of bed, but acknowledged that this was not an approved or trained method for addressing such issues. The resident involved had a complex medical history, including type 2 diabetes, Alzheimer's disease, dementia, dysphagia, benign prostatic hyperplasia, and hyperlipidemia. The Minimum Data Set assessment indicated severe cognitive impairment and total dependence on staff for care. Nursing notes and interviews documented that the resident was typically active in bed, moving his legs frequently, and that the restraint was not authorized by a physician or included in the resident's care plan. The facility's investigation substantiated that the CNA used an unauthorized method to restrict the resident's movement, in violation of facility policy and without a physician's order. Facility policy explicitly prohibits the use of physical restraints, including tucking sheets so tightly that a resident cannot move, unless ordered by a physician and with proper consent. Staff interviews, including those with the Director of Nursing and Director of Staff Development, confirmed that the use of a sheet as a restraint was not standard practice and was considered a violation of resident rights and dignity. The incident was identified as a suspicion of involuntary restraint, and the CNA involved was suspended and subsequently resigned.
Failure to Timely Report Alleged Abuse Involving Unauthorized Restraint
Penalty
Summary
The facility failed to report an allegation of staff-to-resident abuse to the California Department of Public Health (CDPH) and the ombudsman within the required two-hour timeframe. The incident involved a resident with severe cognitive impairment and multiple medical conditions, including Alzheimer's disease, dementia, and type 2 diabetes, who was found with a linen sheet wrapped around his legs and tied to the bedframe. Multiple staff members, including CNAs and RNs, observed the resident with his legs restrained by a sheet, which was not authorized by a physician and was not in accordance with facility policy. The staff immediately notified supervising nurses, and the sheet was removed upon discovery. Interviews and documentation revealed that the CNA responsible for applying the sheet did so in an attempt to prevent the resident from sliding off the bed, but acknowledged that this was not the proper method and was not how he was trained. The facility's investigation substantiated that the CNA used an unauthorized restraint, and the action was identified as a suspicion of involuntary restraint. Staff members who witnessed the incident described the restraint as tight, preventing the resident from moving his legs, and recognized it as a form of abuse. The CNA involved was suspended pending investigation and later resigned. Despite the immediate internal response, the facility administrator, who served as the abuse coordinator, did not report the incident to CDPH and the ombudsman within two hours of becoming aware of the situation. Both the administrator and the director of nursing stated that the delay was due to the absence of serious bodily injury. However, facility policy and regulatory requirements mandate that all allegations of abuse be reported immediately, but not later than two hours if the alleged violation involves abuse, regardless of injury. The delay in reporting constituted a failure to comply with mandated reporting requirements.
Failure to Implement Infection Control Policies During COVID-19 Outbreak
Penalty
Summary
The facility failed to implement its infection control policies and procedures during a COVID-19 outbreak, as evidenced by multiple observed lapses. Staff did not consistently wear N95 masks as required, with some personnel, including staffing coordinators, not wearing N95 masks despite the presence of COVID-19 positive staff and residents. One LVN was observed wearing an N95 mask over a surgical mask, which the infection preventionist confirmed defeats the purpose of the N95 by preventing a proper seal. Additionally, a CNA was seen leaving a resident's room while still wearing gloves, retrieving clean linen from a cart, and re-entering the room without removing or changing gloves, contrary to the facility's standard precautions policy. Further, the facility did not comply with local health department guidelines intended to contain the spread of COVID-19. These lapses included failure to maintain social distancing, not staggering communal activities, not separating laundry of exposed and non-exposed residents, and not keeping doors closed for residents exposed to COVID-19. Interviews with the infection preventionist and director of nursing confirmed that these guidelines were not followed, and that adherence to these protocols is essential for infection mitigation. Review of facility policies indicated that staff are to be educated and adhere to proper infection control techniques, including prompt glove removal and compliance with local masking requirements.
Failure to Notify Responsible Party of Discharge Delay and Inadequate Voicemail Monitoring
Penalty
Summary
The facility failed to notify and update a resident's responsible party (RP) regarding a significant delay in the resident's transportation for discharge. The resident, who was cognitively intact and dependent on staff for several activities of daily living, was scheduled for discharge home with transportation initially set for the morning but delayed multiple times throughout the day. Although the resident was informed of the new transportation time, the RP was not notified of the changes, resulting in the RP waiting and becoming worried when the resident did not arrive home as expected. The RP made several attempts to contact the facility, leaving voicemails that were not reviewed or responded to by staff. Interviews with facility staff revealed that no one was assigned to check the facility's voicemail system, and several staff members, including the receptionist, RN supervisor, and DON, stated they did not know how to retrieve voicemail messages. Facility policy required prompt notification of changes in a resident's condition or status to the resident and their representative, but this was not followed. The lack of communication led to the resident feeling anxious about going home and the RP experiencing distress due to the lack of information.
Failure to Update Care Plan After Medication Discontinuation
Penalty
Summary
The facility failed to revise and update the care plan for a resident after the discontinuation of Alprazolam, a medication used to treat anxiety disorder. The resident, who had diagnoses including anxiety disorder, mood disorder, and generalized muscle weakness, was admitted and later re-admitted to the facility. The resident's Minimum Data Set assessment indicated moderately impaired cognitive skills and significant dependence on staff for daily activities. A physician's order was given to administer Alprazolam as needed for anxiety, and the care plan was developed to reflect this intervention, including monitoring for side effects and effectiveness. However, when the physician discontinued the Alprazolam order, the care plan was not updated to reflect this change. Both the assistant director of nursing and the acting director of nursing confirmed during interviews that the care plan should have been discontinued when the medication was stopped. The facility's policy required ongoing assessment and revision of care plans as resident conditions changed, but this was not followed, resulting in the care plan inaccurately reflecting the actual care provided to the resident.
Failure to Sanitize and Properly Store Used Oxygen Concentrators
Penalty
Summary
The facility failed to adhere to its infection control policy regarding the cleaning and disinfection of reusable medical devices, specifically oxygen concentrators. During an observation in the supply room, five oxygen concentrators that had been used by residents were found not sanitized and not covered with plastic, as required by facility policy. These devices were stored in the same area as clean supplies, and staff interviews confirmed that the concentrators were awaiting pickup by a hospice company and had not been disinfected or separated from clean items. Staff, including an LVN, the infection preventionist, and the assistant director of nursing, acknowledged that the used concentrators were not sanitized and that there was no separate storage area for them. The facility's policy, reviewed on 4/30/25, requires that reusable items such as oxygen concentrators be cleaned and disinfected between residents, then covered and stored in a designated location. The failure to follow these procedures resulted in unsanitized equipment being stored with clean supplies, contrary to established infection control protocols.
Medications Left Unattended at Bedside
Penalty
Summary
A medication cup containing pills was observed left unattended on the bedside table of a resident who had been admitted with diagnoses including hypertension, seizure disorder, and generalized muscle weakness. The resident's care plan required medications to be administered as ordered and for staff to monitor for effectiveness and side effects. The Minimum Data Set indicated the resident was cognitively intact but required moderate assistance with several activities of daily living, including set up with eating. On the morning of the incident, the resident confirmed that a licensed vocational nurse (LVN) had given her the medication but she had not yet taken it. Interviews with facility staff, including the restorative nursing assistant and the LVN involved, confirmed that the medication cup was left at the bedside and that the LVN did not remain with the resident to ensure the medication was taken. The director of nursing also confirmed that facility policy requires staff to remain with residents until all medications have been taken. Review of the facility's policy on administering oral medications reiterated this requirement.
Failure to Implement Care Plan for Intake and Output Monitoring
Penalty
Summary
The facility failed to implement the care plan for a resident with chronic kidney disease, heart failure, and dementia. The care plan, initiated due to impaired renal function, required monitoring of the resident's intake and output to prevent renal complications. Despite this intervention being documented in the care plan, there was no evidence that intake and output were actually monitored or recorded for the resident. Both a licensed vocational nurse and a registered nurse supervisor confirmed the absence of documentation regarding intake and output monitoring during interviews and record reviews. The resident in question was totally dependent on activities of daily living, had severe cognitive impairment, was incontinent of urine and bowel, and received nutrition via a gastrostomy tube. The facility's policy required comprehensive, person-centered care plans with measurable objectives and timetables to be developed and implemented for each resident. However, the lack of documentation and monitoring of intake and output as specified in the care plan constituted a failure to meet the resident's hydration and nutritional needs as outlined in the plan.
Inaccurate Transcription and Documentation of GT Feeding Orders
Penalty
Summary
The facility failed to accurately transcribe and document a physician's order for gastrostomy tube (GT) feeding and water administration for one resident. The physician's order specified that the resident should receive Nutren tube feeding at 50 ml/hr and water at 40 ml/hr for 16 hours, but the order and the Medication Administration Record (MAR) both indicated a start time of 6 p.m. and a stop time of 6 a.m., which only covers 12 hours instead of the prescribed 16 hours. This discrepancy was present in the resident's medical record and persisted from the date of the order through the end of the month, with the MAR signed as if the order had been correctly carried out. The resident involved had significant medical conditions, including heart failure, chronic kidney disease, and dementia, and was totally dependent on activities of daily living with severe cognitive impairment. Both the registered dietitian and a licensed vocational nurse confirmed during interviews and record reviews that the GT feeding and water flush should have been administered over 16 hours, from 6 p.m. to 10 a.m., and agreed that the documentation was incorrect. The facility's policy required that medical records be complete and accurate, but this was not followed in this instance.
Call Light System Malfunction Due to Improper Resetting of Bathroom Switch
Penalty
Summary
The facility failed to ensure that the resident call light system remained functional for all residents on the second floor on 5/3/2025 and 5/4/2025. The deficiency occurred when a bathroom call light switch in one of the resident rooms was not properly reset by staff after being triggered. Instead of returning the switch fully to the 'up' position, it was left halfway, which caused the entire call light system on the second floor to malfunction and enter safety mode. As a result, all call lights for the second floor were activated on the nurse’s station panel, and residents were unable to use the call system to request assistance during this period. During this time, 71 residents on the second floor were affected, including a resident with a history of autonomic nervous system disorder, falls, contractures, muscle weakness, mild cognitive impairment, and a history of TIA. This resident was dependent on staff for all activities of daily living and reported that the call light system was not working throughout the night, requiring the use of a hand bell to summon staff. The resident emphasized the importance of the call light system for requesting help with personal care and in situations of feeling unwell. Interviews with facility staff, including the Maintenance Director and DON, confirmed that the malfunction was due to improper resetting of the bathroom call light switch. The facility’s policy required that each resident have a functional means to call staff from their bed and bathroom at all times, but this was not maintained due to the failure to properly reset the switch, resulting in a system-wide outage for the second floor.
Failure to Implement Fall Prevention Care Plan
Penalty
Summary
The facility failed to implement the comprehensive care plan for a resident who was at high risk for falls. The resident, admitted with diagnoses including dementia and a history of falling, had a care plan intervention that required a floor mat to be placed on the right side of their bed to minimize the risk of injury from falls. However, during an observation, it was noted that the floor mat was not present as required by the care plan. Interviews with facility staff, including a registered nurse supervisor and a licensed vocational nurse, confirmed the absence of the floor mat and acknowledged its necessity to prevent injury in case of a fall. The facility's policy and procedures emphasize the development and implementation of a comprehensive, person-centered care plan to meet the resident's needs, which was not adhered to in this instance.
Failure to Maintain BLS Certification for CNA
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA) maintained current Basic Life Support (BLS) certification, which is a set of emergency procedures designed to sustain life in victims experiencing cardiac arrest. During an interview and record review, it was found that CNA 1's BLS certificate had expired. The Director of Staff Development (DSD) stated that the facility required BLS certification only for licensed staff, which needed to be renewed every two years, and that CNAs were not required to have BLS certification. However, the facility's policy and procedures indicated that personnel should have completed training on the initiation of cardiopulmonary resuscitation (CPR) and BLS, including defibrillation, for victims of sudden cardiac arrest, and that key clinical staff members should obtain and/or maintain certification in BLS. This deficiency had the potential for CNA 1 not to recognize residents who may need immediate emergency intervention.
Failure to Monitor and Respond to Sensor Pad Alarm
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for a resident who was at high risk for falls. The resident, diagnosed with dementia and a history of falling, was admitted with a care plan that included the use of a sensor pad alarm to alert staff when the resident attempted to get out of bed unassisted. However, the facility did not ensure the sensor pad alarm was consistently monitored and functioning, nor did they ensure staff responded immediately when the alarm was triggered. The resident experienced unwitnessed falls on three separate occasions. On each occasion, there was no documentation indicating whether the sensor pad alarm was in place or if it had been triggered. Interviews with staff revealed that the resident sometimes removed the sensor pad alarm, and there was no evidence that staff consistently checked the placement and functionality of the alarm. The facility's policy indicated that alarms should not be the sole intervention to prevent falls, yet there was a lack of documentation and response to the alarm system. The facility's policies on safety and supervision, as well as fall risk management, emphasized the importance of implementing and documenting interventions to reduce accident risks. Despite these policies, the facility did not effectively communicate or implement the necessary interventions to prevent the resident's falls. The lack of immediate response to the alarm and failure to ensure the alarm's functionality contributed to the resident's repeated falls, highlighting a deficiency in the facility's supervision and accident prevention measures.
Failure to Conduct Weekly Blood Tests for Resident with Chronic Kidney Disease
Penalty
Summary
The facility failed to provide necessary laboratory services for a resident diagnosed with osteomyelitis of the vertebra and chronic kidney disease stage five. The physician had ordered weekly blood tests, including a complete blood count (CBC) and a comprehensive metabolic panel (CMP), to be conducted every Friday. However, the facility did not perform the required blood tests on the specified date, 7/5/24, following the initial test on 6/28/24. This oversight was identified during a review of the resident's records and confirmed by the registered nurse supervisor, who could not find documentation explaining why the test was not conducted. The director of nursing also confirmed the absence of documentation regarding the missed blood test and noted that the resident had a history of refusals, although there was no record of refusal for this specific test. The facility's policy and procedures require staff to process test requisitions and ensure tests are conducted as ordered by the physician. The failure to perform the blood test as ordered could potentially hinder the monitoring of the resident's kidney function, which is critical given the resident's condition.
Failure to Prevent Falls for Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure adequate supervision and care for a resident with a history of falls, cognitive impairment, and poor safety awareness. The resident, who required assistance with transferring and toileting, experienced multiple falls over a period of two months. Despite a physician's order for visual checks every 30 minutes after an initial unwitnessed fall, the facility did not consistently implement this intervention. Additionally, the resident's care plan was not updated after a second fall, and no new interventions were developed to prevent further incidents. The resident was readmitted to the facility with multiple diagnoses, including dementia, end-stage renal disease, and hemiplegia following a stroke. The resident's condition required partial to moderate assistance with daily activities and supervision for safety. After the first fall, the facility's interdisciplinary team recommended interventions such as visual checks and physical therapy screening, but these were not effectively implemented or updated after subsequent falls. On the third fall, the resident was found in the bathroom with injuries, including a hematoma and a shoulder fracture, requiring hospitalization. Interviews with staff revealed lapses in supervision, as the assigned CNA was on break without proper coverage, leading to a failure in conducting the required visual checks. The facility's policies on fall risk assessment and care planning were not adequately followed, contributing to the resident's repeated falls and injuries.
Failure to Obtain Proper Discharge Order
Penalty
Summary
The facility failed to obtain a discharge order from the primary physician for a resident before discharging them. The resident was admitted with diagnoses including aftercare following surgery, unsteadiness on feet, and generalized muscle weakness. Despite being cognitively intact, the resident required assistance with various activities of daily living. On 1/22/25, a telephone order was entered by a licensed vocational nurse indicating the primary physician gave an order to discharge the resident on 1/23/25. However, the primary physician's progress note dated 1/24/25 indicated that neither the primary physician nor their team gave such an order. The case manager and registered nurse supervisor were unable to confirm who gave the discharge order, and the director of nursing stated that the physiatrist wrote an order for discharge on 1/23/25. The facility's policy requires nursing services to obtain discharge orders and ensure accurate documentation. The failure to obtain a proper discharge order and the resulting inaccurate documentation led to a deficiency in the facility's adherence to professional standards of practice.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent for psychotropic medications for one resident, identified as Resident 1, before administering Trazadone, Wellbutrin XL, Duloxetine, and Brexpiprazole. The resident was admitted with diagnoses including morbid obesity, cerebral infarction with left-sided weakness, and major depressive disorder. Despite being cognitively intact, the resident did not sign the informed consent forms, nor did a responsible party. The forms were only signed by the physician, and the facility's policy required either the resident or a responsible party to sign, with two nurses witnessing the consent if the resident was unable to sign. The Medication Administration Record (MAR) showed that the resident received these medications over several weeks without the required consent. Interviews with the registered nurse supervisor and the director of nursing confirmed the oversight, acknowledging that the consent forms lacked the necessary signatures. The facility's policy emphasized the importance of obtaining informed consent for psychotropic drugs, involving the resident in care decisions, and verifying consent with the attending physician. However, these procedures were not followed, leading to the deficiency.
Failure to Provide Adequate Hygiene Care for Incontinent Resident
Penalty
Summary
The facility failed to provide adequate toileting and personal hygiene care for a resident who was frequently incontinent of bowel and bladder. The resident, who was cognitively intact but dependent on assistance for activities of daily living, consistently refused personal and toileting hygiene after episodes of incontinence. Despite the resident's refusal, the facility did not involve the resident's responsible party in discussions about the care plan or notify the physician about the resident's refusal of hygiene care. The resident's care plans indicated potential limitations in activities of daily living due to depressive symptoms and nonadherence to hygiene needs. However, the facility did not follow through with the interventions outlined in the care plans, such as reporting non-compliant behavior to the physician and responsible party. Interviews with nursing staff revealed that the resident was often smelly and refused hygiene care, even after being administered pain medication to alleviate discomfort during care. The facility's policy and procedures required that residents unable to perform activities of daily living independently receive necessary services to maintain hygiene. However, the facility did not adhere to these policies, as evidenced by the lack of follow-up interdisciplinary team meetings to address the resident's refusal of care and the absence of physician notification. This deficiency resulted in the resident experiencing poor hygiene and an unpleasant smell, with the potential for developing infections and pressure ulcers.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light devices were within reach for five sampled residents, resulting in their inability to call for assistance when needed. This deficiency was observed during a survey where the call lights for Residents 60, 73, 201, 213, and 225 were found to be out of reach. Each of these residents had specific care plans that included interventions to keep the call light within reach, yet these interventions were not followed. Resident 201, who was admitted with diagnoses including dysphagia and severe cognitive impairment, was observed in a wheelchair with the call light out of reach. Similarly, Resident 213, with hemiplegia and cognitive impairment, and Resident 225, who was cognitively intact but dependent on assistance for personal care, also had their call lights out of reach. These observations were confirmed by LVN 2, who acknowledged the importance of having the call lights accessible to residents. Further observations revealed that Resident 60, with dementia and other health issues, and Resident 73, with hemiplegia and cognitive communication deficits, also had their call lights placed out of reach. Interviews with staff, including CNAs and nurses, confirmed the oversight and highlighted the potential risks of residents being unable to call for help. The facility's policy required call lights to be within reach, but this was not adhered to, leading to the deficiency.
Failure to Notify Physician of Change in Resident's Condition
Penalty
Summary
The facility failed to assess and directly notify the primary physician of a significant change in condition for a resident with limited range of motion and mobility. This deficiency involved a resident who was unable to walk with the Restorative Nursing Aide (RNA) using hand-held assistance or a front-wheeled walker. The failure to communicate this change in condition to the physician resulted in the discontinuation of RNA services without direct discussion with the physician, potentially contributing to the development of a sacro-coccyx wound. The resident, admitted with diagnoses including Alzheimer's disease, dementia, and a history of falling, was initially evaluated by physical therapy to require minimal assistance for bed mobility, transfers, and walking. Despite being admitted to hospice care, the resident's RNA services for ambulation were discontinued based on orders from the hospice company, without direct communication with the resident's physician. The facility's documentation did not reflect any change of condition documentation for the resident's inability to participate in RNA, and the hospice physician did not recall any reports regarding the RNA services. Interviews with facility staff revealed that the RNA had reported the resident's inability to participate in RNA to the Registered Nurse Supervisor, but the change of condition was not documented or communicated to the physician. The Director of Nursing confirmed that the nurse should have assessed the resident, completed SBAR documentation, and directly communicated with the physician. The facility's policy required prompt notification of the physician and detailed observations by the nurse, which were not followed in this case.
Inaccurate Assessment Leads to Unnecessary Psychotropic Medication Administration
Penalty
Summary
The facility failed to ensure an accurate assessment for a resident, leading to the administration of psychotropic medications without proper documentation of diagnoses. The resident, who was admitted with a history of dementia, alcohol dependency, and opioid dependency, was prescribed several psychotropic medications, including Depakote, Quetiapine, and Venlafaxine, without corresponding diagnoses documented in the medical record. The Minimum Data Set (MDS) indicated depression as a diagnosis, but no other psychiatric or mood disorder diagnoses were listed to justify the use of these medications. Interviews with facility staff, including the MDS Nurse, Social Services Director, and Director of Nursing, revealed that the resident had not seen a psychiatrist since readmission, and the necessary psych consult was not conducted. The facility's policy required that psychotropic medication orders include a diagnosis, which was not adhered to in this case. This oversight resulted in an increased risk of the resident receiving unnecessary medications, as confirmed by the staff during the interviews.
Failure to Implement Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered care plans for three residents, which resulted in a deficiency. Resident 197, who was admitted with conditions including hemiplegia, hemiparesis, dementia, and muscle weakness, had a care plan that did not incorporate their preferred activities such as reading magazines and books. Despite the resident's mild cognitive impairment and moderate dependency, the care plan only mentioned social and recreational involvement without specific adaptations for their interests. During an observation, the resident was found lying in bed with the TV on, and a CNA noted the resident liked to sit up and engage in activities, indicating a disconnect between the care plan and the resident's preferences. Resident 530, admitted with depression and muscle wasting, had no cognitive impairment but was moderately dependent on assistance. The resident expressed a preference for group activities but was unable to participate due to mobility issues, leading them to watch TV or listen to music. However, the care plan did not reflect the resident's request to listen to music, which was communicated to the staff but not updated in the care plan. This oversight was confirmed during an interview with the Activities Director, who acknowledged the importance of updating care plans to reflect current interests. Resident 44, with diagnoses of schizophrenia and major depressive disorder, had severe cognitive impairment and was dependent on assistance. The resident's preferences included participating in religious services and playing bingo, but the care plan did not exist, leaving the resident isolated and without structured activities. The Activities Director and the Director of Nursing both confirmed the absence of an activity care plan for Resident 44, emphasizing the necessity of such plans to prevent resident isolation and ensure staff are aware of individual preferences.
Inconsistent Activity Provision for Residents
Penalty
Summary
The facility failed to provide consistent activities for three residents, which had the potential to negatively impact their physical, cognitive, and emotional health. Resident 197, who was admitted with diagnoses including hemiplegia, hemiparesis, dementia, and muscle weakness, was observed in bed with the TV on and no activity materials or staff present. The resident's care plan indicated a need for social and recreational involvement, but observations showed a lack of engagement in activities. Resident 530, admitted with depression and muscle wasting, was also observed in bed with the TV on and no activity materials or staff present. The resident expressed that activity staff visits were inconsistent, despite the care plan emphasizing the importance of group activities. The Activities Director confirmed that the resident was not seen by an activity aide on several days in December, which could affect the resident's psychosocial well-being. Resident 44, with diagnoses of schizophrenia and major depressive disorder, expressed a preference for activities such as bingo and religious services. However, the resident's activity records showed limited engagement in these preferred activities. The Activities Director and Director of Nursing acknowledged that the resident's preferences were not consistently followed, which could impact the resident's psychosocial well-being. The facility's policy indicated that activity programs should be staffed to meet residents' needs, but this was not observed in practice.
Failure to Provide Prescribed ROM and Mobility Services
Penalty
Summary
The facility failed to provide appropriate care to maintain or improve the range of motion (ROM) and mobility for five residents, as per physician orders. Resident 37 did not receive active range of motion (AROM) exercises for both arms and sit-to-stand transfers using a front-wheeled walker (FWW) as prescribed. The documentation for these tasks was incomplete, and the resident reported not receiving these exercises for over a week. The Director of Staff Development (DSD) acknowledged the lack of documentation and stated that the resident could experience a decline in ROM and mobility if the restorative nursing aide (RNA) services were not provided. Resident 127 did not receive passive range of motion (PROM) exercises for both legs and arms, nor the application of prescribed splints and a pressure relief ankle foot orthosis (PRAFO) as ordered. The documentation was incomplete for several dates, and the resident reported not receiving the exercises or splints on certain days. The DSD confirmed the lack of RNA services in accordance with physician orders, which could lead to a decline in ROM and mobility. Similarly, Resident 44 did not receive PROM exercises for both arms and legs as ordered, with documentation missing for several dates. The resident reported receiving exercises only every couple of weeks, and the DSD confirmed the deficiency in RNA services. Resident 36 did not have the left-hand splint applied as ordered, and the documentation did not include this task for several months. The DSD acknowledged the oversight and the potential for a decline in ROM and mobility. Resident 128 was not properly assessed for the application of knee splints, and the physical therapist noted that the splints should not have been applied due to the resident's refusal and potential for pain and skin breakdown. The facility's policy indicated that residents with limited ROM and mobility should receive treatment to prevent further decline, but this was not adhered to for the residents involved.
Failure to Provide Timely Therapy Services
Penalty
Summary
The facility failed to provide necessary occupational therapy (OT) and physical therapy (PT) services to a resident, identified as Resident 96, who had range of motion (ROM) and mobility concerns. Despite having physician-signed care plans for OT and PT, the resident did not receive the prescribed therapy interventions from October 9, 2024, to October 29, 2024. This lapse potentially contributed to further ROM limitations in the resident's knees. Resident 96 was admitted to the facility with a history of falling and adult failure to thrive, and was readmitted after a hospitalization. The PT evaluation on October 9, 2024, indicated the resident had impaired mobility and was referred for PT due to these concerns. The PT plan included therapeutic exercises and gait training, to be conducted three times per week for four weeks. Similarly, the OT evaluation on October 10, 2024, noted decreased strength and mobility, with a plan for therapeutic activities five times per week for 60 days. However, there was a significant gap in therapy sessions, with the resident receiving PT and OT only on October 9 and 10, and then not again until October 29, 2024. The delay in therapy services was attributed to the facility waiting for insurance authorization, despite having physician orders in place. The Director of Rehabilitation and the Director of Nursing acknowledged that the facility's policies did not require waiting for insurance authorization before providing treatment. Observations and interviews revealed that the resident's condition had deteriorated, with bent hips and knees and complaints of pain during repositioning. The facility's failure to provide timely therapy services as per the care plan resulted in a deficiency in the quality of care provided to Resident 96.
Incomplete Therapy Discharge Summaries for Residents
Penalty
Summary
The facility failed to ensure that the clinical records for four residents with limited range of motion and mobility were complete, specifically lacking discharge summaries from physical and occupational therapy. Resident 96's records were missing PT and OT discharge summaries for two separate treatment periods, which were supposed to be completed on the last day of treatment. The absence of these summaries was confirmed during interviews with the occupational and physical therapists, as well as the Director of Rehabilitation, who emphasized the importance of these documents in ensuring proper follow-up care. Resident 130's clinical records also lacked PT and OT discharge summaries following their last treatment sessions. The evaluations indicated that Resident 130 required assistance with mobility and daily activities, and the treatment plans included therapeutic exercises and neuromuscular reeducation. The Director of Rehabilitation reiterated the necessity of completing discharge summaries to ensure that the recommended care was continued after therapy ended. Similarly, Resident 44 and Resident 37's records were incomplete without PT discharge summaries. Resident 44 had conditions such as schizophrenia and functional quadriplegia, while Resident 37 had B-cell lymphoma and diabetes, both requiring extensive therapy plans. The Director of Nursing confirmed that clinical records should accurately reflect the care provided, and the facility's policy stated that discharge summaries are crucial for justifying the treatment period and outlining follow-up care.
Failure to Utilize Translation Services for Non-English Speaking Resident
Penalty
Summary
The facility failed to respect the resident's right to dignity and respect by not utilizing its translation services to communicate with a non-English speaking resident. Resident 82, who was admitted with diagnoses including congestive heart failure, toxic encephalopathy, and depression, had severe cognitive impairment and required moderate assistance with activities of daily living. The resident's preferred language was Mandarin, as indicated in the Social Services Assessment and Language Barrier care plan, which included interventions such as obtaining an interpreter and providing activities in the resident's native language. Despite these documented needs, the facility did not provide adequate translation services. Licensed Vocational Nurse 5, who was responsible for Resident 82, used a personal phone to translate instead of the facility's translation services. The Social Services Director confirmed that residents with language barriers should be provided with tools like translators or communication boards, and the Director of Nursing stated that staff should use the facility's translation service if no staff spoke the resident's language. The facility's policy required providing an interpreter for non-English speaking residents, but this was not followed, potentially affecting the resident's psychosocial wellbeing.
Failure to Update Resident Care Plan Quarterly
Penalty
Summary
The facility failed to update the care plan for Resident 173, who was admitted with diagnoses including diabetes, dysphagia, gastrostomy, and spinal stenosis. The care plan titled 'Alteration in Comfort' was last revised on 5/18/2024, and it was not updated quarterly as required. This oversight was identified during a review of the resident's records and interviews with facility staff, who acknowledged that the care plan should have been reviewed and revised to assess its effectiveness and the resident's progress. Interviews with facility staff, including a Restorative Nursing Aide, a Licensed Vocational Nurse, a Registered Nursing Supervisor, and the Director of Nursing, revealed that the care plan was not updated despite the facility's policy requiring quarterly reviews and updates for any change in the resident's condition. The staff admitted that without regular updates, it was challenging to determine if Resident 173 was making progress toward the care plan goals. The facility's policy and procedure documents also indicated that care plans should be revised according to the Resident Assessment Instrument schedule and as dictated by changes in the resident's condition.
Failure to Provide Ordered Padded Side Rails for Seizure-Prone Resident
Penalty
Summary
The facility failed to ensure that a resident identified as at risk for seizures was free from accidents by not providing the physician-ordered bilateral padded side rails on the resident's bed. The resident, who was admitted with diagnoses including epilepsy, hemiplegia, hemiparesis, and aphasia, was severely impaired in cognitive skills and dependent on staff for activities of daily living. The physician's order dated 9/20/2024, and the care plan revised on 10/26/2024, both indicated the need for bilateral padded side rails to prevent injury during seizures. During an observation and interview, it was confirmed that the resident only had one padded side rail instead of the required two. The Licensed Vocational Nurse and the Director of Nursing acknowledged the importance of having both side rails padded to prevent injury during a seizure. However, the facility did not have a specific policy for seizure precautions that included padded side rails, despite the care plan indicating their necessity. This oversight placed the resident at increased risk for falls and injuries during a seizure.
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What surveyors actually found near you
We read the 6,626 citations issued within 25 miles in the last 12 months — including the 42 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Los Angeles
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Huntington Healthcare Center | 1.1 mi | ★★★★★ | 22 | 0 |
| White Memorial Medical Ctr Dp | 1.8 mi | ★★★★★ | 0 | 0 |
| Montecito Heights Healthcare & Wellness Centre, Lp | 2 mi | ★★★★★ | 0 | 0 |
| Infinity Care Of East Los Angeles | 2 mi | ★★★★★ | 11 | 0 |
| Hollenbeck Palms | 2.5 mi | ★★★★★ | 21 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release June 2026) and official state health department websites.