Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lomita Post-acute Care Center during CMS and state inspections, most recent first.
Surveyors found that staff failed to respond promptly to call lights and provide timely ADL assistance for three cognitively intact residents who required varying levels of help with toileting, transfers, and incontinence care. One resident reported waiting 30–60 minutes at night for assistance with bathroom use and water, and another reported similar delays for incontinence care. A third resident, fully dependent for toileting and always incontinent, was observed with the call light on requesting to urinate while an ADM and a CNA instructed her to void in her brief instead of offering a bedpan or bedside commode, despite her stating she was continent and disliked being left wet. Staff interviews, including a CNA, an LVN, and the DON, confirmed that all staff were expected to answer call lights promptly and that the observed and reported delays and directions to use briefs were inconsistent with facility policies on call light response and perineal care.
Two residents received psychotropic medications without clear supporting diagnoses in the record. One resident was given quetiapine for psychosis/agitation despite documentation showing dementia and no psychiatric or mood disorder diagnosis, while the other resident received escitalopram for depression even though the admission record and MDS did not document depression and no psych eval was found. Staff interviews confirmed the lack of specific diagnosis and psychiatric evaluation for these medications.
Missed ROM and restorative nursing services: Two residents with significant mobility and ROM limitations did not receive ordered RNA interventions as scheduled. One resident with left hemiplegia, severe cognitive impairment, and a left-hand contracture had incomplete OT measurement of finger ROM, missed multiple AAROM/PROM sessions, and missed splint applications; an RNA session also omitted PROM to the right knee. Another resident with left hemiplegia and hemiparesis had numerous missed AAROM sessions to both arms and both legs, and staff stated the resident did not receive RNA treatments as ordered.
Surveyors found a medication error rate above the allowed threshold during med pass. An LVN gave ferrous sulfate late to two residents with anemia, left a lidocaine patch on a resident’s knee without dating it or removing it within the 12-hour manufacturer limit, and crushed acetaminophen and aspirin together for another resident instead of administering crushed meds separately. The DON and LVN acknowledged the timing and administration issues during observation and record review.
PRN opioid meds were administered outside ordered pain parameters for a resident with severe cognitive impairment, fractures, and chronic pain syndrome. The resident had orders for hydrocodone-APAP for moderate pain and morphine sulfate for severe pain, but the MAR showed multiple doses of hydrocodone-APAP given for severe pain scores and morphine sulfate given for moderate pain scores. The DON and an LVN stated the orders needed numeric pain-scale parameters to determine the correct medication.
Unlabeled food items were found in refrigerators, a freezer, and dry storage, including produce, dairy, eggs, meats, bread, and mayonnaise. The CK could not explain why items were not labeled or dated, and the DS stated food should be labeled and dated immediately after opening or preparation. The ice machine interior bin door had black residue that the CK, PS, and DS described as dirty or possibly mold/dirt, and the facility’s cold storage, sanitizer, and dish machine logs had multiple missing entries that the CK and DS could not explain.
An LVN failed to perform hand hygiene and/or change gloves before administering artificial tears eye drops to a resident with glaucoma and impaired cognition during a medication pass. In the laundry area, open trash bags were left on top of linen hampers, dirty linens were sorted in the same room where clean laundry was handled, and a reusable gown was hung near the clean laundry area. The DON, IPN, and other staff stated these practices created cross-contamination concerns.
Failure to Obtain Informed Consent Before Influenza Vaccination: A resident with dementia and fluctuating capacity received an influenza vaccine without a signed consent from the resident or representative. The record showed an unsigned consent form, a later documented refusal by the representative, and no evidence that education on the vaccine’s risks, benefits, or purpose was provided before administration. The IP, CM, and DON all confirmed the vaccine should not have been given without verified consent.
Failure to provide and document Advance Directive information for two residents. One resident had severe cognitive impairment with dysphagia and pneumonia, and another was cognitively intact with CKD, CHF, and AFib. The SW confirmed no written Advance Directive information was given to either resident or their responsible parties, and the DON stated the facility reviews Advance Directives with families but the chart should document it even if the resident refuses.
MDS assessment entries did not accurately reflect a resident’s status when the resident was receiving Lexapro for depression, but no depression diagnosis was documented in the MDS record. The resident had Parkinson’s disease, delirium, unspecified psychosis, and severely impaired cognition, and the MDSC stated the diagnosis should have been clarified with the physician; the DON stated inaccurate MDS assessment prevents proper care and treatment.
Failure to document behavioral monitoring for Seroquel use: A resident with Parkinson's disease, delirium, unspecified psychosis, and severely impaired cognition had a physician order for Seroquel for psychosis manifested by restlessness, with monitoring required every shift. The MAR showed missing documentation of psychotic behaviors on multiple shifts, and staff interviews confirmed that documenting and monitoring behaviors was necessary to determine whether the medication was effective.
A resident with left knee pain and bilateral knee OA had a lidocaine 5% patch applied to the left knee without the date written on the patch, and the patch remained in place beyond the 12-hour limit in the manufacturer instructions. An LVN stated she had applied the patch the prior day, while the DON confirmed the patch should have been labeled with the date and removed after 12 hours per the order, MAR, manufacturer labeling, and facility policy.
A resident with chronic respiratory failure and continuous O2 orders was observed with an unlabeled nasal cannula and an oxygen flow meter reading zero, and the resident stated she did not feel air through her nostrils. The RN supervisor said the concentrator was not functioning well and replaced it, while staff interviews and the facility policy confirmed that LNs were responsible for verifying the prescribed O2 flow, ensuring the concentrator worked properly, and dating/changing oxygen tubing and cannulas as required.
The facility failed to ensure nursing staff had the required competencies for resident care. An LVN had no 2025 performance evaluation in the employee file, even though the DON stated licensed nurses should be reviewed 90 days after hire and annually. In addition, a CNA had an online-only BLS certificate, which did not meet the facility CPR policy requiring hands-on practice and in-person skills assessment.
Missing Annual CNA Performance Evaluations: The facility failed to complete annual performance evaluations for three CNAs. The DSD reviewed employee files and found that CNA 3, CNA 4, and CNA 6 had no current-year performance review, while the DON stated evaluations were to be completed after 90 days of employment and annually thereafter. The facility's policy and Employee Handbook both stated that performance reviews are used to assess strengths, areas for improvement, and staff competency.
A resident with recurrent major depressive disorder and severely impaired cognition did not have documented treatment, physician orders, or behavioral monitoring for depression. The H&P, order summary, and progress notes did not reflect depression treatment, and the facility could not provide psych eval notes. An LVN and the DON stated the resident had depression, had a moderate PHQ-2 result, and should have been seen by psych, but no monitoring parameters were found for depression-related behaviors.
The facility failed to ensure complete physician orders for topical pain medications for two residents. One resident received a lidocaine 5% patch for knee pain, but the order did not clearly state the number of patches to apply, and another resident had an incomplete diclofenac sodium gel order that lacked dose, frequency, and application site. The DON stated the lidocaine order should have been specific enough to show the dose.
A resident’s lidocaine patch was applied without the date of application written on it, even though the LVN stated it had been placed the day before and should have been labeled for timely removal. In a separate finding, a discontinued fluticasone-salmeterol Diskus inhaler remained on the med cart without an open date, despite no active order and facility policy requiring inhalers to be dated when opened and discontinued drugs to be removed from storage.
Dietary aides were not competent to independently follow meal tickets and food service instructions. One aide was observed on tray line assembly without verbally clarifying diet orders, and the dietary supervisor stated staff relied on gestures, basic phrases, and visual demonstrations rather than written instructions. A second aide stated he could not independently read or interpret meal tickets, relied on others for direction, and was unable to explain IDDSI or diet texture and liquid consistency levels.
Failure to Honor Resident Food Preferences: A resident with DM, CHF, and iron deficiency anemia, who had intact cognition and was on a CCHO, NAS, soft and bite sized diet, had documented preferences for soup, fish, and no pork or meat. During observation, the resident was served beef at lunch despite stating she disliked beef and pork, and the meal tray card also reflected that preference. The DS said beef was served by mistake during tray line instead of turkey and acknowledged the resident would be upset because her food preferences were not accommodated.
Incorrect splint type documented across OT, care plan, and RNA flowsheet. A resident with a left-hand contracture, left hemiplegia, and severe cognitive impairment was observed receiving RNA ROM and splinting care, but the OT eval, care plan, and RNA flowsheet documented an RHS while the physician order and OT narrative indicated a left wrist splint. The DOR, OT, and DON all confirmed the records did not match and that the OT had incorrectly documented the splint type.
A resident with COPD, atrial fibrillation, dementia, and moderate cognitive impairment received an influenza vaccine despite no signed consent form and a documented refusal by the resident representative. Staff interviews confirmed that education on the vaccine’s risks, benefits, and purpose was not provided before administration, and the DON acknowledged the vaccine should not have been given without verified consent.
Resident Rooms Did Not Meet Required Square Footage: Multiple resident rooms failed to meet the required 80 sq. ft. per resident. Observation showed residents and staff had enough space to move and provide care, but room measurements and the Client Accommodations Analysis confirmed several double-occupancy rooms were only 68.75 to 77.6 sq. ft. per resident. The ADM’s waiver letter noted no resident complaints and stated resident care space was adequate.
A resident with a history of stroke and left side paralysis, who was dependent on staff and had a care plan for pain management, reported pain in her left arm and hand during showering and transfer. Staff did not provide timely pain relief or report the pain as required, resulting in unmanaged pain despite facility policy and care plan interventions.
A facility failed to post a contact precaution sign indicating necessary PPE for visitors of a resident who tested positive for C. Diff. Although staff instructions were present, visitor instructions were missing, which was acknowledged by an RN. The resident had a history of surgical amputation and type 2 DM, and tested positive for C. Diff. Facility policies emphasized infection control, but the lack of visitor signage represented a policy adherence failure.
The facility failed to maintain an effective pest control program, leading to a gnat infestation in various areas, including residents' rooms and the kitchen. Observations revealed unsanitary conditions, such as undated food containers and a strong odor in the shared refrigerator. Staff and family members reported gnats emerging during meal times, with potential contamination risks for residents. Despite efforts to address the issue, the facility's response was delayed, and pest control measures were not promptly implemented.
The facility failed to complete accurate PASARR assessments for three residents diagnosed with mental illnesses prior to admission. These residents were prescribed psychotropic medications, but their PASARR assessments did not reflect their diagnoses, potentially impacting their care. The DON acknowledged the inaccuracies, which could delay necessary treatment and services.
A resident's hearing status was inaccurately documented as adequate in the MDS, despite being hard of hearing and requiring specific communication interventions. Interviews with staff and the resident confirmed the need for hearing aids, and both the MDS Nurse and DON acknowledged the error, emphasizing the importance of accurate MDS documentation.
A resident on Eliquis for venous thrombosis and undergoing renal dialysis was not monitored for bleeding as required by their care plan. Despite the care plan's directives and the facility's policy on anticoagulation management, there was no documentation of monitoring for signs of bleeding, leading to a deficiency in care.
A resident with a hip fracture and other medical conditions was not provided necessary assistance with ADLs, leading to feelings of abandonment. The resident requested a shower due to a wet diaper, but the CNA encountered difficulties with the transfer and did not follow through with promised care. Lack of communication and coordination among staff contributed to the unmet needs.
A resident with a history of a ruptured popliteal artery did not receive a timely venous and arterial doppler test as ordered by the physician due to the unavailability of an x-ray technician. The facility failed to notify the physician of the delay, and there was inadequate monitoring of a hematoma on the resident's left leg, as it was only visually checked without accurate measurement. This lack of communication and assessment could have delayed diagnosis and treatment.
A resident with anxiety and major depressive disorder was not provided access to necessary hearing services despite being hard of hearing. The care plan noted communication issues, and staff confirmed the resident's need for hearing aids. The facility's policy required assessment for ancillary services, but the resident did not receive the needed audiology services.
A resident at risk for falls had a bedside table placed on top of landing pads intended to cushion falls, posing a potential injury risk. Facility staff acknowledged the inappropriate placement and the potential hazard it created.
The facility failed to maintain up-to-date employee files, resulting in missing TB tests, skills competency checklists, performance evaluations, health exams, and background checks for several staff members. The DSD and DON acknowledged these deficiencies, which could impact resident care and safety.
Two residents were affected by the facility's failure to monitor and justify medication use. One resident was on methenamine without proper testing or history of UTIs, risking antibiotic resistance. Another resident on Eliquis lacked monitoring for adverse effects, risking bleeding and anemia. Facility policies on medication management were not followed.
Two residents were administered psychotropic medications without proper non-pharmacological interventions or reevaluation of medication appropriateness. One resident received Ativan without documented anxiety episodes or attempts at non-pharmacological interventions, while another resident's medication regimen was not reviewed despite recommendations. Facility policies on medication administration were not followed, leading to potential unnecessary medication use.
A medication cart was left unlocked and unattended by an LVN during medication administration, posing a risk of unauthorized access and accidental ingestion by residents. Interviews with the RNS and DON confirmed the importance of securing the cart, as outlined in the facility's policy.
The facility failed to follow infection control protocols for two residents by not changing and labeling nasal cannulas as per policy. A resident's outdated nasal cannula was not replaced weekly, and another resident's nasal cannula and humidifier were not labeled upon admission, increasing infection risk.
The facility lacked a qualified Infection Preventionist (IP) with the necessary CDC-required training. The IPN held a 16-hour Boot Camp certificate, insufficient for the 19.75-hour requirement. The IPN and DON acknowledged the certification gap, and no policy outlined the required qualifications. The facility's job description mandated compliance with CDC and OSHA regulations, which was not achieved.
The facility failed to meet the required square footage per resident in 12 rooms, with some rooms housing two residents each measuring between 68.75 to 77.6 square feet per resident, and single-resident rooms not meeting the 100 square feet requirement. Despite this, observations showed residents had sufficient space for movement and care, with no adverse effects on privacy, health, or safety noted.
Failure to Provide Timely ADL Assistance and Call Light Response
Penalty
Summary
The deficiency involves the facility’s failure to provide timely assistance with activities of daily living (ADLs) and to respond promptly to call lights for three residents who required staff help. Surveyors observed a resident’s call light illuminated while an LVN, PT, and CNAs walked past the room without responding. Facility policy on call lights stated they were to be answered within a reasonable time, and the DON, LVN, and CNA interviewed all stated that all staff were responsible for answering call lights as soon as they were activated. One resident with diabetes, gait abnormalities, and coordination problems required substantial to maximal assistance with lower body dressing, toileting hygiene, transfers, and bed mobility, and was cognitively intact and able to communicate needs. This resident reported that on unspecified dates it sometimes took 30 minutes to one hour for night-shift nurses to respond to call lights for assistance with bathroom use and obtaining water. Another resident with diabetes, gait abnormalities, and a right below-knee amputation, who required supervision or touching assistance for ADLs and was frequently incontinent of urine and occasionally incontinent of bowel, stated that it sometimes took one hour for night-shift nurses to respond to call lights for incontinence care. A third resident with COPD, diabetes, gait abnormalities, and muscle weakness was totally dependent on staff for toileting, showering, and lower body dressing, was always incontinent of bowel and bladder, and was care planned for nursing assistance with toilet use. During observation and interview, this resident was seated in a chair with the call light on, stating a need to urinate. The ADM and CNA told the resident to urinate in the incontinence brief, and the resident reported that staff typically took about 30 minutes to respond to call lights, that she considered herself continent, that staff told her to urinate in her brief, and that she had not been provided a bedside commode and did not like being left wet while waiting to be changed. CNA and LVN interviews confirmed that telling the resident to urinate in the brief instead of offering a bedpan or bedside commode was not appropriate and that leaving residents wet or with unanswered call lights for extended periods was inconsistent with facility expectations and policies for perineal care and call light response.
Unnecessary psychotropic medications used without supporting diagnoses
Penalty
Summary
The facility failed to ensure that two sampled residents were free from unnecessary psychotropic medications. For one resident, quetiapine (Seroquel) was continued for psychosis manifested by agitation even though the record did not show a specific psychiatric diagnosis supporting its use. For the other resident, escitalopram (Lexapro) was ordered for depression manifested by little interest in doing things, but the admission record did not document a diagnosis of depression and there was no psychiatric evaluation documented for the medication after admission. For the resident receiving quetiapine, the admission record listed dementia with behavioral disturbance and a history of falls. The H&P described the resident as mostly nonverbal with dementia and did not identify a psychiatric or mood disorder. The MDS showed severely impaired cognition and did not list schizophrenia, bipolar disorder, or depression. The order summary and MAR showed quetiapine was administered repeatedly for psychosis or dementia with psychosis manifested by agitation. During interview, the RNS stated the resident did not have a specific diagnosis for quetiapine use beyond dementia psychosis, that the psychotropic evaluation did not include assessment notes, and that there were no specific behaviors being monitored or documented. The DON stated the resident was placed on Seroquel for psychosis manifested by agitation and that a diagnosis based on a psychiatrist’s evaluation should have been present. For the resident receiving Lexapro, the admission record listed Parkinson’s disease, delirium, and unspecified psychosis, but no diagnosis of depression. The MDS indicated the resident was on an antidepressant but did not document depression. The order summary showed escitalopram 5 mg daily for depression manifested by little interest in doing things, and the care plan addressed antidepressant use related to depression. The MDSC stated she did not see a depression diagnosis in the hospital H&P, coded the antidepressant because the resident was receiving the medication, and found no evidence of a psychiatric consultation. The DON stated residents admitted on psychotropic medications from the hospital and continued on those medications should be evaluated by a psychiatrist, and that confirming the diagnosis and indication was necessary for appropriate use.
Missed ROM and restorative nursing services
Penalty
Summary
The facility failed to provide ordered ROM services for two residents with ROM concerns. Resident 65 was admitted with a left-hand contracture, left hemiplegia, and COPD, and the MDS documented severe cognitive impairment with dependence or substantial assistance for multiple ADLs. An OT evaluation dated 3/25/2025 documented impaired ROM in the left thumb, index finger, middle finger, ring finger, and little finger, but the evaluation did not objectively measure the limited finger ROM. The resident also had physician orders for RNA to provide AAROM to the right arm, PROM to the left arm, PROM to both legs, and to apply a resting hand splint to the left hand for 2 to 4 hours, 4 times a week. Review of Resident 65’s RNA flowsheets for June, July, and August 2025 showed multiple blank entries for ordered ROM exercises and splint application. During an observed RNA session, the resident was in bed with the left arm positioned in a contracted posture and both legs fully straight with the toes pointed downward. RNA 1 provided ROM to the left arm, applied the left wrist splint, and assisted with ROM to the right arm, but did not provide PROM to the right knee even though the order was for both legs. RNA 1 stated she forgot to do the right knee and confirmed the order required ROM to the entire leg, including hips, knees, and ankles. The DSD confirmed missed RNA sessions for both arms and both legs and missed splint applications across the reviewed months, and stated the resident did not receive RNA treatments as ordered. Resident 52 was admitted with left hemiplegia and hemiparesis following a cerebral infarction and dysphagia. The resident had physician orders for AAROM to both arms and both legs three times a week. Review of the June, July, and August 2025 RNA flowsheets showed numerous blank squares indicating missed restorative sessions. During observation, Resident 52 was sitting in a wheelchair, stated staff did not assist with ROM exercises, raised the left arm to shoulder height, minimally lifted the left leg off the leg rest, was unable to fully straighten the left knee, and moved the left ankle only minimally. The DSD confirmed the missed RNA sessions for Resident 52 and stated the resident did not receive RNA treatments as ordered by the physician.
Medication Administration Errors Exceeded Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5% during medication pass, with surveyors identifying errors affecting four sampled residents. The report states the medication error rate was 16.67%, based on observation, interview, and record review. The deficiencies involved late administration of ferrous sulfate for two residents, improper handling of a lidocaine patch for one resident, and crushing and mixing acetaminophen and aspirin together for another resident. For one resident admitted with unspecified anemia, surveyors observed an LVN administer ferrous sulfate at 10:00 a.m. even though the order was scheduled for 7:15 a.m. The resident’s record showed the ferrous sulfate order was for 325 mg twice daily for anemia. For another resident with anemia, the eMAR showed ferrous sulfate scheduled for 7:15 a.m. but administered at 10:38 a.m. The LVN stated the medication was supposed to be given at 7:15 a.m. and that it should have been given with breakfast, and the DON later stated both residents received the medication late. For a resident with left knee pain and bilateral knee osteoarthritis, surveyors observed a lidocaine patch on the left knee with no date or time written on it. The LVN stated she remembered placing the patch the previous day, but the patch was still present during the next morning’s medication pass. The resident’s order summary showed lidocaine patch use for pain management, and the manufacturer labeling reviewed by surveyors stated the patch should be applied only once for up to 12 hours within a 24-hour period. The DON stated the patch should have been labeled with the date of application and removed after 12 hours. For a resident with a displaced right femur fracture and severe cognitive impairment, an LVN prepared acetaminophen and aspirin and crushed two acetaminophen tablets and one aspirin tablet together in the same bag. The LVN stated she planned to crush additional medications together as well, and only after being questioned did she discard the mixed powder and crush the medications individually. The resident’s orders included acetaminophen, aspirin, zinc, vitamin C, and docusate sodium, and the facility’s medication administration policy stated multiple crushed medications must be crushed and administered separately and never mixed together.
PRN Opioid Medications Given Outside Ordered Pain Parameters
Penalty
Summary
Resident 3 was admitted with diagnoses that included a nondisplaced longitudinal fracture of the left patella, fractures of the right pubis, and chronic pain syndrome. The MDS dated 3/29/2025 indicated the resident’s cognition was severely impaired and that the resident required varying levels of assistance with ADLs, including setup or clean-up assistance for eating, oral hygiene, and personal hygiene, moderate assistance for upper body dressing, and maximal assistance for toileting hygiene, showering, lower body dressing, and putting on or taking off footwear. The resident had active physician orders for pain monitoring and two PRN opioid medications: hydrocodone-acetaminophen 10-325 mg every 6 hours as needed for moderate pain and morphine sulfate oral solution 20 mg/5 mL, 1 mL every 4 hours as needed for severe pain. The order summary initially did not specify numeric pain-scale parameters for the medications. The MAR showed hydrocodone-acetaminophen was administered multiple times when the documented pain score was 7 or 8, and morphine sulfate was administered multiple times when the documented pain score was 6, which was outside the prescribed parameters for moderate pain and severe pain. The MAR for 11/1/2025 through 11/30/2025 showed seven hydrocodone-acetaminophen administrations outside the ordered moderate-pain range and nine morphine sulfate administrations outside the ordered severe-pain range. The MAR for 12/1/2025 through 12/10/2025 showed three hydrocodone-acetaminophen administrations outside the ordered moderate-pain range and three morphine sulfate administrations outside the ordered severe-pain range. During interviews, the DON stated each PRN order should have included a pain level so staff could determine the correct medication, and that giving both medications inaccurately or for the same pain level could increase the resident’s risk for drowsiness, sedation, respiratory depression, hospitalization, and death. An LVN stated hydrocodone-acetaminophen should not have been given for a pain level of 8 because that would be severe pain and morphine sulfate should have been given, and stated the facility should have clarified the orders that did not specify pain level.
Unlabeled Food, Incomplete Monitoring Logs, and Dirty Ice Machine
Penalty
Summary
Food items were observed stored without labels or dates in multiple areas of the kitchen during a concurrent observation and interview with the CK. In refrigerator #1, tomatoes, celery, and bell peppers were unlabeled and undated. In refrigerator #2, butter, milk, eggs, cheese, and tortillas were unlabeled. In the freezer, tilapia, ground beef, turkey, and pork were observed without labels or dates. In the dry storage area, two loaves of bread and a container of mayonnaise were also unlabeled. The CK stated he was unable to explain why the items were not labeled or dated and stated that all food items should be labeled and dated according to facility policy. The facility’s ice machine was observed during a concurrent observation and interview with the CK, and the interior bin door surface was wiped with a white paper towel that revealed black residue resembling dirt or dust. The CK stated dietary staff are responsible for monthly cleaning of the ice machine and the PS is responsible for servicing and cleaning it every three months. During later interviews, the PS stated the residue could be mold or dirt and that the interior bin door did not appear clean and looked as though it had not been adequately cleaned. The DS also reviewed the photograph and stated the residue appeared dirty and could pose a risk for contamination. The DS stated dietary aides are responsible for routine cleaning and wipe-down of the ice machine monthly, while the PS is responsible for quarterly deep cleaning and maintenance. Review of the Cold Storage Temperature Log, Quaternary Ammonia Log, and Dish Machine Temperature Log showed multiple missing entries. There was no documentation for refrigerator #1, refrigerator #2, and the freezer for the am shift on December 8, and no documentation for the pm shift on December 6, 7, and 8. The dishwashing sanitation logs were missing entries for the am shift on December 7 and 8 and the pm shift on December 5, 6, and 8. The dishwashing temperature logs were also incomplete for dinner on December 5 and 6, dinner on December 7, breakfast and lunch, and breakfast on December 8. The CK and DS stated these logs were required to be completed daily, but neither could explain the missing entries at the time of review. The DS stated that unlabeled food, incomplete logs, improper sanitizer monitoring, and ice machine sanitation failures could result from system failures, and the facility policies reviewed required food labeling and dating, dish machine temperature logging, and cleaning of the ice machine according to manufacturer instructions.
Infection Control Failures in Medication Pass and Laundry Handling
Penalty
Summary
The facility failed to implement proper infection control practices during medication administration and laundry handling. During a medication pass observation, an LVN prepared multiple medications for a resident with unspecified glaucoma and moderately impaired cognition, including lidocaine patches, artificial tears eye drops, and several oral medications. Although the LVN checked the resident’s blood pressure and heart rate before giving the medications, she did not perform hand hygiene and/or change disposable gloves before administering the artificial tears eye drops. The resident’s record showed the eye drops were ordered for dry eyes, and both the LVN and DON stated handwashing was important before eye drop administration to prevent eye infection. In the laundry area, open trash bags were observed on top of dirty linen hampers. A laundry aide stated the trash bags should have been tied and placed inside the hampers rather than left on top. The Maintenance Supervisor and DON both stated that open garbage bags should not be left on top of hampers because of cross-contamination concerns. The facility also failed to separate dirty and clean laundry activities. Two hampers of dirty clothes and linens were observed across from washing machines in the same room where clean laundry was removed from the machines, and the laundry aide stated dirty linens and clothes were sorted in that same room. In addition, a reusable isolation gown was observed hanging on the wall next to the clean laundry area, and the laundry aide stated it was clean and would be used to sort dirty clothes and linens. The Infection Prevention Nurse and DON stated that sorting dirty laundry in the same area as clean laundry and hanging a reusable gown near the clean area created cross-contamination concerns.
Failure to Obtain Informed Consent Before Influenza Vaccination
Penalty
Summary
The facility failed to obtain a signed informed consent before administering the influenza vaccine to one resident with chronic obstructive pulmonary disease, atrial fibrillation, and dementia. The resident’s H&P noted fluctuating decision-making capacity, and the MDS indicated moderate cognitive impairment with partial/moderate assistance needed for several activities of daily living. Review of the immunization consent documentation showed an August consent form with no resident or resident representative signature, and a later consent form documented that the resident representative declined the influenza vaccine. Despite the documented refusal and the absence of a signed consent, the resident’s immunization record showed the influenza vaccine was administered on October 2, 2025. During interview and record review, the IP confirmed the consent should have been obtained before any immunization and stated the facility’s process requires staff to notify the resident representative, obtain documented consent or refusal, and ensure the consent form is signed and entered into the EHR before vaccination is given. The IP also confirmed the record did not show a signed consent or that the representative was contacted before the vaccine was administered. The CM stated she witnessed the consent form even though it lacked a resident or resident representative signature. The DON reviewed the record and stated there was no education provided to the resident or resident representative regarding the risks, benefits, or purpose of the influenza vaccine before administration, and acknowledged the vaccine should not have been given. Facility policy stated residents or their representatives must receive education before a vaccine is offered and must be given the opportunity to refuse immunizations, with a physician order obtained if consent is given.
Failure to Provide and Document Advance Directive Information
Penalty
Summary
The facility failed to provide and document that Advance Directive information was discussed with two sampled residents and/or their responsible parties, Resident 16 and Resident 54. Resident 16 was admitted with diagnoses including Mixed Receptive-Expressive Language Disorder, dysphagia, and pneumonia, and the MDS dated 10/01/2025 indicated severe cognitive impairment and a need for partial/moderate assistance with hygiene and toileting. Resident 54 was admitted with diagnoses including Chronic Kidney Disease, Congestive Heart Failure, and Atrial Fibrillation, and the MDS indicated the resident was cognitively intact and required substantial/maximal assistance with bed mobility, transfer, dressing, toilet use, personal hygiene, and bathing. During a concurrent interview and record review on 12/10/2025, the SW stated the medical records showed no written information regarding an Advance Directive had been provided to Resident 16 or Resident 54, and that she did not provide written information on how to complete an Advance Directive to either resident or their responsible parties. During an interview on 12/11/20256, the DON stated the facility reviews Advance Directives with families and that it was important to document this in the resident chart even if the resident refused. The facility policy dated 4/2025 stated that prior to, upon, or immediately after admission, staff shall provide written information regarding the right to accept or refuse medical or surgical treatment and the right to formulate Advance Directives, and document that this information was provided.
MDS Did Not Reflect Depression Diagnosis for Resident Receiving Lexapro
Penalty
Summary
The facility failed to ensure that Resident 25’s MDS accurately reflected the resident’s status during the assessment period. Resident 25 was admitted with diagnoses including Parkinson’s disease, delirium, and unspecified psychosis, and the MDS dated 11/30/2025 showed severely impaired cognitive skills and substantial/maximal assistance with transfer from bed to chair and bed mobility. The MDS also indicated the resident was receiving an antidepressant, but no diagnosis of depression was documented in the assessment record. Record review showed an order for escitalopram oxalate 5 mg daily for depression manifested by little interest in doing things, and the care plan was titled for antidepressant medication use related to depression manifested by little interest in doing things. During interview, the MDSC stated the resident was receiving Lexapro from the GACH but she did not see a diagnosis of depression in the H&P during her assessment, and she coded antidepressant use because the resident was receiving the medication. The MDSC stated there was no evidence of a psychiatric consultation while the resident was receiving psychotropic medications and that the licensed nurse should have clarified the diagnosis for Lexapro use with the physician at admission. The DON stated that proper care cannot be provided if the MDS assessment was inaccurate.
Failure to Document Behavioral Monitoring for Seroquel Use
Penalty
Summary
The facility failed to follow the care plan intervention for monitoring signs and symptoms of psychosis for one resident receiving Seroquel for psychosis manifested by restlessness. The resident was admitted with diagnoses including Parkinson's disease, delirium, and unspecified psychosis, and the MDS indicated severely impaired cognitive skills and use of an antipsychotic medication. A physician order directed Quetiapine (Seroquel) 50 mg by mouth at bedtime for psychosis manifested by restlessness, with monitoring of episodes of psychotic behavior every shift. During record review, behavioral monitoring for episodes of psychotic behavior such as restlessness was not documented on multiple shifts in the resident's MAR. In interviews, an LVN stated that licensed nurses should document and monitor episodes of psychotic behavior to ensure the effectiveness of Seroquel, and another LVN stated that consistently monitoring and documenting behaviors was essential to determine whether Seroquel was effective in managing psychotic symptoms. The DON also stated that following the resident's care plan was essential to determine whether the interventions related to Seroquel were effective and if the medication was successfully managing behaviors associated with psychosis.
Lidocaine Patch Not Labeled or Removed on Schedule
Penalty
Summary
The facility failed to ensure Resident 18’s lidocaine 5% patch was implemented according to manufacturer specifications and professional standards of practice. Resident 18 was admitted with left knee pain and bilateral primary osteoarthritis of the knee, and the MDS dated 11/14/2025 indicated moderately impaired cognition and need for varying levels of assistance with ADLs. The physician order was for lidocaine external patch 5% to the left knee in the morning for pain management and removal per schedule. During observation on 12/10/2025 at 9:28 a.m., an LVN prepared medications for Resident 18 and removed a lidocaine 5% patch from its package for application to the resident’s left knee. During a concurrent observation and interview at 9:45 a.m., the LVN stated the patch on the resident’s left knee did not have a date written on it, but she remembered it had been applied the previous day because she had placed it there on 12/9/2025. The MAR documented the patch was to be removed daily at 8:59 a.m. and applied daily at 9:00 a.m. During later interview and record review, the LVN and DON stated the patch should have been labeled with the date of application and removed after 12 hours per manufacturer instructions. The manufacturer labeling reviewed with the LVN stated the patch should be applied only once for up to 12 hours within a 24-hour period. The facility policy for transdermal patch application also required the patch to be labeled with the date and nurse’s initials, and the DON stated the patch should not have remained on the resident’s affected area the following morning during medication pass.
Failure to Provide Ordered Oxygen Therapy and Label Oxygen Equipment
Penalty
Summary
Resident 22, who was admitted with dependence on supplemental oxygen, weakness, and chronic respiratory failure with hypoxia, was assessed as having severe cognitive impairment and requiring partial/moderate assistance with bed mobility and transfers. The resident had a physician order for continuous oxygen at 2 liters per minute via nasal cannula/mask to keep oxygen saturation above 90%, and the care plan directed staff to monitor for respiratory distress and administer continuous oxygen as ordered. The order summary also directed that oxygen tubing and humidifier be changed every Monday and on night shift. During a concurrent observation and interview, the resident’s nasal cannula was found with no date label and the oxygen flow meter was reading zero. The RN supervisor stated the oxygen concentrator was not functioning well and replaced it immediately. The resident stated she did not feel any air going through her nostrils via the nasal cannula. In interviews, CNA staff stated licensed nurses were responsible for ensuring the oxygen concentrator functioned properly and that the correct amount of oxygen was administered, while the RN supervisor and DON stated licensed nurses were responsible for verifying the prescribed oxygen flow, ensuring the concentrator worked properly, and changing and labeling oxygen tubing and nasal cannula weekly. The facility policy stated oxygen cannulas are changed at least every 7 days and tubing, masks, and other oxygen disposables are dated.
Incomplete Nurse Performance Review and Invalid CPR Certification
Penalty
Summary
The facility failed to ensure nursing staff had the necessary competencies to care for residents in a safe and competent manner. During interview and record review, the employee file for LVN 1 showed no performance evaluation had been completed for 2025. The DSD stated LVN 1 began employment as an LVN on [DATE], and the DON stated performance evaluations should be completed 90 days after hire for newly hired staff and annually thereafter. The DON also stated the evaluation process is used to confirm licensed nurses are providing correct treatments and fulfilling job responsibilities safely, and to identify strengths and weaknesses that can help prevent potential errors in resident care. The facility also failed to follow its CPR policy for CNA 4. Review of CNA 4's employee file showed a BLS certificate obtained online. The facility's CPR policy stated staff must maintain current CPR certification through a provider whose training includes hands-on practice and in-person skills assessment, and that online-only certification is not acceptable. The DSD stated CNA 4 would not be able to perform efficiently during emergencies if the CPR certification was obtained solely online. RN Supervisor 1 stated maintaining a valid CPR certificate is important so the CNA can respond and implement life-saving measures during emergencies involving residents in the facility.
Missing Annual CNA Performance Evaluations
Penalty
Summary
The facility failed to ensure performance evaluations were completed at least once every 12 months for three of five CNAs. During a concurrent interview and record review with the DSD, the employee files for CNA 3, CNA 4, and CNA 6 were reviewed. The DSD stated that CNA 4 began employment on 3/29/2022 and did not have a performance review for 2025. CNA 3, who started on 8/23/2021, also had no performance review for 2025. CNA 6, who started on 10/12/2022, did not have a performance review for 2025. During an interview, the DON stated that performance evaluations were conducted after 90 days of employment for newly hired staff and annually thereafter. The DSD stated that failure to conduct performance reviews for CNAs can lead to improper resident care because their performance was not assessed. The facility's Nursing Competency policy dated 4/2025 stated the facility will have sufficient nursing staff with appropriate skillsets and competencies to ensure safe provision of nursing and related services to residents. The Employee Handbook updated 9/1/2021 stated performance evaluations identify strengths, areas for improvements and objectives or goals for future work performance, and that the supervisor will complete and conduct performance reviews annually.
Failure to Provide Treatment and Monitoring for Depression
Penalty
Summary
The facility failed to provide treatment, monitoring, and services for a resident with a diagnosis of recurrent major depressive disorder. The resident’s admission record listed depression, and the MDS showed severely impaired cognition, need for assistance with ADLs, and a diagnosis of depression. However, the history and physical did not indicate any diagnosis or treatment of depression, and the order summary report did not show any physician orders for treatment or behavioral monitoring for signs and symptoms of depression. The progress note also did not reflect any diagnosis or treatment related to depression. The facility could not provide psychiatrist evaluation notes. During interview, an LVN stated the resident had major depressive disorder as one of her psychiatric conditions, but there was no treatment or medication documented for depression and no behavioral monitoring parameters could be located. The DON stated the resident had depression, that a PHQ-2 indicated a moderate category for depression, and that the resident should have been seen by a psychiatrist. The DON also stated there was no monitoring for depression-related behaviors such as hopelessness, lack of socialization, and refusal to participate in family activities.
Incomplete Medication Orders for Topical Pain Treatments
Penalty
Summary
The facility failed to ensure physician orders for medications were complete and accurate for two of five sampled residents, contrary to its policy titled Physician Orders. For Resident 18, who was admitted with diagnoses including left knee pain and bilateral primary osteoarthritis of the knee and had moderately impaired cognition, staff prepared and administered a lidocaine 5% patch for the left knee. The active order summary stated, "Lidocaine External Patch 5% (Lidocaine), apply to left knee topically in the morning for pain management and remove per schedule," but it did not clearly specify the number of patches to be applied. During interview, the DON stated the order should have been entered in two steps and should have indicated the dose, such as one patch or two patches, to make the order specific. For Resident 11, who was admitted with bilateral primary osteoarthritis of the hip and had moderately impaired cognition, the medication reconciliation performed during observation of the medication pass identified an active physician order for diclofenac sodium external gel that was incomplete. The report states the order lacked a dose, frequency, and location for use. Resident 11's record also showed the resident had varying levels of assistance with ADLs, including setup or supervision for several tasks and supervision for toileting hygiene, showering, lower body dressing, putting on/taking off footwear, and personal hygiene.
Improper Labeling and Storage of a Transdermal Patch and Discontinued Inhaler
Penalty
Summary
The facility failed to ensure a lidocaine 5% patch applied to a resident’s left knee was labeled with the date of application on the day it was applied. The resident had diagnoses including left knee pain and bilateral primary osteoarthritis of the knee, and the MDS indicated moderately impaired cognition and varying levels of assistance needed with ADLs. During medication administration, an LVN applied the patch, but during a later observation the patch on the resident’s left knee did not have a date showing when it had been applied. The LVN stated she remembered it was from the previous day because she had placed it on the resident’s left knee the day before. Record review showed the order for lidocaine external patch 5% was to apply it to the left knee in the morning for pain management and remove it per schedule. The LVN reviewed the manufacturer label and stated it was important to label the patch with the date of application so licensed nurses would know when it was placed. She also stated the patch should have been removed during the 3 p.m. to 11 p.m. shift and that leaving it on longer than 12 hours placed the resident at risk for skin breakdown. The DON stated licensed nurses should have verified the order and labeled the patch with the date of application, and that the patch should only remain in place for 12 hours per manufacturer instructions. The facility also failed to ensure a discontinued fluticasone-salmeterol Diskus inhaler for another resident was removed from Station A and B Medication Cart 1 and labeled with an open date in accordance with manufacturer specifications and facility policy. The resident had COPD and intact cognition, and the medication had been discontinued because the physician changed the order to a different medication. During observation, the inhaler was still present on the cart with no open date. The LVN stated there was no active order for the medication and that it should have been removed from the medication cart immediately after discontinuation and discarded in the medication room. The DON stated the inhaler should have had an open date and should have been removed when discontinued.
Dietary aides were not competent to independently follow meal tickets and food service instructions
Penalty
Summary
The facility failed to ensure dietary staff were competent and able to safely perform assigned job duties, including understanding and accurately following meal tickets and food service instructions, for two dietary aides. During an observation in the kitchen, one dietary aide was seen participating in tray line assembly and appeared to pause before assembling trays, but did not verbally communicate with other staff to clarify diet orders. During a concurrent interview, the dietary supervisor stated dietary staff primarily used single-word communication, gestures, and basic phrases, and that aides did not have direct resident contact. The supervisor also stated that staff asked other employees for help and that tasks were shown visually rather than relying on written instructions. During an interview with the second dietary aide using an interpreter line, the aide stated his duties included assisting with tray line service, reading meal tickets, assembling meal trays according to posted meal tickets, delivering trays, cleaning the kitchen, and assisting supervisory staff. He stated he relied on verbal direction, demonstrations, and instructions from supervisory staff, did not independently read or interpret meal tickets, and followed directions from other dietary staff to ensure trays were assembled correctly. He was unable to state what IDDSI was or independently describe diet texture or liquid consistency levels. A review of the facility's dietary aide job description stated the aide must function independently, have flexibility, personal integrity, and the ability to work effectively.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor Resident 54’s food preference by serving beef at lunch even though the resident had stated a dislike for beef and pork. Resident 54 was admitted and later readmitted with diagnoses including DM, CHF, and iron deficiency anemia. The MDS dated 11/9/2025 indicated the resident had intact cognition and required set-up or clean-up assistance with eating and personal hygiene. The order summary dated 11/16/2025 showed the resident was on a CCHO, NAS, soft and bite sized diet. The Social Services Assessment and Evaluation dated 11/18/2025 documented that Resident 54 loved soup and fish and preferred no pork or meat. During interview and observation on 12/8/2025, Resident 54 stated the food looked mushy, liked fish and scrambled eggs, and disliked meat like pork and beef. The lunch tray served that day contained bite size beef, vegetables, and mashed potatoes, and the resident stated she did not like the food and that the meat tasted like beef. The meal tray card also indicated the resident disliked meat like pork and beef. The Dietary Supervisor stated beef was served instead of turkey because CK 1 made a mistake during tray line, and stated the resident would feel upset because her food preferences were not accommodated. The DON stated not following resident food preferences can put the resident at risk for loss of appetite and interest in ADLs and weakness. The facility policy stated individual food preferences are to be assessed upon admission and communicated to the IDT.
Incorrect splint type documented across OT, care plan, and RNA flowsheet
Penalty
Summary
The facility failed to ensure that splinting recommendations and interventions were accurately documented for one sampled resident with a left-hand contracture, left hemiplegia, severe cognitive impairment, and dependence for most ADLs. During an RNA session, the resident was observed lying in bed with the left arm positioned at her side, the elbow straight, the forearm rotated downward, the wrist fully bent downward, and the hand in a fist. RNA assisted with AAROM to the left shoulder and elbow, attempted to open the left hand, and then applied a splint to the left arm from the forearm to the palm, with the fingers not included in the splint. Record review showed the resident’s OT evaluation, care plan, and December RNA flowsheet did not match the actual splint being used. The OT evaluation referred to a left resting hand splint and the care plan and RNA flowsheet also documented an RHS for 2 to 4 hours, 4 times a week. However, the physician order and the OT evaluation narrative indicated a left wrist splint, and the OT evaluation stated the resident was being trialed for a left resting hand/wrist splint. The resident’s admission record, MDS, care plan, OT evaluation, and RNA flowsheet were reviewed in relation to the splinting intervention. During interviews, the DOR, OT, and DON all confirmed the documentation was incorrect and did not match. The DOR stated the resident had been issued a left wrist splint, not an RHS, and that the OT evaluation, care plan, and RNA flowsheet should have matched. OT stated she had performed the evaluation and initiated the care plan, but incorrectly documented the splint type, and confirmed she had trained RNA on a left wrist splint rather than an RHS. The DON also confirmed the records did not match and stated accurate documentation was important to ensure the proper care and services were provided.
Influenza Vaccine Given Without Valid Consent
Penalty
Summary
The facility failed to obtain informed consent and involve the resident representative before administering the influenza vaccine to one resident. The resident had been admitted and readmitted with diagnoses including COPD, atrial fibrillation, and dementia, and the H&P noted fluctuating capacity to make decisions. The MDS later indicated moderate cognitive impairment and that the resident required partial to moderate assistance with toileting hygiene, showering, bathing, and personal hygiene. During interview and record review, the Influenza and Pneumococcal Immunization Consent Forms were reviewed and showed no resident or resident representative signature on the influenza consent form. A separate informed consent form for the pneumococcal vaccine indicated that the resident representative declined the influenza vaccine. Despite that documented refusal and the absence of a signed consent form, the resident’s immunization record showed the influenza vaccine was administered. The Infection Preventionist stated consent should have been obtained before any immunization and that the facility’s process required staff to notify the resident representative, provide education on risks and benefits, obtain documented consent or refusal, and ensure the form was signed and entered into the EHR before vaccination. The Case Manager stated vaccinations should not be given without verified consent from the resident or legal representative. The DON stated no education regarding the risks, benefits, or purpose of the influenza vaccine had been provided before administration and acknowledged the event as a system failure involving consent verification and communication with the resident representative.
Resident Rooms Did Not Meet Required Square Footage
Penalty
Summary
The facility failed to ensure that multiple resident rooms met the required square footage per resident, with Rooms 1, 2, 3, 5, 6, 7, 9, 12, 14, and 15 identified as not meeting the 80 sq. ft. requirement for each resident. During a facility tour and observation, residents in these rooms were seen with enough space to move around freely and staff had enough space to provide care, and no adverse effects were noted to residents' privacy, health, or safety. However, a later observation found Rooms 1, 2, 3, 4, 5, 6, 7, 9, 12, 14, 15, and 17 did not meet the 80 sq. ft. per resident requirement. Review of the Client Accommodations Analysis form showed Rooms 1, 2, 3, 5, 6, 7, 9, 12, and 15 were occupied by two residents each, and the Maintenance Supervisor stated the total square footage measured between 68.75 sq. ft. and 77.6 sq. ft. per resident. The Administrator's Room Waiver letter stated there were no resident complaints about available space and that there was adequate space for resident care, with residents' health and safety not in jeopardy.
Failure to Provide Timely Pain Management for Resident with Known Pain History
Penalty
Summary
A deficiency occurred when a resident with a history of cerebrovascular accident (CVA) and left side hemiplegia, who was known to experience acute and chronic pain, reported pain in her left arm and hand during care activities. The resident, who was severely cognitively impaired and dependent on staff for all activities of daily living, informed a CNA that her left hand was in pain after it became caught in the shower chair and again when it was stuck behind her during a mechanical lift transfer. Despite the resident's complaints, she was told to wait until after the shower, and her pain was not addressed at the time. The CNA stated she informed the LVN of the resident's pain, but the LVN reported being unaware of any pain complaints. Additionally, a restorative nursing assistant present during the transfer did not report the pain to anyone. The resident was not premedicated prior to care, despite her known history of pain and a care plan that called for administering pain medication before activities likely to cause discomfort. The facility's policy required prompt assessment and intervention for pain, but these steps were not followed, resulting in unmanaged pain for the resident.
Failure to Post Visitor PPE Instructions for C. Diff Positive Resident
Penalty
Summary
The facility failed to ensure that a contact precaution sign indicating the necessary personal protective equipment (PPE) for visitors was posted for a resident who tested positive for Clostridium difficile (C. Diff). This oversight was identified during an observation and interview with a Registered Nurse (RN) in front of the resident's room. Although a stop sign was present, instructing staff to follow contact isolation procedures and apply PPE, it did not provide instructions for visitors to wear PPE. The RN acknowledged the absence of visitor instructions and emphasized the importance of such signage to prevent the spread of C. Diff to other residents, visitors, and staff. The resident involved was admitted to the facility with diagnoses including orthopedic aftercare following surgical amputation and type 2 Diabetes Mellitus. The resident's lab results confirmed a positive test for C. Diff. The facility's policy and procedure documents, including the Infection Prevention and Control Program and Transmission-Based Precautions, as well as the Visitation policy, were reviewed. These documents indicated the facility's commitment to implementing infection control measures and establishing guidelines for visitors to prevent the transmission of communicable diseases. However, the lack of appropriate signage for visitors in this case represented a failure to adhere to these policies.
Facility Fails to Control Gnat Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in an infestation of gnats throughout the premises. Observations revealed gnats in various areas, including the residents' shared refrigerator, Resident 3's room, and the kitchen storage room. The shared refrigerator was found to contain numerous gnats, undated food containers, and a strong odor, indicating a lack of sanitation. Resident 3, who has cognitive impairments and requires assistance with daily activities, was observed swatting gnats away from her food, highlighting the potential for contamination. Interviews with staff and family members confirmed the presence of gnats during meal times, with reports of gnats emerging when food was present. The Dietary Manager and Maintenance Director acknowledged the issue, noting that the gnats were primarily originating from the kitchen drainage and bad fruits in the pantry. Despite efforts to clean and pour hot water down the drains, the infestation persisted. The Maintenance Director admitted that the facility's response was delayed, and pest control measures, such as fogging the kitchen, were not immediately implemented. The facility's pest control policy was not effectively enforced, as evidenced by the lack of UV fly traps in key areas and the improper maintenance of existing traps. The Director of Nursing and other staff members recognized the ongoing issue, with reports of gnats in residents' rooms and dining areas. The facility's failure to adhere to its policies on food storage and environmental sanitation contributed to the infestation, posing a risk of food contamination and discomfort for residents and staff.
Failure to Complete Accurate PASARR Assessments for Residents with Mental Illness
Penalty
Summary
The facility failed to ensure that three residents, who were diagnosed with mental illnesses prior to admission, had a Preadmission Screening and Resident Review (PASARR) assessment completed. This federal requirement is intended to prevent inappropriate placement in nursing homes and ensure residents receive necessary psychiatric services. The deficiency was identified during interviews and record reviews, revealing that the PASARR assessments for these residents were either inaccurately completed or not reviewed, potentially impacting their care and treatment. Resident 22 was admitted with diagnoses including major depressive disorder and psychosis, and was prescribed multiple psychotropic medications. However, the PASARR Level 1 assessment did not reflect these diagnoses or medications. The Director of Nursing (DON) acknowledged the inaccuracies and the potential impact on the resident's care. Similarly, Resident 24, with diagnoses of major depressive disorder, psychosis, and bipolar disorder, had a PASARR that incorrectly indicated no mental illness, which the DON admitted was documented incorrectly. Resident 13, diagnosed with psychosis and prescribed psychotropic medication, also had a PASARR that failed to indicate the diagnosis. The DON confirmed the PASARR was completed inaccurately, which could affect the resident's care. The facility's policy requires accurate PASARR screenings, but the deficiencies in these cases suggest a failure to adhere to this policy, potentially delaying necessary treatment and services for the residents involved.
Inaccurate MDS Documentation of Resident's Hearing Status
Penalty
Summary
The facility failed to ensure the accurate documentation of a resident's hearing status in the Minimum Data Set (MDS), a federally mandated resident assessment tool. The resident, who was admitted with diagnoses including anxiety and major depressive disorder, was documented in the MDS as having adequate hearing. However, the resident's care plan indicated a communication problem related to being hard of hearing in both ears, with interventions such as repeating messages aloud and using non-verbal communication cues. Interviews with the resident, a Certified Nurse Assistant (CNA), and a Registered Nurse Supervisor (RNS) confirmed that the resident was hard of hearing and would benefit from hearing aids. The Minimum Data Set Nurse (MDSN) acknowledged that the MDS inaccurately reflected the resident's hearing as adequate instead of minimal, which was necessary to ensure the resident received appropriate care and services. The Director of Nursing (DON) also confirmed that the MDS should have been marked as minimal for the resident's hearing. The MDS Nurse's job description emphasized the importance of accurate MDS completion and validation of medical record documentation to support MDS coding, highlighting the deficiency in this case.
Failure to Implement Anticoagulant Monitoring Care Plan
Penalty
Summary
The facility failed to implement care plan interventions for a resident receiving anti-coagulant therapy, specifically Eliquis, which is used to prevent or treat blood clots. The resident, who was admitted with diagnoses including venous thrombosis, embolism, and undergoing renal dialysis, had a care plan that required monitoring for signs and symptoms of bleeding, such as blood in urine, black tarry stools, and bruising. However, during interviews and record reviews, it was found that there was no documentation of monitoring for these symptoms, indicating that the care plan was not followed. Licensed Vocational Nurse (LVN) 3 and Registered Nurse Supervisor (RNS) 1 both acknowledged the lack of documentation and monitoring for bleeding, despite the resident's increased risk due to renal dialysis. The Director of Nursing (DON) also confirmed the importance of following the care plan to monitor for bleeding. The facility's policy on General Anticoagulation Management outlined the need for evaluation of bleeding, but this was not implemented for the resident, leading to a deficiency in care.
Failure to Assist Resident with ADLs
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) to Resident 163, who was dependent on staff for showering and toileting hygiene. Resident 163, who had a displaced intertrochanteric fracture of the left femur and other medical conditions, required substantial assistance with mobility and dressing. On the day of the incident, Resident 163 requested a shower due to a wet diaper, but the Certified Nursing Assistant (CNA1) encountered difficulties transferring the resident to the shower chair because of the resident's inability to bend her left leg. CNA1, who was inexperienced in transferring Resident 163, returned the resident to bed with the help of another staff member and promised to provide a bed bath after lunch. However, CNA1 did not follow through with this promise, leaving Resident 163 feeling abandoned and neglected. The resident used the call light for assistance but did not receive the necessary care in a timely manner. CNA1 admitted to not seeking additional help or information on how to properly assist Resident 163, which contributed to the resident's unmet needs. Interviews with other staff members, including CNA2, LVN2, and the Director of Nursing (DON), revealed a lack of communication and coordination in addressing Resident 163's needs. The Physical Therapist (PT1) and RN Supervisor (RNS1) indicated that proper assistance and communication were necessary to prevent such incidents. The facility's policies on resident rights and ADL care emphasize the importance of timely and respectful care, which was not upheld in this case.
Failure to Conduct Timely Medical Test and Monitor Hematoma
Penalty
Summary
The facility failed to provide necessary care and services to Resident 32 by not ensuring a venous and arterial doppler test was conducted in a timely manner as ordered by the physician. The physician had ordered the test on 10/28/2024 to assess circulation in the resident's left leg due to pain and swelling. However, the test was not performed because the x-ray technician was unavailable, and there was no documentation indicating that the physician was notified of this delay. This lack of communication and follow-up could have led to a delay in diagnosis and treatment for the resident. Additionally, the facility did not adequately monitor and assess the size of a hematoma on Resident 32's left leg. The hematoma was first documented on 9/16/2024, and although it was visually checked, there was no accurate measurement to determine if it was increasing or decreasing in size. The resident had a history of a ruptured popliteal artery and was experiencing discomfort, yet the assessment of the hematoma was not specific, and the licensed nurse did not measure its size. The facility's policies and procedures require that the nurse supervisor notify the resident's attending physician when there is a significant change in the resident's condition or treatment. However, in this case, there was no documentation of such notification, and the resident was not informed of the delay in the medical test. This oversight in communication and assessment could have resulted in a delay in addressing potential complications related to the resident's condition.
Failure to Provide Hearing Services to Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 12, received access to necessary hearing services. Resident 12 was admitted with diagnoses including anxiety and major depressive disorder. Despite the Minimum Data Set (MDS) indicating normal hearing, the resident's care plan noted a communication problem related to being hard of hearing in both ears. The care plan included interventions such as repeating messages aloud and using non-verbal communication methods. However, interviews with the resident and staff, including a CNA, a Registered Nurse Supervisor, and the Director of Nursing, confirmed that Resident 12 was hard of hearing and would benefit from hearing aids. The resident expressed a desire for hearing aids to improve her ability to hear, especially when watching television. The facility's policy on ancillary services stated that residents should be assessed for needs such as audiology services upon admission and reassessed quarterly or as needed. Despite this policy, the facility did not provide Resident 12 with access to hearing services, resulting in her continued difficulty in hearing. The staff acknowledged the resident's hearing issues and the potential benefits of hearing aids, yet no action was taken to address this need, leading to the deficiency noted in the report.
Inadequate Fall Risk Precaution for Resident
Penalty
Summary
The facility failed to provide appropriate safety precautions for a resident at risk for falls. Specifically, the resident, who had a history of transient ischemic attack, cardiac pacemaker, dementia, and anxiety, was on fall risk precaution with landing pads placed on the side of the bed. However, a bedside table was observed to be placed on top of the landing pads, which could potentially cause injury if the resident were to fall out of bed and hit their head on the table. Interviews with facility staff, including a CNA, LVN, RNS, and the DON, confirmed that the landing pads were intended to provide a cushioned landing to prevent injury in the event of a fall. The staff acknowledged that the placement of the bedside table on the landing pads was inappropriate and could pose a risk of injury to the resident. The facility's policy on falls indicated that interventions should be identified to prevent falls and address risks, but the presence of the bedside table on the landing pads was contrary to this protocol.
Deficiencies in Employee File Management and Competency Assessments
Penalty
Summary
The facility failed to ensure that employee files were reviewed and kept up to date, resulting in deficiencies in several key areas. Specifically, the facility did not conduct Tuberculosis (TB) tests upon hire and annually for several staff members, including the Director of Staff Development (DSD), Registered Nurse Supervisor (RNS) 1, Licensed Vocational Nurses (LVNs) 3, 4, and 5, and Certified Nurse Assistants (CNAs) 5 and 6. Additionally, these employees did not have a skills competency checklist at the time of hire and annually, nor did they receive annual performance evaluations. Health examinations were also not completed upon hire and annually, and background checks were not conducted prior to the hire date for these employees. During interviews, the DSD acknowledged the lack of TB tests, background checks, and annual competency skills assessments. The Director of Nursing (DON) confirmed that it was the DSD's responsibility to maintain up-to-date employee files to ensure staff competency and performance. The DON emphasized the importance of these records in maintaining resident care and safety, noting that the absence of annual health exams, including TB testing, could potentially expose residents and staff to TB. The facility's job descriptions for LVNs and RNs required evidence of being free of tuberculosis infection upon hire, which was not adhered to in these cases.
Failure to Monitor and Justify Medication Use
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary medications, leading to potential adverse effects. Resident 8 was prescribed methenamine for urinary tract infection prophylaxis without adequate monitoring or justification. The resident's records indicated no history of urinary tract infections, and no urinalysis or culture and sensitivity tests were conducted to confirm the need for the medication. Interviews with the Infection Preventionist Nurse and the Director of Nursing revealed that the prolonged use of methenamine could lead to antibiotic resistance and other adverse effects, such as diarrhea and the destruction of normal flora. Resident 32 was prescribed Eliquis for deep vein thrombosis prophylaxis, but the facility failed to monitor for potential adverse effects of the anticoagulant. The resident's care plan included monitoring for signs of bleeding and other complications, but there was no documentation of such monitoring in the Medication Administration Record. Interviews with nursing staff confirmed that the lack of monitoring placed the resident at risk for preventable conditions like bleeding and anemia. The facility's policies on medication regimen review and antibiotic stewardship were not followed, contributing to the deficiencies. The policies required that each resident's medication regimen be free from unnecessary drugs, with adequate monitoring and indications for use. The failure to adhere to these policies resulted in the inappropriate use of medications for both residents, highlighting a lapse in the facility's medication management practices.
Failure to Ensure Residents Are Free from Unnecessary Psychotropic Medications
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary psychotropic medications. For Resident 11, the facility did not provide non-pharmacological interventions before administering Ativan, a psychotropic medication, as needed for anxiety. Despite having a care plan that included non-pharmacological interventions, the Medication Administration Record (MAR) showed that these interventions were not documented or provided before administering the medication. Interviews with the Licensed Vocational Nurse (LVN) and the RN Supervisor confirmed that Ativan was given without documented episodes of anxiety, and non-pharmacological interventions were not attempted, which could lead to unnecessary medication use and potential side effects. Resident 22's case involved a failure to reevaluate the appropriateness of psychotropic medications. The resident was prescribed multiple psychotropic medications, including Abilify and Quetiapine Fumarate, for psychosis and depression. A Consultant Pharmacist's Medication Regimen Review recommended evaluating the use of these medications due to their similar actions, but this recommendation was not followed up. The Director of Nursing (DON) acknowledged that the psychiatrist referral was needed but not called, leading to a delay in evaluating the resident's condition and the appropriateness of the medications. This oversight could result in the use of unnecessary medications. The facility's policies and procedures on medication regimen review and psychotropic medications were not adhered to in these cases. The policies indicated that non-pharmacological interventions should be attempted before administering psychotropic drugs and that residents should not receive unnecessary medications. The failure to follow these policies resulted in the administration of psychotropic medications without proper assessment and documentation, placing the residents at risk for adverse effects.
Medication Cart Security Breach
Penalty
Summary
The facility failed to ensure that the medication cart was locked and secure during the administration of medications to residents. During an observation, a Licensed Vocational Nurse (LVN) left the medication cart unlocked and unattended while performing handwashing in another room and while entering a resident's room to administer medications. The LVN acknowledged the failure to lock the cart after preparing medications and before administering them to residents. Interviews with the Registered Nurse Supervisor (RNS) and the Director of Nursing (DON) confirmed that the medication cart should be locked when unattended to prevent unauthorized access and potential accidental ingestion of non-prescribed medicines by residents, particularly those with cognitive impairments. A review of the facility's policy and procedure on the security of the medication cart indicated that the cart must be locked before the nurse enters a resident's room or when out of the nurse's view.
Infection Control Deficiency in Nasal Cannula Management
Penalty
Summary
The facility failed to adhere to its infection control measures for two residents, leading to potential risks of infection. Resident 17, who was admitted with acute respiratory failure and atrial fibrillation, had a nasal cannula that was not changed according to the facility's policy. The nasal cannula was observed to be outdated, as it was dated 10/20/2024, despite the policy requiring a change every seven days. This oversight was confirmed by a Licensed Vocational Nurse (LVN), who acknowledged the importance of changing the nasal cannula to prevent infection. Similarly, Resident 168, admitted with a displaced intertrochanteric fracture and traumatic subdural hemorrhage, had a nasal cannula and humidifier that were not dated or labeled upon admission. This was contrary to the facility's policy, which mandates dating and labeling to ensure timely replacement. The Infection Prevention Nurse and the Director of Nursing both emphasized the necessity of changing the nasal cannula weekly to prevent infections, which could lead to serious health issues such as pneumonia.
Inadequate Infection Preventionist Certification
Penalty
Summary
The facility failed to have a qualified Infection Preventionist (IP) on staff with the necessary qualifications and specialized training in Infection Control and Prevention. During a record review, it was found that the Infection Prevention Nurse (IPN) held a 16-hour Boot Camp certificate for Long Term Care Facilities, dated 6/5/2018, which did not meet the required 19.75 hours of training as specified by the Centers for Disease Control and Prevention (CDC). In an interview, the IPN admitted to not having the correct certification and was unaware of the specific requirements. The Director of Nursing (DON) confirmed that the IPN did not possess the appropriate certification. Additionally, there was no policy or procedure in place regarding the required certification for the IP role. The facility's Infection Preventionist Job Description, dated 12/17/202, indicated the need for compliance with CDC, OSHA, and local regulations concerning infection control, which was not met.
Deficiency in Resident Room Size Requirements
Penalty
Summary
The facility failed to ensure that 12 resident rooms met the required square footage per resident, as mandated by regulations. Specifically, rooms 1, 2, 3, 5, 6, 7, 9, 12, 14, and 15, which housed two residents each, did not meet the 80 square feet per resident requirement, with measurements ranging from 68.75 to 77.6 square feet per resident. Additionally, rooms 4 and 17, which housed one resident each, did not meet the 100 square feet requirement, with room sizes of 149.5 and 155.25 square feet, respectively. This deficiency was identified through observations and a review of the Client Accommodations Analysis form provided by the facility's Maintenance Supervisor. Despite the deficiency in room size, observations conducted from October 29 to November 1, 2024, indicated that residents had sufficient space to move around freely, and nursing staff had adequate space to provide care. The rooms were equipped with necessary furniture and resident care equipment, and there were no adverse effects noted on the residents' privacy, health, or safety due to the room sizes. A Room Waiver letter dated October 19, 2023, indicated that no residents had complained about the available space, and there was no evidence suggesting that the room size variation adversely affected the residents' health and safety.
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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.
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Nursing homes near Lomita
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Palos Verdes Health Care Center | 1.1 mi | ★★★★★ | 24 | 0 |
| Sunnyside Nursing Center | 1.9 mi | ★★★★★ | 28 | 1 |
| Torrance Memorial Med Ctr Snf/dp | 1.9 mi | ★★★★★ | 3 | 0 |
| Vermont Healthcare Center | 2.2 mi | ★★★★★ | 29 | 1 |
| Beachside Post Acute | 2.4 mi | ★★★★★ | 10 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.