Above average — CMS composite of the measures below.
The next survey window likely opens around August 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at La Palma Nursing Center during CMS and state inspections, most recent first.
A resident who lacked decision-making capacity had a POLST and physician order indicating Do Not Attempt Resuscitation (DNR). Facility policy required honoring such directives and using them to guide Basic Life Support and CPR decisions. When the resident became unresponsive and pulseless, a CNA initiated CPR and called for help. An RN and an LVN responded, confirmed the absence of a pulse, and continued CPR without first verifying the resident’s code status in the chart, despite later acknowledging that a DNR order was in place and that CPR should not have been initiated.
Unsafe Water Temperatures in Resident Care Areas: Facility water in resident rooms and shower areas was repeatedly measured above the safe range, with readings as high as 146 degrees Fahrenheit. The Maintenance Supervisor knew the acceptable range but could not explain what to do when temperatures were out of range and did not follow up. Direct care staff reported using hot and cold water or testing by touch, but the DSD verified that staff had not received in-service education on safe water temperature before the survey.
Two residents who were assessed as not safe to self-administer meds were found with meds at the bedside and using them on their own. One resident had Refresh eyedrops and Lidocaine patches, and the other had Advil. RN and DON verification showed there were no physician orders or care plan problems addressing self-administration, and both residents’ assessments indicated they preferred nurse-administered meds and were not able to safely self-administer.
A facility failed to properly monitor and document psychotropic medication use for three residents. One resident on sertraline and Depakote had no documented orthostatic BP monitoring despite a physician order, another resident’s Depakote order did not specify the exact behaviors being targeted, and a third resident on mirtazapine had meal intake documentation that did not clearly identify intake below 50% and lacked a completed monthly behavior summary. The DON and nursing staff acknowledged the missing or incomplete documentation during interview.
Failure to investigate an injury of unknown origin for a resident with severe cognitive impairment. The resident had purplish discoloration with a yellow border on the left mid breast and left upper backside, and an LPN notified the RN while the resident denied being hit or injured. The DON stated no incident report was received, so the source was not investigated, despite the facility policy requiring immediate reporting and thorough investigation of unknown injuries.
Conflicting code status documentation left a resident’s current wishes unclear. The chart contained a DNR POLST, a physician DNR order, and a care plan reflecting comfort-focused treatment, but it also contained a later POLST indicating CPR/full treatment. Staff gave inconsistent responses when asked whether the resident was DNR or full code, and different departments relied on different documents, including the POLST, physician orders, and care conference summary.
A resident with impaired hearing and no decision-making capacity had orders for bilateral hearing aids to be applied in the morning and removed at night, but staff repeatedly left MAR entries blank or documented the devices inconsistently. Surveyors observed the resident without the hearing aids, and staff found only the right hearing aid in the medication cart while the left hearing aid had been missing for months per the RP. The resident’s inventory did not list hearing aids, and there was no documented report of the missing device.
A resident with a GT feeding order was observed receiving enteral nutrition while in bed with the head of the bed only slightly elevated at about 20 to 21 degrees, despite the care plan calling for elevation above 30 degrees during feeding and for one hour afterward. The resident was coughing during the infusion, and an RN confirmed the angle was not appropriate and that the resident could not reach the bed controls.
A facility failed to ensure less restrictive interventions were tried before using bed grab bars for three residents. Two residents with severe cognitive impairment and one cognitively intact resident had right or bilateral grab bars elevated as enablers for bed mobility, turning, repositioning, and transfers, but the care plans and entrapment risk evaluations did not show prior use of less restrictive alternatives. Staff interviews confirmed that no less restrictive measures had been attempted before the grab bars were used.
Controlled medication handling failed for multiple residents when insulin orders for a resident were not clarified, a tramadol dose was not properly signed out or documented on the MAR, multiple hydrocodone/acetaminophen doses were removed from supply without MAR documentation, and an ABHR cream controlled medication was found stored outside the incineration container in the med room. The DON and pharmacist consultant confirmed the documentation and storage problems.
A pharmacist consultant reviewed a resident with Type 2 DM who was receiving Novolin R sliding scale insulin and Novolin 70/30 BID, but did not make recommendations after the resident’s A1c increased from 8.2% to 8.8%. Monthly DRR notes showed the chart was reviewed, yet no follow-up with the physician was documented, and the pharmacist later confirmed recommendations should have been made.
Failure to Monitor Residents on Clopidogrel for Bleeding: Two residents receiving clopidogrel for CVA prophylaxis were not properly monitored for bleeding. One resident's record lacked documented evidence of bleeding surveillance despite staff acknowledging the resident was high risk, and another resident's order summary did not include a physician order to monitor for bleeding. RN staff stated residents on anticoagulants should be checked for bleeding signs such as blood in stool or urine, nosebleeds, gum bleeding, and bruising.
Medication administration errors exceeded the allowed rate, with two LPNs involved in observed errors. One LPN failed to check a resident’s HR before giving metoprolol ordered with hold parameters and left residue of GT-administered supplements in medicine cups. Another LPN left crushed medication residue in pill pouches for one resident and missed a scheduled calcium tablet for another resident because the eMAR was not fully reviewed.
Kitchen sanitation and food handling failures were observed when clean scoops were found in dusty, crumb-covered containers, freezer foods were stored with only delivery dates or no use-by dates, and dietary staff wore hair restraints that covered only part of their scalps. A cognitively intact resident also kept a PB&J sandwich and kimchi from the kitchen on the bedside nightstand, which staff confirmed was not allowed.
A resident had unlabeled outside food stored at the bedside, including containers of fruit, sandwiches, and chips. Staff stated the facility had no refrigerator or microwave for resident food brought from outside and that such food had to be consumed immediately or discarded, but RN and CNA staff reported they had not received training on handling outside food. The DSD confirmed no in-service was provided, and there was no documented evidence that the resident or the responsible party received education on safe handling of food brought in from home.
Infection control practices were not consistently followed in the facility. The IP's August surveillance records and monthly mapping did not match, and the mapping omitted infections that did not meet McGeer criteria and COVID-19 cases. In the laundry area, residents' blankets were stored near dusty wedge pillows and splints. During resident care, staff failed to use gowns for EBP precautions, failed to perform hand hygiene and glove changes during blood sugar testing and GT care, and a resident on COVID-19 precautions had the room door left open.
Failure to Document Routine Bed Inspections: The facility did not document routine maintenance inspections of resident beds, bed frames, mattresses, and related equipment as required by its bed safety policy. Three residents had grab bar orders for bed mobility and transfers; two had severe cognitive impairment and one was cognitively intact but needed assistance with bed-related transfers. Maintenance staff said monthly bed inspections were their responsibility, but the binder only contained a siderail/bedrail assessment form and did not show routine inspection documentation for the resident beds.
Advance directive documentation was missing or incomplete for two residents. One resident’s record did not show that staff followed up about whether an advance directive existed, and the resident’s acknowledgment form lacked a signature. Another resident had an advance directive per SSD interview, but the copy was not in the medical record, and the POLST had an incomplete Section D.
A resident was transferred to an acute care hospital for low O2 saturation and HR concerns, but the record did not show that the resident or representative received the required written transfer/discharge notice or bed-hold information. The transfer/discharge form and bed-hold consent were unsigned, and staff stated they could not find documentation that the notices were provided in writing; the SSD said she faxed the notice to the ombudsman but did not mail or email it to the resident or representative.
A resident’s Significant Change in Status MDS was not completed timely after hospice services were ordered. The MDS Coordinator verified the hospice order triggered the assessment, and the MDS Consultant confirmed the MDS had to be completed by the 14th calendar day, but it was completed 20 calendar days after hospice admission.
Inaccurate PASRR screening was completed for a resident with anxiety disorder, major depressive disorder, schizophrenia, and dementia. The PASRR incorrectly stated the resident did not have serious mental illness despite psychotropic meds being listed, and the MDS Coordinator said she did not review the PASRR for accuracy at admission. A required resident review Level 1 screening was also completed late.
Incomplete Care Plans for Medication-Related Monitoring: The facility failed to include key monitoring in care plans for three residents receiving medications associated with bleeding or orthostatic hypotension. One resident on clopidogrel lacked bleeding surveillance in the care plan, another resident on psychotropic medications lacked ordered orthostatic BP monitoring, and a third resident on clopidogrel had a care plan focused on skin changes but not bleeding from the gums, stool, or urine.
A resident had a seizure-related fall, and the post-fall assessment documented a recommendation not to leave the resident unattended. Although family-provided caregivers were present and monitored the resident for safety while he was up in his wheelchair, the care plan was not revised to include the caregiver support or the need for continuous monitoring when the resident was in the wheelchair.
A resident with a Foley catheter had inconsistent urine output monitoring despite an order to track I&O every shift. The chart repeatedly listed output as N/A instead of the actual amount, and the record lacked 24-hour totals and weekly evaluation of average I&O. The DON verified the gaps in documentation and confirmed the LPN/RN staff did not complete the required monitoring.
Improper Storage of Opened Vaginal Creams: Surveyors found two opened and used vaginal creams stored in the medication room with floor stock medications instead of being kept in the med cart. LVN 6 verified the creams were labeled as opened and the DON stated opened medicated creams should remain in the med cart to avoid contamination with new and unopened medications.
Improperly Covered Garbage Dumpsters: The facility failed to keep garbage dumpsters tightly covered, with three of four dumpsters observed partially open on both sides by about one and a half to two inches. The Dietary Director verified the condition and stated he had not followed up to obtain tight-fitting lids. The report also noted small flying insects in Nursing Station A and in the doorway of a resident's room, and the DON acknowledged the findings.
Incomplete MARs, Missing POLST Update, and Undocumented Oxygen Intervention. The facility had incomplete MAR documentation for two residents, with multiple scheduled meds and monitoring entries left blank on the MARs. It also lacked an updated POLST for a resident who later completed an Advance Directive, and another resident’s record did not document the full emergency response when low O2 sat and bradycardia led to hospital transfer, including the increase in O2 delivery that staff later confirmed occurred.
A resident in an LTC facility sustained multiple rib fractures after a fall, but the facility failed to investigate or document the incident properly. The facility did not request a physician's fracture progress report or conduct a root cause analysis as per policy. Additionally, after another fall, the facility did not perform required neurological evaluations or document the physician's recommendations, despite the resident being on blood thinners.
The facility failed to develop comprehensive care plans for the use of grab bars for several residents, as identified through observations and medical record reviews. This deficiency affected residents who relied on grab bars for mobility and repositioning, with care plans lacking necessary interventions and assessments. The absence of individualized care plans was acknowledged by the DON and staff.
The facility failed to ensure the safety of residents using bed rails, as assessments for 13 residents lacked documentation of the effectiveness of less restrictive measures before using grab bars. Observations and staff interviews confirmed incomplete assessments, putting residents at risk of entrapment and serious injuries.
The facility failed to maintain sanitary conditions in the kitchen, with issues such as unsanitary cutting boards, wet and dirty utensils, and improperly maintained equipment like blenders and ice machines. These deficiencies were observed during a survey, with the Dietary Director and Maintenance Supervisor acknowledging the potential for cross-contamination and foodborne illnesses.
The facility failed to ensure complete entrapment assessments for residents using grab bars, with missing documentation for several zones. Observations showed residents using grab bars for mobility and transfers, but assessments often lacked documentation for Zones 5 to 7. The Maintenance Supervisor did not document or communicate results to nurses, leading to incomplete assessments, acknowledged by the DON and staff.
A resident with limited English proficiency, who spoke Gujarati, was not provided with effective communication tools in the facility. Staff communicated in English, which the resident did not understand, and relied on guessing or family translation. The facility's translation device was not used, and there was no communication board at the bedside, highlighting a deficiency in promoting dignity and respect.
A facility failed to obtain a physician's signature on the informed consent for a resident's psychotropic medication, trazadone, as required by their policy. The resident, who had the capacity to understand and make decisions, was prescribed trazadone for insomnia. Interviews with an LVN and the DON confirmed the absence of the necessary physician's signature, which is required to ensure the resident is informed about their care and treatment.
A resident was found with medications at her bedside without a proper assessment or physician's order for self-administration, contrary to facility policy. Despite being cognitively intact, her records lacked documentation of an assessment by the Interdisciplinary Team to determine if self-administration was clinically appropriate. Interviews with staff confirmed the oversight, and the resident indicated she had informed the facility about medication discrepancies.
A resident was found with their call light on the floor, out of reach, during a facility tour. The resident, who had intact cognition, was unable to communicate with staff due to this oversight. A CNA confirmed the call light should have been accessible, as per facility policy. The DON was informed and acknowledged the issue.
A facility failed to include a resident's advance directive in her medical record, despite its existence being noted on her POLST form. Staff interviews confirmed the absence of the document, which is crucial for guiding the resident's care and identifying the responsible party.
A facility failed to incorporate PASARR Level II recommendations into a resident's care plan, who was diagnosed with anxiety disorder and schizoaffective disorder. The oversight was confirmed by the DON and MDS Coordinator, who admitted to not having a system to alert them to review the determination results, leading to incorrect MDS coding and potential inadequate care.
The facility failed to provide adequate respiratory care for several residents, including incorrect oxygen administration for a resident, undated oxygen tubing for another, and improper storage of nebulizer tubing. Additionally, a resident's oxygen saturation levels were not documented, hindering assessment of their ability to tolerate room air. These deficiencies were confirmed by facility staff.
The facility failed to accurately post Daily Hours Per Patient Day (DHPPD) nurse staffing forms as per AFL 18-27 guidelines. Missing information included the facility's license number, total licensed bed capacity, and the DON's signature. The DON confirmed that the DHPPD was not signed daily, leading to potential inaccuracies in public staffing information.
The facility failed to document the administration of a controlled medication for a resident and did not follow proper procedures for the disposal of non-controlled medications. An LVN admitted to administering clonazepam without proper documentation, and the disposal of non-controlled medications was not signed off by two nurses as required.
The facility failed to ensure accurate monitoring and documentation for three residents using psychotropic medications. One resident's behavior manifestation for divalproex use was not specified, and orthostatic blood pressure readings were inaccurately recorded. Another resident's meal intake related to mirtazapine use showed discrepancies between MAR and CNA documentation. A third resident's orthostatic hypotension was not properly monitored, with identical blood pressure readings for different positions.
A medication error rate of 7.14% was identified in the facility, exceeding the acceptable threshold of 5%. An LVN failed to follow physician's orders by not checking a resident's heart rate before administering antihypertensive medications, metoprolol and diltiazem, which required specific parameters for safe administration. The DON acknowledged the error and confirmed the expectation for compliance with physician's orders.
A resident was administered metoprolol and diltiazem without checking their heart rate, contrary to physician's orders. The LVN admitted to forgetting this step, which was required to ensure the resident's safety due to the risk of an abnormally slow heart rate. The deficiency was acknowledged by the DON.
A facility failed to ensure proper storage, labeling, and disposal of medications, with medications for discharged or deceased residents not removed from supply, expired medications not discarded, and opened inhalation solutions not labeled. Bubble packs were found torn, and medications were left unattended, risking unauthorized access. These deficiencies were confirmed by staff during inspections.
The facility failed to implement its infection prevention and control program, with deficiencies in water management and laundry services. The Legionella Risk Assessment was not completed for the current year, and the facility lacked a water flow chart. In the laundry area, personal items were found on the clean linen folding table, violating infection control practices. The Administrator and MDS Coordinator acknowledged these issues.
The facility failed to maintain essential equipment safely, as a new glucometer was used without required calibration, and a medication refrigerator had significant ice buildup. An LVN confirmed the glucometer was used without quality checks, and an RN verified the refrigerator's condition, both posing potential risks to residents.
A facility failed to document a resident's name on a Grab Bar Use and Entrapment Risk Evaluation, posing a risk for inaccurate care. Interviews with LVN and DON confirmed the oversight, highlighting the importance of including resident names in documentation to ensure proper care.
Failure to Honor DNR Order and POLST During Cardio-Pulmonary Arrest
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s documented wishes to withhold life-sustaining treatment, including CPR, as specified in a POLST and physician order for Do Not Attempt Resuscitation (DNR). The facility’s policy on Basic Life Support and Cardiopulmonary Resuscitation, revised 10/2017, states that resident wishes expressed in an advance directive or POLST, including DNR orders, are to be honored and that a DNR order indicates the resident should not be resuscitated if respirations and/or cardiac function cease. The resident in question was admitted without capacity to make medical decisions and had a POLST form signed by the legally recognized decision maker indicating DNR, as well as a physician’s order for DNR documented on the Order Summary Report. Despite these orders, when the resident became unresponsive and pulseless, staff initiated and continued CPR. A CNA reported that while accompanying the resident in his room, the resident became unresponsive within approximately five minutes; the CNA checked for a pulse, found none, and immediately began CPR while calling for help. An RN responded to the emergency, assessed the resident, confirmed absence of a pulse, and provided CPR, later acknowledging awareness that the resident had a DNR order and stating she should have verified the code status by checking the Physician Order Summary Report and POLST form. An LVN also participated in providing CPR without verifying the resident’s code status and stated that CPR should not be initiated when a DNR order is in place. The Administrator and DON were informed of and acknowledged these findings.
Unsafe Water Temperatures in Resident Care Areas
Penalty
Summary
The facility failed to maintain safe water temperatures in resident care areas, including resident rooms and shower rooms. Facility policy stated water heaters serving resident areas were to be set at no more than 120 degrees Fahrenheit, and maintenance staff were responsible for checking and recording water temperatures. During observation and concurrent interview, the Maintenance Supervisor tested water in multiple resident rooms and found temperatures of 130, 134, 131, 133, and 130.5 degrees Fahrenheit, which he acknowledged were high and could cause scalding. Facility water temperature logs for August and September 2025 showed daily testing of resident rooms, shower rooms, kitchen, and laundry. The logs documented resident room and shower room temperatures ranging from 121 to 146 degrees Fahrenheit in August and from 116 to 141 degrees Fahrenheit in September, with averages of approximately 133 and 130 degrees Fahrenheit, respectively. The Maintenance Supervisor stated he and two Maintenance Assistants checked temperatures daily and that he knew the safe range was 105 to 120 degrees Fahrenheit, but he could not explain what to do when temperatures were outside that range and acknowledged he did not follow up. Interviews with staff showed that direct care staff were aware of the need to mix hot and cold water or test water by touch, but the DSD verified that in-service education on safe water temperature had not been provided before the survey date. The Maintenance Assistant stated he reported out-of-range temperatures to the Maintenance Supervisor but did not document the notification and did not follow up when the concern was not addressed. Interviews with the Administrator and DON confirmed awareness of the findings, and the DON stated there had been no burn incidents in the facility. Resident interviews showed one resident was cognitively intact and used the bathroom independently, while another required staff assistance for showers and reported no burn injury from facility water.
Unsafe bedside self-administration of medications
Penalty
Summary
The facility failed to ensure that residents who were assessed as not safe to self-administer medications did not keep and use medications at the bedside. The report identified two nonsampled residents, Residents 35 and 78, who both had self-administration assessments showing they were not safe to self-administer their medications. Despite those assessments, medications were found at the bedside for both residents, and both were observed using those medications on their own. Resident 78 was observed in bed with a bottle of Refresh eyedrops on the overbed table and a box of Lidocaine patches on the nightstand. He stated he had been using three drops of the artificial tears in his eyes twice a day and applying the Lidocaine patch to his back when he felt like it. RN 1 verified the medications were at the bedside and stated the resident could not keep medications at bedside because he could not administer them himself and only nurses could administer medications. The record showed Resident 78 did not want to self-administer medications, was not physically able to do so, preferred the licensed nurse to administer them, and was determined by the IDT to be unsafe due to periods of confusion and generalized weakness. Resident 35 was observed in bed with a bottle of Advil on the nightstand and stated she had brought it to the facility and took it for pain or flu-like symptoms such as a cold or runny nose, in addition to medications given by nurses. RN 1 verified the Advil was at the bedside. The record showed Resident 35 did not want to self-administer medications, was not physically able to do so, preferred the licensed nurse to administer them, and was determined by the IDT to be unsafe because she was forgetful. For both residents, the medical record did not show a physician order for the bedside medications, and the plan of care did not include a care plan problem addressing self-administration of those medications. The DON verified the findings and stated the residents were not safe to self-administer their own medications and that there were no physician orders or care plans addressing self-administration.
Unnecessary Psychotropic Medication Monitoring and Documentation Deficiencies
Penalty
Summary
The facility failed to ensure Resident 9 was monitored for orthostatic hypotension related to psychotropic medication use. Resident 9 had physician orders for sertraline 50 mg at bedtime for depression and Depakote 125 mg twice daily for mood disorder manifested by poor impulse control. The physician also ordered blood pressure monitoring lying and sitting every Sunday for orthostatic hypotension, with notification parameters for a systolic difference of 20 mmHg or greater or a diastolic difference of 10 mmHg or greater. Review of the medical record and MAR showed the medications were administered, but there was no documented evidence that the orthostatic hypotension monitoring was completed, and the order did not carry over into the September MAR. The facility also failed to ensure Resident 34’s Depakote order identified the specific behavior targeted by the medication. Resident 34 had a physician order for Depakote Delayed Release 125 mg at bedtime for mood disorder manifested by poor impulse control leading to a fall from bed. During interview, nursing staff stated they monitored the resident for trying to get out of bed, but acknowledged there were no specific behaviors listed in the order. The DON verified the behaviors targeted by the medication should have been more specific, and another nurse reviewed the order and confirmed there were no specific behaviors to monitor. For Resident 11, the facility failed to ensure meal intake documentation was accurate enough to identify when intake was less than 50%, and failed to complete the monthly behavior summary related to mirtazapine use. Resident 11 had orders for mirtazapine 7.5 mg at bedtime for depression manifested by poor oral intake and for monitoring poor oral intake less than 50% with meals. The MAR documented episodes of poor oral intake, and task documentation showed several meal entries in the 26% to 50% range and one entry of 0% to 25%. The DON stated poor intake meant less than 50% of the meal tray, but also stated the electronic record only allowed percentage ranges rather than exact percentages. The DON verified the monthly behavior summary for August was not completed and stated it would begin later because the resident had been transferred to the hospital and returned to the facility.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure an injury of unknown origin was thoroughly investigated for Resident 34, who had severe cognitive impairment. Review of the resident’s SBAR Communication Form showed discoloration on the left mid breast and left upper backside. LVN 7 stated the discolorations were purplish with a yellow border, that the RN was notified, and that the resident denied being hit or having an injury when assessed. The facility’s Abuse Reporting and Prevention policy stated that all injuries of unknown source are to be reported immediately to the Administrator and thoroughly investigated. During interviews, the DON stated the SBAR form was initiated due to skin discoloration and that the facility investigated change of condition for skin discoloration from an unknown source. On follow-up, the DON stated she did not receive an incident report notifying management of Resident 34’s injuries of unknown origin and therefore did not investigate the source of the discolorations; she could not recall whether nursing staff notified her of the discolorations. The Administrator stated injuries of unknown origin were to be reported immediately to the DON or Administrator and investigated to determine the source.
Conflicting Code Status Documentation for a Resident
Penalty
Summary
The facility failed to clearly identify Resident 5’s current code status. The resident had a POLST indicating DNR with comfort-focused treatment, and the medical record also contained a physician’s order for DNR and comfort-focused treatment, along with a baseline care plan reflecting DNR status and comfort-focused interventions with no artificial means. However, the chart also contained a later POLST signed by the resident that selected attempt resuscitation/CPR and full treatment as medical interventions. During interviews and concurrent record reviews, staff gave conflicting answers about the resident’s code status. One LVN initially stated the resident was DNR, then after reviewing the chart said she would follow the later POLST showing full code. Another LVN stated she would perform CPR and said she was confused after finding the physician’s DNR order in the electronic record. The SSD stated the resident’s code status had changed to full code based on the later POLST and said she only reviewed the POLST, not the physician’s orders. RN 1 also identified that the later POLST did not match the physician’s DNR order and stated staff would follow the later POLST because it was updated and signed by the resident and doctor. The DON verified that the electronic record showed DNR while the paper chart contained two POLST forms, one showing DNR and one showing full code. The IDT/Care Plan Conference Summary still showed the resident as DNR with comfort-focused medical interventions and hospital transfer. The DON and LVN 6 confirmed the care conference summary reflected DNR, while the DON stated they would follow the later POLST, which meant full code. The resident’s H&P showed the resident had capacity to understand and make decisions.
Missing Hearing Aid and Incomplete Hearing Aid Documentation
Penalty
Summary
The facility failed to ensure a resident who required bilateral hearing aids received the ordered assistive devices and proper treatment to maintain hearing abilities. The resident had no capacity to understand and make decisions, and the medical record showed an order for the left and right hearing aids to be applied at 0900 and removed at 2100. The care plan addressed impaired communication related to hearing impairment and the use of both hearing aids. During observation, the resident was awake in bed and pointed to the left ear while appearing unable to hear the surveyor clearly. The resident apologized for not being able to hear and asked the surveyor to speak louder. Later observations showed the resident without the hearing aids on. Review of the MAR showed multiple dates where the hearing aids were documented as applied and removed, but several 0900 entries were left blank rather than documented as refused or otherwise explained. The resident’s left hearing aid was also missing. The resident’s responsible party stated the last time she saw the left hearing aid was in February 2025 and that she had informed staff on the PM shift. Staff interviews showed the right hearing aid was present in a green container, but the left hearing aid could not be found in the medication cart or the resident’s room. The resident’s clothing and possessions inventory did not list hearing aids, and facility staff and the SSD verified there was no report showing the missing left hearing aid had been formally documented or reported for the months reviewed.
GT Feeding While Head of Bed Was Too Low
Penalty
Summary
The facility failed to provide necessary GT care and services for one resident with a feeding tube. The resident had physician orders for water flushes via GT and for Nutren 2.0 enteral feeding to be administered by pump at 43 ml per hour for 20 hours, and the resident’s care plan included elevating the head of the bed more than 30 degrees during feeding and for one hour afterward. During observation, the resident was in bed with the GT feeding infusing while the head of the bed was only slightly elevated at about 20 to 21 degrees. The resident was observed coughing during the feeding. A concurrent interview with an RN confirmed the head of the bed was at 21 degrees while the feeding was infusing, and the RN stated it was not appropriate at that angle and that the bed should have been elevated to 45 degrees. The RN also verified the resident could not use the bed remote to lower the head of the bed and that the control was not within the resident’s reach.
Failure to Attempt Less Restrictive Measures Before Using Bed Grab Bars
Penalty
Summary
The facility failed to ensure less restrictive interventions were completed before using bed side rails/grab bars for three sampled residents. The report states that Residents 2, 3, and 5 had right or bilateral grab bars elevated as enablers for bed mobility, turning, repositioning, and transfers, but the medical records did not show that less restrictive measures were attempted before the grab bars were used. Facility policy required that side rails or bed rails only be used after other alternatives had been tried unsuccessfully and after informed consent, and that residents be assessed for least restrictive measures such as transfer poles or trapeze bars. Resident 2 was observed sleeping in bed with the right grab bar elevated and later observed awake with the same grab bar elevated. The resident had severe cognitive impairment, required partial/moderate assistance with mobility, and had diagnoses including dementia and confusion. The care plan and Bedrail/Grab Bar Use and Entrapment Risk Evaluation identified the right grab bar as an enabler, but neither document showed any less restrictive alternatives attempted before its use. A CNA stated the resident used the grab bar during repositioning. Resident 3 was observed with bilateral grab bars elevated and had severe cognitive impairment, no capacity to understand and make decisions, and dependence with mobility. The care plan and Bedrail/Grab Bar Use and Entrapment Risk Evaluation identified the bilateral grab bars as enablers, but did not show any less restrictive measures attempted before their use. Resident 5 was observed in bed with the right grab bar elevated and stated he used it to get out of bed. He was cognitively intact and required supervision or touching assistance for several bed mobility tasks, but the record did not show documented evidence that any less restrictive alternative was attempted before the right grab bar was used.
Controlled Medication Documentation and Storage Failures
Penalty
Summary
The facility failed to provide necessary pharmacy services for Resident 34 when the physician’s order for insulin was not clarified. Resident 34’s order summary showed Novolin 70/30 FlexPen 10 units subcutaneously twice daily and instructions to administer rapid acting insulin no more than 15 minutes before meals or at the beginning of the meal, along with a separate order for Novolin R insulin per sliding scale. During a telephone interview, the Pharmacist Consultant stated Resident 34 was not currently receiving any rapid acting insulin and that the order should have been clarified with the physician. The facility also failed to accurately document and account for controlled medications for Resident 47 and Resident 13, and failed to properly discard a controlled medication in the medication room. Resident 47’s tramadol controlled drug record showed 52 tablets supplied, but tablet #31 had a blank date and time entry and an illegible, potentially scratched out signature, and the MAR did not show the dose was administered. Resident 13’s hydrocodone/acetaminophen controlled drug record showed multiple tablets removed from supply on several occasions, but the MAR did not show those tablets were administered. In Medication room [ROOM NUMBER], an ABHR cream container was observed outside the incineration container inside the locked cabinet, and the LVN verified it was a controlled medication that should not have been kept in the medication room.
Pharmacist Failed to Address Elevated A1c in Resident on Insulin
Penalty
Summary
The facility failed to ensure that a licensed pharmacist completed a monthly drug regimen review with appropriate recommendations for one sampled resident, Resident 34, who had Type 2 diabetes and was receiving insulin for diabetic management. Resident 34’s medication orders included Novolin R insulin on a sliding scale and Novolin 70/30 FlexPen 10 units subcutaneously twice daily. Laboratory review showed hemoglobin A1c results of 8.2% and later 8.8%, indicating worsening blood sugar control. Monthly drug regimen reviews dated 7/8/25, 8/7/25, and 9/8/25 showed the Pharmacist Consultant reviewed Resident 34’s medical record but did not make recommendations based on the elevated hemoglobin A1c results and did not follow up with the physician. During a telephone interview on 9/12/25, the Pharmacist Consultant verified that recommendations should have been made because the resident’s hemoglobin A1c had increased and follow-up with the physician should have occurred.
Failure to Monitor Residents on Clopidogrel for Bleeding
Penalty
Summary
The facility failed to ensure two sampled residents receiving clopidogrel bisulfate were monitored for signs and symptoms of bleeding. Resident 3 had an order dated 6/22/23 for clopidogrel bisulfate 75 mg by mouth daily for CVA prophylaxis and was noted in the H&P dated 5/18/25 to have no capacity to understand and make decisions. The medical record did not show documented evidence that Resident 3 was observed or monitored for bleeding related to clopidogrel use. During interview and concurrent record review, RN 2 stated Resident 3 was high risk for bleeding, identified signs and symptoms such as blood in stool or urine, nosebleeds, gum bleeding, and bruising, and verified there was no documented evidence of monitoring. Resident 34 was readmitted to the facility and had an order dated 3/7/25 for clopidogrel bisulfate 75 mg by mouth daily for CVA prophylaxis. The order summary report did not show a physician's order to monitor the resident for signs or symptoms of bleeding related to clopidogrel use. During interview and concurrent record review, RN 1 stated residents on anticoagulants should be monitored for bleeding and bruising, including checks of the gums, stool, urine, and skin, and stated Resident 34 should have had a physician's order to monitor for bleeding with documentation each shift on the MAR.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to keep the medication error rate below 5 percent; the reported medication error rate was 39.29%. During observation, interview, and record review, two of two licensed nurses were found to have made medication administration errors involving three residents. The facility policy required medications to be administered safely, timely, and in accordance with physician orders, including any required parameters. For Resident 10, who had no capacity to understand and make decisions, the physician ordered metoprolol tartrate 50 mg via GT every 12 hours with instructions to hold if SBP was less than 100 or HR was less than 60, and to check BP and HR before giving the medication. During observation, LVN 3 checked the resident’s BP and prepared to give metoprolol, but did not check the resident’s HR before administration and stated she forgot to do so. During the same medication pass, residue of vitamin D3 and Rena Vite mixed with water remained in the medicine cups after the medications were given via GT, and LVN 3 verified that residue was left in the cups. For Resident 62, LVN 2 crushed 10 medications in separate pill pouches and administered them with applesauce, but seven of the pill pouches still had residual medication remaining after administration. For Resident 63, the physician ordered calcium 500 mg twice daily, scheduled for 0900, but LVN 2 did not remove or administer the calcium tablet during the observed medication pass and later stated she missed it because she did not scroll the eMAR page and did not see the medication was scheduled.
Kitchen sanitation, food storage, hair restraint, and bedside food storage failures
Penalty
Summary
The facility failed to ensure sanitary requirements were met in the kitchen. During observation, two plastic containers holding clean scoops were found with dust and dry food crumbs on them, and the Dietary Director verified the condition. The facility also failed to ensure safe storage and labeling of food items in the freezer. Two packages of meat were covered with clear plastic and dated only with delivery dates, and two packages of chicken did not show a use-by date or when the meat would last. In the freezer, French toast and multiple packages of ice cream were also observed in clear plastic bags with only delivery dates, and the Dietary Director stated the dates were vendor delivery dates and that he was not required to label the items with a use-by or expiration date. The facility also failed to ensure complete hair restraint for dietary staff in the kitchen. Dietary Aid 1 was observed with a hair restraint covering only half of the scalp, and later Dietary Aid 1 and another staff member were again observed with hair restraints covering only half of their scalps. In addition, Resident 47, who was cognitively intact, had unlabeled bread in clear plastic and a paper container with kimchi on the bedside nightstand. Resident 47 stated the bread was a peanut butter and jelly sandwich received from the kitchen a couple hours earlier and the kimchi had been received from the kitchen 2 days earlier. CNA 1 verified that Resident 47 was not allowed to store food from the kitchen at the bedside.
Unlabeled Outside Food Stored at Resident Bedside Without Staff or Family Education
Penalty
Summary
The facility failed to follow its policy regarding food brought in from outside sources for one resident. During an observation, an unlabeled container of food and two undated bags with sandwiches were seen at the bedside of Resident 76, and on a later observation an unlabeled plastic container of pieces of apple and blueberry and an unlabeled bag of chips inside a plastic bag were again observed stored at the bedside. The facility policy stated that food brought in by visitors should be checked for conflict with the resident’s prescribed diet, and potentially hazardous foods should be consumed immediately and not stored in the facility. Interviews showed staff were aware the facility had no refrigerator or microwave for resident food brought from outside, and that outside food was expected to be consumed immediately or discarded. RN 1 and CNA 5 both stated they had not received training on how to handle food brought in from outside sources. The DSD verified she did not provide in-service training to staff on this topic. Resident 76 stated her daughter brought food from home, and Responsible Party 2 stated she occasionally brought food prepared at home, but neither remembered receiving education on safe handling of outside food. LVN 6 verified there was no documented evidence that Resident 76 or the representative were educated on how to handle food brought in from outside sources.
Infection Control and Isolation Precaution Failures
Penalty
Summary
The facility failed to maintain an accurate infection control surveillance program for August 2025. During review of the Infection Control Summary, the surveillance log, and the monthly infection surveillance mapping, the Infection Preventionist stated she used the summary report for the infection control meeting and that the summary did not match the surveillance log because she counted only new infections in the summary while the log included residents treated with antibiotics and those with changes in antibiotic treatment. The surveillance log showed residents on antibiotics, residents on antivirals, residents with HAIs, residents with CAIs, residents with infections that did not meet McGeer criteria, and residents marked for surveillance only with COVID-19, while the monthly mapping did not include residents who did not meet McGeer criteria or COVID-19 infections. The facility also failed to store residents' blankets, wedge pillows, and splints in a clean and sanitary manner in the laundry area. During inspection of the clean area of the laundry room, residents' blankets were observed stored in a linen rack next to another rack containing very dusty wedge pillows and splints. The racks were positioned against a wall with chipped paint. The Maintenance Supervisor verified these observations. Several infection control practices were not followed during resident care. CNA 7 provided high-contact care to a resident on EBP precautions, including changing an incontinence brief and bed linens, while wearing only a mask and gloves and not a gown. LVN 2 cleaned a blood sugar machine with alcohol wipes while wearing gloves, then checked another resident's blood sugar without changing gloves or performing hand hygiene. LVN 3 and the Care Plan Coordinator provided GT-related care to a resident on EBP precautions without wearing gowns, and LVN 3 did not perform hand hygiene between glove changes, handled GT supplies in an unsanitary manner, and reused a 60-cc syringe after placing it on a tray without covering the tip. CNA 4 also provided care and transferred a resident with a GT who was on EBP precautions without wearing a gown. In addition, a resident with COVID-19 precautions had the room door observed open while staff passed by, even though the care plan directed that the door remain closed at all times.
Failure to Document Routine Bed Inspections
Penalty
Summary
The facility failed to ensure that regular inspections of resident beds, bed frames, mattresses, and related equipment were completed as part of its regular maintenance program. The facility’s Bed Safety policy stated that maintenance staff were to inspect all beds and related equipment as part of the regular bed safety program and report results to the Administrator and QAPI Committee. Review of the facility census showed a 72-bed capacity with 64 residents present, but there was no documented evidence that routine inspections of all beds and related equipment had been conducted. Medical record review showed that Resident 2 had a physician’s order for a right grab bar as an enabler to assist with bed mobility, turning, repositioning, and transfers. Resident 2 had severe cognitive impairment, required partial/moderate assistance with mobility, and was confused with a diagnosis of dementia. Resident 3 had physician’s orders for bilateral grab bars as enablers to assist with bed mobility, turning, repositioning, and transfers. Resident 3 had no capacity to understand and make decisions, had severe cognitive impairment, and was dependent with mobility. Their records did not show documented evidence that a routine bed inspection was conducted. Resident 5 had a physician’s order for a right grab bar as an enabler to assist with bed mobility, turning, and repositioning. Resident 5 was cognitively intact and required supervision or touching assistance for chair/bed-to-chair transfers, sit to stand, sit to lying, and lying to sitting on the side of the bed. The maintenance consultant and maintenance supervisor stated that monthly bed inspections were their responsibility and described the items included in those inspections, but the maintenance binder only contained a siderail or bedrail assessment guidance form with room numbers and entrapment measurements. The binder did not contain documented evidence of routine bed inspections for the resident beds, including the brakes, bed frame, mattress, headboard, and footboard.
Advance Directive Documentation Missing or Incomplete
Penalty
Summary
The facility failed to obtain and maintain advance directive documentation for two of four sampled residents reviewed for advance directives. For Resident 8, the record showed the resident was admitted to the facility, had no capacity to understand and make decisions on the H&P, and later had an MDS assessment showing cognitive intactness. The resident’s POLST indicated a legally recognized decision maker and no advance directive, but the medical record did not show that the facility followed up with the resident or representative regarding whether an advance directive existed. The Advance Health Care Directive Acknowledgement also did not contain the signature of the resident or representative. For Resident 33, the record showed the resident was admitted to the facility and had severe cognitive impairment on the MDS assessment. Resident 33’s POLST had Section D incomplete, and the medical record did not show that the facility followed up with the resident or representative regarding the existence of an advance directive. During interview and concurrent record review, the SSD stated Resident 33 had an advance directive, but the copy was not available in the medical record and was not readily retrievable by staff. The SSD also verified that Resident 33’s POLST Section D was incomplete and did not show whether the resident had an advance directive.
Failure to Provide Written Transfer Notice and Bed-Hold Information
Penalty
Summary
The facility failed to provide required written transfer/discharge documentation and bed-hold information to a resident who was transferred to an acute care hospital. Resident 51 was admitted to the facility and later readmitted, had an H&P showing the resident was able to make simple decisions, and an MDS showing the resident was cognitively intact. A physician order dated 8/27/25 directed transfer to the acute care hospital for further evaluation of low oxygen saturation and heart rate and to provide a seven-day bed hold if admitted. The SBAR form showed the resident was transferred at 0543 hours on 8/27/25. The medical record included a Notice of Transfer/Discharge listing the hospital as the transfer location and stating the reason was that the resident's welfare required transfer because needs could not be met in the facility, but the signature line for the resident or representative was blank. The record also included a Bed Hold Informed Consent stating the option to request a seven-day bed hold, but it also lacked the resident's or representative's signature. The record did not show that the resident or representative was provided written notice of the transfer or the facility's bed-hold policy when the resident was transferred. During interview, RN 1 stated the resident's representative was informed about the bed hold and transfer notice, but documentation could not be found showing the written notices were provided. The SSD stated she faxed the transfer/discharge notice to the ombudsman but did not mail or email the transfer/discharge notices or bed-hold policies to the resident or representative.
Untimely Significant Change MDS After Hospice Admission
Penalty
Summary
The facility failed to ensure the MDS assessment for significant change was completed timely for one resident who was admitted to hospice services. Review of the resident’s record showed a physician order for hospice services dated 6/19/25, which triggered a Significant Change in Status MDS dated 7/1/25. The MDS assessment was completed on 7/9/25, 20 calendar days after the resident was admitted to hospice services. During interview and concurrent record review on 9/11/25, the MDS Coordinator verified that the hospice order triggered the Significant Change in Status MDS. A telephone interview with the MDS Consultant, conducted with the MDS Coordinator present, confirmed that a Significant Change in Status MDS must be completed by the 14th calendar day from a resident’s order for hospice services. The MDS Coordinator acknowledged that the assessment for this resident was not completed timely.
Inaccurate and Late PASRR Screening
Penalty
Summary
PASRR screening for mental disorders or intellectual disabilities was not accurately completed for one sampled resident. Resident 9 was admitted with an acute hospital diagnosis of anxiety disorder, major depressive disorder, and schizophrenia, and the hospital discharge paperwork showed a negative Level 1 screening that did not require a Level II mental health evaluation. The resident’s PASRR Level 1 Screening dated 8/1/25 stated the resident was not diagnosed with serious mental illness or suspected mental illness, even though the same form listed psychotropic medications including Risperdal, Zoloft, and Ativan. The resident’s H&P dated 8/4/25 documented no capacity to understand and make decisions due to dementia. During interview, the MDS Coordinator stated she did not review the PASRR for accuracy when the resident was admitted and verified the information on the 8/1/25 PASRR was not accurate. She also verified that a new Level 1 Screening was required as a Resident Review on the 31st day of stay, but the screening was completed on 9/2/25, past the 31-day requirement. The DON was informed and acknowledged these findings.
Incomplete Care Plans for Medication-Related Monitoring
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three sampled residents by not including specific monitoring related to their medications. For Resident 3, who had no capacity to understand and make decisions, the physician ordered clopidogrel bisulfate 75 mg daily for CVA prophylaxis, but the care plan for cardiovascular monitoring did not include specific monitoring for signs and symptoms of bleeding related to clopidogrel use. During interview and record review, RN 2 stated the resident was at high risk for bleeding from clopidogrel and identified signs such as blood in stool or urine, nosebleeds, gum bleeding, and bruising, and verified the care plan did not address this monitoring. For Resident 9, who also had no capacity to understand and make decisions, the physician ordered weekly lying and sitting blood pressure checks for orthostatic hypotension and prescribed sertraline for depression and Depakote for mood disorder. The care plan for risk for drug-related side effects due to psychoactive medications did not include the ordered blood pressure monitoring for orthostatic hypotension. LVN 2 stated orthostatic hypotension needed to be monitored when the resident was taking psychotropic medications and verified the care plan failed to address this need. For Resident 34, who was readmitted to the facility, the physician ordered clopidogrel bisulfate 75 mg daily for CVA prophylaxis. The care plan addressed skin tear/discoloration risk related to antiplatelet and anticoagulant medication use and included daily skin monitoring, but it did not include monitoring for bleeding related to anticoagulant use. RN 1 stated residents on anticoagulants should be monitored for bleeding and bruising, including checks of the gums, stool, urine, and skin, and the DON verified the care plan only addressed skin tears/bruising and did not include bleeding monitoring from stool, urine, or mouth.
Failure to Revise Care Plan After Fall and New Safety Needs
Penalty
Summary
The facility failed to revise Resident 54’s resident-centered care plan after the resident had a seizure that resulted in a fall and new safety interventions were identified. The facility’s policy stated that after a resident’s fall, the interdisciplinary team would make recommendations for additional approaches to help prevent further falls, and any additional approaches would be included in the resident’s plan of care. Resident 54 was admitted to the facility and, after the fall, a Status Post Fall Assessment documented the recommendation to not leave the resident unattended. Medical record review and observations showed Resident 54 was seen with a caregiver on multiple occasions, and the caregiver stated they watched the resident for safety. The DON stated the resident had family-provided caregivers who were usually present from around 0800 hours to around 2000 hours and helped monitor the resident while he was up in his wheelchair. The DON verified the care plan showed close monitoring but was not revised to reflect that the resident had caregivers and that he should be up in his wheelchair only when caregivers were available to provide continuous monitoring.
Inconsistent Foley Output Monitoring and Missing I&O Totals
Penalty
Summary
The facility failed to provide appropriate care and services for a resident with an indwelling urinary catheter by not consistently monitoring urinary output as ordered. The resident was readmitted with a Foley catheter and had physician orders to monitor intake and output every shift for 30 days, with the catheter later removed for bladder training and then reinserted. Facility policy required intake and output measurement and documentation every eight hours for SNF residents with indwelling catheters, including 24-hour totals and weekly evaluation, but the resident’s task documentation repeatedly listed urine output as “not applicable” on multiple dates and times instead of recording the actual amount. Medical record review also showed no documented 24-hour total of the resident’s intake and output and no weekly evaluation of the resident’s average intake and output. Change-of-condition notes reflected catheter removal, voiding, and one note documenting 1000 ml output, but the record still lacked consistent shift-by-shift output documentation. During interview, the DON verified the resident had an indwelling urinary catheter, confirmed the urine output was not consistently documented per shift, and acknowledged that licensed nurses did not document a 24-hour total or complete a weekly evaluation of the resident’s average intake and output.
Improper Storage of Opened Vaginal Creams
Penalty
Summary
The facility failed to provide the necessary pharmacy services to ensure proper storage of medications. During an inspection of the medication room with LVN 6, surveyors found two opened and used vaginal creams labeled with open dates of 8/19/24 and 8/28/24 stored together in a cabinet with floor stock medications. The facility’s policy stated that medications and biologicals are to be stored safely, securely, and properly, and that medications labeled for individual residents are to be stored separately from floor stock medications when not in the medication cart. In an interview, the DON stated that once the medicated creams were opened and used, they should have been kept in the medication cart and not in the medication room to prevent contamination with other new and unopened medications.
Improperly Covered Garbage Dumpsters
Penalty
Summary
The facility failed to ensure garbage and refuse were properly stored in three of four garbage dumpsters. During observation and interview, the dumpster lids were found partially open on both sides by approximately one and a half to two inches, rather than tightly closed. The Dietary Director verified the observation and stated he had not followed up to have tight-fitting lids for the dumpsters. The Dietary Director also acknowledged that disease-carrying pests such as flies and rodents could easily get in and out through the partially open sides of the dumpsters. The report also noted a small flying insect in Nursing Station A and another small flying insect in the doorway of a resident's room, and the DON was informed and acknowledged these findings.
Incomplete MARs, Missing POLST Update, and Undocumented Oxygen Intervention
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents whose MARs showed missing documentation of medications and monitoring. For one resident, the September 2025 MAR had no documentation for multiple scheduled medications and monitoring tasks on 9/5 and 9/8, including vitamin D, docusate sodium, hydrochlorothiazide, lisinopril, a multivitamin with minerals, amlodipine, calcium with vitamin D, vitamin C, carvedilol, clonidine, ferrous sulfate, metformin, potassium chloride ER, Humulin R, blood sugar checks two hours after meals, and BP monitoring for PRN hydralazine use. The DON reviewed the MAR and verified the missing documentation. For the second resident, the September 2025 MAR had no documentation for several scheduled medications, including chewable aspirin, Lantus, losartan, potassium chloride ER, cholecalciferol, calcium, Vascepa, and Xarelto on 9/5 and 9/8. The DON again reviewed the MAR and verified the missing documentation. In both cases, the facility’s medication administration policy stated the nurse must electronically sign the MAR after administration, and the DON stated all scheduled medications and monitoring must be documented with no blanks. The facility also failed to keep an updated POLST in the record for a resident who later formulated an Advance Directive with the Ombudsman while at the facility. The resident’s record showed a POLST dated 2/3/19 and an Advance Health Care Directive dated 10/28/20, but no updated POLST reflecting the new Advance Directive. In addition, for another resident transferred to the hospital for low oxygen saturation and low heart rate, the record documented repositioning, high Fowler’s positioning, oral and nasal care, and oxygen saturation improving from 64% to 70% on 5 liters per minute, but it did not document whether oxygen was increased beyond 5 liters per minute before EMS transport. The RN and LVN interviews confirmed that oxygen had been titrated to 10 liters per minute with a non-rebreather mask and that this intervention was not documented.
Failure to Investigate and Document Resident's Fractures and Falls
Penalty
Summary
The facility failed to ensure that a resident received the necessary care and services to prevent accident hazards, specifically in the case of a resident who sustained a subacute closed fracture of multiple ribs. The facility did not thoroughly investigate or document the resident's rib fractures, nor did they request the physician to complete a fracture progress report. Additionally, the facility did not conduct a root cause analysis by the interdisciplinary team (IDT) as per the facility's policy and procedures (P&P) when the fractures were identified after a fall incident. The facility's P&P required immediate notification and assessment by a licensed nurse following a fall, with an incident report and investigation to be reviewed by the Director of Nurses and the IDT. However, the facility did not follow these procedures for the resident's fall on 10/16/24, which resulted in multiple rib fractures. The resident's medical record did not show documentation of the fractures prior to the fall, and there was no evidence of an investigation into the cause of the fractures or a request for a physician's fracture progress report. Furthermore, after another fall incident on 10/25/24, the facility failed to conduct and document neurological evaluations and the physician's recommendations. The resident, who was on a blood thinner medication, was found lying on the floor with a bump to the head, but the facility did not complete the required change in condition evaluation or follow up with the physician. The Director of Nursing confirmed that the staff did not notify her or complete the necessary evaluations and documentation after the fall.
Failure to Develop Comprehensive Care Plans for Grab Bar Use
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans for the use of grab bars for 13 out of 16 sampled residents. This deficiency was identified through observations, interviews, and medical record reviews, which revealed that the care plans did not reflect the individual care needs of the residents. The absence of these care plans meant that the residents were not provided with appropriate, consistent, and individualized care regarding the use of grab bars. For instance, Resident 32 was observed using bilateral grab bars for bed mobility, turning, and repositioning, as per a physician's order. However, the care plan did not include interventions for the use of grab bars, such as assessing for entrapment risks or considering less restrictive alternatives. Similarly, Resident 35's care plan lacked documentation for the use of grab bars, despite a physician's order and the resident's reliance on them for mobility and repositioning. The deficiency was further highlighted by the lack of care plans for other residents, such as Resident 40, who had no capacity to make decisions, and Resident 45, who used grab bars for transfers. The Director of Nursing (DON) and other staff members acknowledged the absence of individualized care plans for these residents, confirming the facility's failure to ensure comprehensive care planning for the use of grab bars.
Deficiency in Bed Rail Safety Assessments
Penalty
Summary
The facility failed to ensure the safety of residents using bed rails, as evidenced by the lack of complete and accurate assessments for 13 out of 16 residents reviewed. The facility's policy required an assessment of a resident's risk for entrapment before the installation of side rails or bed rails, but this was not consistently followed. The assessments did not document whether the least restrictive measures were effective or ineffective before resorting to the use of grab bars. This oversight put residents at risk of entrapment and serious injuries. Several residents, including those with cognitive impairments and those who could make decisions, were observed with elevated grab bars without proper documentation of the effectiveness of less restrictive measures. For instance, Resident 32, who was alert and responsive, had grab bars installed without evidence of prior assessment of alternative measures. Similarly, Resident 40, who lacked decision-making capacity, had grab bars installed without the completion of the least restrictive measures section in the assessment. Interviews with facility staff, including CNAs, LVNs, and the DON, confirmed the lack of documentation and assessment of the effectiveness of less restrictive measures. The DON acknowledged that proper assessments were not completed, and least restrictive approaches were not tried before the use of grab bars. The MDS Coordinator also verified that sections of the assessments were left incomplete, and the least restrictive measures were not reevaluated during quarterly reviews.
Sanitation Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, which was observed during a survey. The cutting boards were found to be in poor condition, with deep grooves, discoloration, and fuzziness, making them difficult to clean and sanitize. This was acknowledged by the Dietary Director, who stated that new cutting boards had been ordered. Additionally, scoops used for food portioning were stored wet with visible water and dry, crusted food residue, which was verified by the Dietary Director. Further observations revealed that various kitchen utensils were not in good repair or cleanable condition. Stainless spatulas, a can opener, a peeler, a lemon squeezer, and a rolling pin were found to be chipped, deformed, dirty, and stained. The Dietary Assistant Director confirmed these findings and stated that these items should not be used to prevent food contamination. Additional utensils, such as a stainless slotted scooper, rubber spatulas, and a stainless strainer, were also found to be in poor condition, with melted handles and brownish stains. The facility also failed to ensure that equipment such as blenders, measuring containers, and drinking cups were air-dried before storage, as they were found wet with visible water. The kitchen hood was observed with a black, greasy residue, and the microwave used for reheating residents' food had dry, crusted food residue. The ice machine, used by residents and staff, was found with a light yellowish/pinkish stain, indicating a lack of proper cleaning and maintenance. These findings were verified by the Dietary Director and Maintenance Supervisor, who acknowledged the potential for cross-contamination and foodborne illnesses.
Incomplete Entrapment Assessments for Residents Using Grab Bars
Penalty
Summary
The facility failed to ensure accurate and complete entrapment assessments for residents using grab bars, which could potentially lead to entrapment, serious injury, or death. The assessments were incomplete for 13 out of 16 sampled residents, with missing documentation for several entrapment zones. The facility's policy required assessments to be conducted prior to the installation of siderails or bedrails, but the assessments were not fully completed, leaving several zones unchecked. Observations and interviews revealed that residents were using grab bars for assistance with bed mobility, turning, repositioning, and transfers. However, the Grab Bar Use and Entrapment Risk Evaluations often lacked documentation for Zones 5 to 7, and in some cases, Zones 1 to 4 were also incomplete. The Maintenance Supervisor, who was responsible for measuring the entrapment zones, did not document or communicate the results to the licensed nurses, leading to incomplete assessments. The Director of Nursing (DON) and other staff members acknowledged the deficiencies in the entrapment assessments. The Maintenance Supervisor admitted to only recently starting to document the measurements and assessments, and there was a lack of communication between the maintenance and nursing staff regarding the entrapment zone measurements. This lack of documentation and communication contributed to the incomplete assessments, potentially putting residents at risk.
Failure to Provide Effective Communication for Non-English Speaking Resident
Penalty
Summary
The facility failed to provide effective communication for a resident with limited English proficiency, specifically Resident 28, who spoke and understood only the Gujarati language. Despite having a care plan in place that included the use of translation tools and communication aids, these were not effectively utilized. Observations revealed that staff members, including CNAs, communicated with Resident 28 in English, which the resident did not understand. The staff often guessed the resident's needs based on routine rather than using available translation resources. There was no communication board at the resident's bedside, and the translation device available in the facility was not used or demonstrated to support the Gujarati language. Interviews with staff, including the DON and DSD, confirmed the lack of training on the translation device and the absence of a communication board for Resident 28. The DON acknowledged that the staff typically relied on the resident's family for translation, indicating a gap in the facility's ability to independently meet the communication needs of residents with language barriers. The Administrator and MDS Coordinator were informed of these findings, acknowledging the deficiency in providing necessary care that promotes dignity and respect for Resident 28.
Failure to Obtain Physician-Signed Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that the informed consent for psychotropic medication was signed by the physician for one of the residents, identified as Resident 366. The facility's policy and procedure require that the attending physician, PA, or NP obtain informed consent from the resident or their responsible party before prescribing or increasing an order for psychotherapeutic medication. This policy also mandates that the facility verify informed consent has been obtained prior to administering such medication. However, a review of Resident 366's medical records revealed that the informed consent for the use of trazadone, prescribed for insomnia, lacked the physician's signature. Interviews conducted with LVN 4 and the DON confirmed the absence of the physician's signature on the informed consent form for Resident 366's trazadone medication. LVN 4 acknowledged that the physician's signature was necessary to indicate that the medication had been reviewed with the resident and approved. The DON also confirmed that the informed consent needed to be signed by the physician to allow the facility to administer the medication as ordered. This oversight posed a risk of the resident not being fully informed about their care and treatment regarding the use of psychotropic medication.
Failure to Assess Resident's Ability to Self-Administer Medications
Penalty
Summary
The facility failed to determine if it was safe for Resident 316 to self-administer medications, as required by their policy. During an initial tour, Resident 316 was observed with several medications at her bedside, including Synthroid, Equate Gas Relief, Tylenol, and Neuriva Brain Health Plus. Despite being cognitively intact and having the capacity to understand and make decisions, there was no physician's order or care plan addressing her self-administration of medications. The facility's policy requires an assessment by the Interdisciplinary Team to determine if self-administration is clinically appropriate, but this was not documented in Resident 316's records. Interviews with facility staff, including a CNA, LVN, and the DON, confirmed the presence of medications at Resident 316's bedside and the lack of a reassessment for her ability to self-administer medications. The resident herself stated that she informed the facility about the discrepancy in medication supply strength and that the licensed nurses were aware of her self-administration. However, her self-administration assessment indicated she preferred the licensed nurse to administer her medications. The Administrator and MDS Coordinator acknowledged these findings, highlighting a lapse in following the facility's policy for medication self-administration assessments.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to provide reasonable accommodation to meet the needs of a nonsampled resident, identified as Resident 60. During an initial tour of the facility, Resident 60 was observed lying in bed with the call light on the floor, out of reach. This observation was confirmed by CNA 4, who acknowledged that the call light should have been within the resident's reach. Resident 60's medical records indicated that their cognition was intact, suggesting they were capable of using the call light if it had been accessible. The facility's policy and procedure for call lights, dated January 2017, required staff to ensure call lights were within easy reach of residents when they were in bed or seated. The Director of Nursing was informed of these findings and acknowledged the deficiency.
Failure to Include Advance Directive in Medical Record
Penalty
Summary
The facility failed to ensure that a resident's advance directive was included in her medical record, which could potentially lead to her healthcare decisions not being honored. The facility's policy and procedure on advance directives, revised in April 2017, requires that residents or their responsible parties provide a copy of the advance directive for inclusion in the clinical record. However, during a medical record review initiated on August 27, 2024, it was found that Resident 43, who was admitted earlier in the year, did not have a copy of her advance directive in her medical record. Interviews with facility staff confirmed the absence of the advance directive in the resident's medical record. The Health Information Director and LVN 9 both verified that although the resident's POLST form indicated the existence of an advance directive, no copy was found in the record. The Social Services Director also acknowledged the absence of the document, emphasizing its importance in guiding the resident's care and identifying the appointed responsible party. This oversight in documentation could potentially impact the resident's medical care and treatment decisions.
Failure to Implement PASARR Recommendations for Resident Care
Penalty
Summary
The facility failed to incorporate the recommendations from the Preadmission Screening and Resident Review (PASARR) Level II determination into the care plan for a resident diagnosed with anxiety disorder and schizoaffective disorder. The PASARR Level II Evaluation, conducted by the Department of Health Care Services, recommended special services for the resident due to their medical and mental health conditions. However, a review of the resident's medical records and care plan revealed that these recommendations were not followed up or documented, indicating a lack of coordination in the resident's care planning process. Interviews with the Director of Nursing (DON) and the MDS Coordinator confirmed the oversight. The MDS Coordinator admitted to not having a system in place to alert her to review the Level II determination results, leading to an incorrect coding in the resident's annual MDS. The DON acknowledged the absence of documentation and the potential risk of the resident not receiving adequate care and services as recommended by the PASARR Level II determination.
Deficiencies in Respiratory Care and Equipment Management
Penalty
Summary
The facility failed to provide necessary respiratory care for several residents, leading to deficiencies in oxygen administration and equipment management. Resident 55 was observed receiving three liters per minute of oxygen via nasal cannula, contrary to the physician's order of one to two liters per minute. This adjustment was made by the night shift nurse without documentation of the resident's difficulty breathing or physician notification. LVN 3 confirmed these findings, indicating a lack of adherence to the prescribed oxygen therapy. Resident 15's oxygen tubing was not dated, and the humidifier was dated 8/11/24, despite the facility's policy of changing and dating the tubing and humidifier every Sunday. LVN 3 was unable to confirm when the oxygen tubing was last changed, highlighting a lapse in the facility's protocol for equipment maintenance. Additionally, Resident 34's nebulizer tubing was found touching the floor, and the oxygen tubing was not stored in a plastic bag when not in use, as verified by LVN 5 and the MDS Coordinator. Resident 59's medical records lacked documentation of oxygen saturation levels on room air, which was necessary to assess the resident's ability to tolerate room air without supplemental oxygen. The MAR showed check marks instead of actual oxygen saturation levels for several shifts, and both LVN 5 and the DON acknowledged this oversight. This deficiency in documentation prevented the facility from determining the resident's potential for weaning off oxygen, as required by the care plan.
Inaccurate Posting of Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the Daily Hours Per Patient Day (DHPPD) nurse staffing forms were accurately posted in accordance with the All Facility Letter (AFL) 18-27 guidelines. The review of the facility's documents titled Daily Staff from specific dates showed missing information such as the facility's license number, total licensed bed capacity, names of the administrator and the Director of Nursing (DON) or designee, designated census periods, actual nursing hours worked, actual DHPPD hours, and the DON or designee's signature to verify the accuracy of the information. The Payroll Director confirmed that the DON did not sign the DHPPD form daily but only twice a month, which was not in compliance with the AFL 18-27 requirements. Interviews with the Director of Staff Development (DSD), Payroll Director, and the DON confirmed the findings. The DSD acknowledged that the Daily Staff document was incomplete and only posted projected nursing hours without including actual nursing hours. The DON admitted that the facility's Daily Staff document did not accurately reflect the information as per AFL 18-27 guidelines and acknowledged that the DHPPD should be signed daily to ensure accurate staffing coordination based on the census. The failure to post accurate staffing information had the potential to result in inaccurate information being provided to the public.
Deficiencies in Medication Administration and Disposal
Penalty
Summary
The facility failed to provide adequate pharmaceutical services, specifically in the administration and documentation of controlled medications for a resident. During an inspection, it was found that a bubble pack of clonazepam, a controlled medication for anxiety, was not properly documented in the controlled drug record and Medication Administration Record (MAR) after administration. A Licensed Vocational Nurse (LVN) admitted to administering the medication but failed to document the removal and administration of the clonazepam on the required records. This oversight was confirmed by the Director of Nursing (DON) during a review. Additionally, the facility did not adhere to its policy for the disposal of non-controlled medications. The policy requires two licensed nurses to sign off on the disposal of such medications. However, a review of the Medication Disposition Record/Pass Log revealed that non-controlled medications were disposed of with only one nurse's signature. This discrepancy was verified by a Registered Nurse (RN) during an interview and document review.
Inaccurate Monitoring and Documentation of Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that three residents were free from unnecessary psychotropic medications, as evidenced by the lack of specific behavior manifestations and inaccurate monitoring of vital signs and meal intake. For one resident, the facility did not identify a specific behavior manifestation related to the use of divalproex, an antipsychotic medication. Additionally, the resident's orthostatic blood pressure was not accurately monitored, with identical readings recorded for both sitting and lying positions, contrary to physician orders. Furthermore, discrepancies were found between the meal intake documented by licensed nurses in the MAR and the documentation by CNAs in the POC Legend Report. Another resident's meal intake monitoring related to the use of mirtazapine, an antidepressant, also showed inconsistencies between the MAR and the POC Legend Report. The facility's failure to accurately document meal intake and behavior episodes related to poor appetite was evident, as the psychotherapeutic drug summary sheet did not match the actual meal intake records. Interviews with staff revealed conflicting accounts of the resident's meal consumption, further highlighting the lack of coordination in monitoring. For a third resident, the facility did not accurately monitor orthostatic hypotension as ordered by the physician. The blood pressure readings for both sitting and lying positions were identical, indicating a failure to properly assess the resident's condition. Interviews with the DON and LVN confirmed that the staff did not follow the correct procedure for monitoring orthostatic hypotension, as the blood pressure readings should have differed between positions.
Medication Administration Error Due to Non-compliance with Physician's Orders
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with the observed rate being 7.14%. This deficiency was identified during a medication administration observation involving a licensed vocational nurse (LVN 5) and Resident 16. LVN 5 did not adhere to the physician's orders for administering antihypertensive medications, specifically metoprolol and diltiazem. The orders required checking both the systolic blood pressure (SBP) and heart rate before administration, with instructions to hold the medication if the SBP was less than 110 mmHg or the heart rate was less than 60 beats per minute. However, LVN 5 only checked the resident's blood pressure and failed to measure the heart rate before administering the medications. Resident 16 had specific physician's orders for the administration of diltiazem and metoprolol due to hypertension, with parameters set to ensure safe administration. Despite these orders, LVN 5 proceeded to administer the medications without verifying the heart rate, which was a critical step in the process. The Director of Nursing (DON) acknowledged the findings and confirmed that the medications should be administered as per the physician's orders, emphasizing the expectation for licensed nurses to follow the specified parameters.
Failure to Monitor Heart Rate Before Administering Antihypertensive Medications
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically in the administration of antihypertensive medications. During a medication administration observation, it was noted that a Licensed Vocational Nurse (LVN) did not check the resident's heart rate before administering metoprolol and diltiazem. According to the physician's orders, these medications should be withheld if the systolic blood pressure (SBP) is less than 110 mmHg or the heart rate is less than 60 beats per minute, and both the blood pressure and heart rate should be checked prior to administration. The resident involved had specific physician's orders requiring the monitoring of vital signs before medication administration due to the potential risk of an abnormally slow heart rate. The LVN admitted to forgetting to check the resident's heart rate before administering the medications. This oversight was acknowledged by the Director of Nursing (DON) after being informed of the findings. The failure to adhere to the physician's orders and facility policy and procedures (P&P) regarding medication administration led to this deficiency.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage, labeling, and disposal of medications, which was observed during an inspection of Medication Room A and Medication Cart A. Medications for residents who were discharged, transferred, or deceased were not removed from the current medication supply. Specifically, medications for Residents 22, 53, and 63 were found in the medication room despite their discharge or death. Additionally, expired medications were not removed from Medication Cart B, and opened inhalation solution medications for Residents 5, 15, and 40 were not labeled with an opened date. The facility also failed to maintain the integrity of medication packaging. Bubble packs containing medication tablets for Residents 2, 16, 37, and 45 were found with tears, compromising the tamper-evident packaging. Furthermore, orally administered medications were not stored separately from externally used medications, and medications were left unattended, posing a risk of unauthorized access. Resident 55's inhalation solution medication and Resident 37's insulin pen were left unattended on top of the medication cart and bedside table, respectively. These deficiencies were verified by the nursing staff during the inspection and interviews. The facility's policies and procedures for medication storage were not adhered to, as evidenced by the presence of outdated and improperly stored medications. The lack of proper medication management had the potential to negatively impact the residents' well-being and the effectiveness of the medications.
Infection Control Deficiencies in Water Management and Laundry Services
Penalty
Summary
The facility failed to implement its infection prevention and control program effectively, as evidenced by deficiencies in its water management and laundry services. The facility did not complete the Legionella Risk Assessment for the current year, which is crucial for identifying potential Legionella outbreaks. Additionally, the facility lacked a water flow chart to document how water circulates through the building and identify areas where water may stagnate. This oversight was confirmed during an interview with the Administrator, who acknowledged that the assessment and documentation were incomplete. In the laundry services area, the facility did not adhere to infection control practices. During an inspection, personal items belonging to the laundry staff, such as a water bottle, opened soda can, radio, purses, cookies, and a Styrofoam container, were found on the clean linen folding table. The Maintenance Supervisor confirmed that these items should not have been on the table, as it is designated as a clean area. The Administrator and MDS Coordinator were informed of these findings and acknowledged the breach in infection control practices.
Deficiencies in Equipment Maintenance and Calibration
Penalty
Summary
The facility failed to ensure that essential equipment was maintained in safe operating condition, specifically regarding the use of a new glucometer and the maintenance of a medication refrigerator. An inspection revealed that a new Assure Platinum glucometer, with serial number 1040-4324393, was used for residents' blood glucose monitoring without performing the required calibration or quality control checks. LVN 3 confirmed that the glucometer was brand new and acknowledged that no documentation was available to show that these checks were performed, despite the facility's protocol requiring such checks before using a new meter or test strips. Additionally, an inspection of the refrigerator used for medications in Medication Room A showed a significant ice buildup in the freezer compartment. This condition was verified by RN 1 and acknowledged by the DON. The ice buildup had the potential to affect the refrigerator's functionality and the potency of the medications stored inside, posing a risk to the residents who rely on these medications.
Failure to Document Resident's Name on Facility Document
Penalty
Summary
The facility failed to document the resident's name on a critical facility document for one of the sampled residents, identified as Resident 366. This oversight was discovered during a review of the Grab Bar Use and Entrapment Risk Evaluation dated 8/10/24, which lacked the resident's name. The absence of the resident's name on this document posed a risk for Resident 366 not receiving accurate and necessary care. The facility's policy and procedure (P&P) titled Facility Assessment emphasized the importance of personalized care and accurate resident assessments, yet this standard was not met in this instance. Interviews conducted with facility staff, including LVN 4 and the Director of Nursing (DON), confirmed the deficiency. LVN 4 acknowledged that the Grab Bar Use and Entrapment Risk Evaluation document was incomplete without the resident's name, which is essential for ensuring proper care and treatment. The DON also confirmed that facility documentation should include the resident's name and the date of completion, acknowledging the findings of the surveyors. This lapse in documentation accuracy was identified through a combination of interviews, medical record reviews, and facility policy reviews.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Anaheim
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Leisure Court Nursing Center | 0 mi | ★★★★★ | 3 | 0 |
| Sun Mar Nursing Center | 1.6 mi | ★★★★★ | 1 | 0 |
| Harbor Villa Care Center | 1.7 mi | ★★★★★ | 25 | 0 |
| Parkview Healthcare Center | 1.8 mi | ★★★★★ | 0 | 0 |
| St. Catherine Healthcare | 1.8 mi | ★★★★★ | 22 | 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.