Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Longwood Manor Conv.hospital during CMS and state inspections, most recent first.
Late Medication Documentation: A resident with HTN, dementia, hemiplegia/hemiparesis after CVA, and G-tube medication orders had morning meds administered by an LVN, but the MAR entries were completed hours later. The covering nurse did not give the morning meds, and the LVN stated documentation should be done right after administration to avoid medication errors such as omitted doses or duplicate dosing.
Failure to timely issue NOMNC before end of skilled coverage. The facility did not provide the NOMNC to resident representatives at least 48 to 72 hours before skilled coverage ended for three residents. Records showed one resident with UTI, acute respiratory failure, and dysphagia; another with UTI, acute kidney failure, and DM; and a third with HTN, COPD, and DM. The BOMA confirmed the notices were given late or at the wrong time, including one notice issued long after skilled services had ended and another signed by the resident before the end of coverage.
A resident's diltiazem HCL was not administered within the ordered pre-meal timeframe, and the MAR showed it was given later than ordered. In addition, the facility failed to obtain two LPN/RN signatures as witnesses on multiple Medication Disposition Records for destroyed non-controlled meds for several residents with serious diagnoses and impaired cognition. The DON and RN confirmed the facility required two licensed nurse signatures for medication destruction.
Unlabeled and expired food items were found in the kitchen, including items in the walk-in refrigerator, freezer, and on the spice rack. An opened bag of chicken patties and several other food items were not labeled, and one container of minced garlic was expired. In a resident's room, opened jars of peanut butter and mayonnaise were not dated or labeled; the resident had COPD, emphysema, schizophrenia, intact cognition, and a history of hoarding food items in the room.
A resident with dementia and severe cognitive impairment was given Rexulti for agitation associated with dementia, but informed consent was not properly obtained and documented before the medication was started. The consent form listed the resident’s son as the representative and noted phone consent, yet an LVN could not confirm the prescriber actually spoke with him, and the LVN was unaware the son had died before the consent date. Facility policy required residents or their representatives to be fully informed of the benefits, risks, side effects, and alternatives before psychotherapeutic drugs were initiated.
A resident with COPD, hemiplegia, muscle weakness, severe cognitive impairment, and right-sided contractures was observed in bed with the call light placed on the contracted side and out of reach. The resident stated he could not reach it, and a CNA and MDS nurse both confirmed it should have been on the left side and accessible; the facility policy also stated the call light must be accessible when the resident is in bed.
Advance directive documentation was not completed for two residents. One resident with impaired decision-making and dependence for ADLs had an AHCD form that did not show the representative was informed of the right to formulate an AHCD and had no representative signature. Another resident with heart failure, pacemaker, and dementia had an AHDA in the chart, but the current AHCD was not maintained in the record and the form remained incomplete after the son who usually made decisions died.
Failure to complete COC documentation after a resident reported chest pain and 911 was called. The resident had COPD, emphysema, and schizophrenia, with intact cognition and capacity to make medical decisions. RN stated the COC was not done, even though it should have included assessment of the change and notification of the MD and family; facility policy required detailed observations and notification within 24 hours.
Failure to Provide Written Transfer and Discharge Notice: A resident with HTN, COPD, and DM was transferred to an acute hospital, but the facility did not provide a written Notice of Proposed Transfer and Discharge to the resident’s representative or notify the local ombudsman. RN stated the representative was not informed about the appeal process, and the SSD noted the written notice is needed so the resident or representative is aware of appeal rights.
Missing Comprehensive Care Plans for Bipolar Disorder and Dementia: Two residents lacked comprehensive person-centered care plans for key diagnoses. One resident with bipolar disorder had no bipolar care plan despite an active diagnosis and significant cognitive and functional impairment. Another resident with dementia had no care plan for the diagnosis or related meds, including Aricept, memantine, and Zunveyl. Staff confirmed the missing care plans during record review and stated the plans were needed to guide monitoring and care.
Failure to Update Diabetic Ulcer Care Plan: A resident with respiratory failure, CVA, and Type 2 DM had a diabetic ulcer care plan that was initiated but not shown as revised. The MDS nurse stated the care plan lacked a revision date, and the facility could not determine whether the wound care interventions were effective or if the wound was healing. Facility policy required the interdisciplinary team to review and update care plans at least quarterly and as needed when condition or needs changed.
A resident with COPD, emphysema, and oxygen therapy had a pack of cigarettes and a loose cigarette left on his bedside table despite a smoking policy that prohibited smoking materials in rooms or where oxygen was in use. Staff acknowledged the cigarettes were not allowed and posed a fire hazard. Separately, a resident with a history of aspiration pneumonia, dysphagia, and cognitive impairment required close supervision during meals, but staff left meal trays in the room without supervision and did not respond when the resident called for help, contrary to the physician order, ST guidance, and care plan.
A resident with emphysema, respiratory failure, and asthma had NC tubing that was not changed weekly as ordered and per facility policy. The resident was observed using NC tubing dated earlier than the expected weekly change date, and the MDS nurse confirmed the tubing should be changed every Sunday to prevent bacteria accumulation. The facility policy for changing disposable equipment also required NC changes on Saturdays and as needed.
Delayed refill of pain medications: A resident with DM, contractures, muscle weakness, and major depressive disorder reported severe bilateral leg pain and neuropathy pain rated 9/10 after not receiving morning doses of Gabapentin and Duloxetine because the meds were not available. The MAR showed the doses were missed due to nonavailability, and an LVN stated refills should be requested a week before medication runs out and that the resident should not have run out.
Improper medication storage was observed when staff food was found in a medication refrigerator, discontinued ondansetron remained on a med cart for a resident with intact cognition, and aerosol nebulizers were left at another resident’s bedside despite an assessment stating the resident was unsafe to self-administer meds. Staff confirmed the food should not have been in the refrigerator, the discontinued medication should have been removed, and the nebulizers were to be stored in the med cart.
Failure to Complete Ordered Lab Tests: A resident with bipolar disorder, DM, and anemia had physician orders for CBC, TSH, BMP, FT4, pre-albumin, iron panel, and a Depakote level, but several ordered labs were not completed and results were unavailable. RN stated there was no documentation of refusal or follow-up with the lab provider, and the resident had moderately impaired cognition and required staff assistance with ADLs.
Incomplete documentation of lab orders and OOP log: A resident with bipolar disorder, DM, and anemia had physician-ordered CBC, TSH, BMP, FT4, pre-albumin, iron panel, and Depakote level testing, but the RN did not document the order in the progress notes. Another resident with COPD, emphysema, and schizophrenia went out on pass, but the OOP log was missing a legible date, departure time, return date, and clear return time, and the ADON confirmed the record was incomplete.
A resident with DM, schizoaffective disorder-bipolar type, HTN, and COPD had foam padded siderails on the bed. The IPN confirmed the foam siderails were porous and could hold bacteria and viruses, and stated they were used for residents with seizures and falls; the resident was identified as a fall risk. The facility policy addressed maintaining a safe, sanitary, and comfortable environment.
Surveyors found that a resident on Enhanced Barrier Precautions (EBP) for wound-related concerns had multiple staff personal items, including purses, bags, and drink containers, stored on top of the closet in the resident’s room. The resident, who had cirrhosis, pleural effusion, and muscle weakness and required substantial/maximal assistance with ADLs, denied ownership of the items and could not identify who placed them there. The IPN confirmed that staff should not store personal belongings in an EBP room, as this practice conflicted with the facility’s EBP and infection control policies intended to prevent transmission of multidrug-resistant organisms and other infections.
Staff failed to keep the smoking patio door closed, allowing cigarette smoke to enter the building and be detected in hallways near resident rooms. A CNA was observed leaving the door open and acknowledged the issue, while the Infection Prevention Nurse confirmed that smoke in the building can cause annoyance and breathing difficulties for residents. Facility policy requires maintaining a homelike environment with neutral scents, which was not upheld.
A resident with muscle weakness, an artificial hip joint, and a contracture was not provided with physician-ordered bilateral knee splint application by the RNA as required. Documentation over a 30-day period showed no evidence that the splints were applied as ordered, despite the care plan and facility policy specifying the need for restorative nursing care to maintain function.
Multiple residents did not receive their prescribed medications, including metformin, gabapentin, and pain medications, at the times ordered by their physicians. Medications were administered late or missed entirely, and pain assessments were not consistently documented, contrary to facility policy. Staff interviews confirmed delays and omissions in medication administration and documentation.
A resident's insulin was not relabeled or discarded after a physician changed the dosing order, resulting in the medication cart containing insulin with outdated instructions. The nurse did not immediately notify the pharmacy or place a change of order label on the medication, contrary to facility policy, leading to a risk of medication administration errors.
Surveyors found that staff did not ensure call lights were within reach for two residents who required significant assistance with ADLs, and oral care was not provided for one resident after meals. Both a CNA and an LVN confirmed the call lights were not accessible as required by care plans and facility policy, and the CNA acknowledged oral care was missed following a room transfer.
A registered nurse lacked the necessary competencies to accurately assess a newly admitted resident, resulting in the resident receiving an unnecessary higher dose of Seroquel for an incorrect diagnosis and experiencing a delay in the identification and treatment of a significant pressure ulcer. Facility staff did not follow proper admission assessment protocols, leading to both medication errors and delayed wound care.
A resident was administered Seroquel, an antipsychotic medication, without documented assessment or adequate indication for its use. The medication was continued for a diagnosis of bipolar disorder that was not supported by clinical records, and behavior monitoring did not show symptoms warranting its use. Staff and family noted increased lethargy and reduced participation in therapy, while the physician confirmed the absence of a bipolar diagnosis and acknowledged the medication was continued without proper verification.
Several residents at risk for pressure ulcers were not provided with low air loss mattresses as ordered, and two residents with such mattresses had incorrect weight settings, contrary to physician orders and facility policy. Staff interviews and observations confirmed these deficiencies, with staff acknowledging the importance of proper mattress use and settings for pressure ulcer prevention.
Two residents with significant physical dependencies and physician orders for daily bilateral elbow splint application did not receive these restorative nursing services every day as required. Review of documentation and staff interviews confirmed that the splints were not applied daily, contrary to care plans and facility policy, placing the residents at risk for decreased range of motion and contractures.
Three residents were found to have accident hazards in their rooms, including vape devices with cannabis symbols, an improperly padded bed rail for a resident with a seizure disorder, and a lighter kept by a supervised smoker. Staff interviews and observations confirmed that these items were not properly secured or supervised, contrary to facility policy and physician orders.
The facility did not ensure that physician-ordered laboratory tests were completed for two residents, including missing a CBC, CMP, and Ammonia level for a resident with malnutrition and failing to perform weekly pre-albumin blood draws for another resident with encephalopathy and generalized edema, as confirmed by staff interviews and record reviews.
Surveyors observed that an opened box of pasta in dry storage was not labeled with an open date, contrary to facility policy, and the outside compartment of the ice machine was found dirty with hard water deposits. The Dietary Service Supervisor confirmed that staff were responsible for labeling opened food items and cleaning the ice machine, but these practices were not followed or documented as required.
Two residents with significant respiratory conditions and dependent on staff for care were not offered the influenza vaccine, and there was no documentation of the vaccine being administered or declined. Facility records, care plans, and the immunization registry all lacked evidence of vaccine offer or refusal, despite facility policy requiring such documentation.
A resident with cognitive impairment and dependence on staff for ADLs was found with all four bed rails raised without proper assessment or documentation of alternatives, as required by facility policy. Staff interviews and record reviews confirmed that alternatives to bed rails were not attempted or documented prior to their use.
A resident with a documented diagnosis of depression and prescribed antidepressant medication did not have this diagnosis coded in the MDS assessment under the appropriate section. The MDS nurse confirmed the omission, despite facility policy requiring accuracy in MDS completion. This resulted in incorrect data being sent to CMS and could have impacted the resident's care plan.
A resident with documented diagnoses of bipolar disorder and major depressive disorder was admitted without the facility completing and resubmitting a PASARR Level I screening to reflect these mental illness diagnoses. The initial screening from another facility did not identify serious mental illness, and as a result, no Level II evaluation or referral to the state mental health authority was made, contrary to facility policy and federal requirements.
A resident with significant cognitive and physical impairments, who was at risk for pressure ulcers, did not have a care plan updated to specify the use of a low air loss (LAL) mattress. The care plan only referenced general pressure-relieving devices without identifying the LAL mattress, and staff confirmed the omission during review.
A resident with malnutrition, diabetes, and heart failure experienced significant weight loss and had a physician's order for weekly weights, but staff failed to complete and document these weights as required. This resulted in inadequate monitoring of the resident's weight loss, despite care plan interventions and facility policy requiring such monitoring.
A resident with bilateral lower extremity edema and a physician's order for daily compression stockings did not receive them for two weeks due to ill-fitting old stockings and a delay in obtaining new ones. The resident, who was cognitively intact, reported the issue to staff, and both the treatment nurse and DON confirmed the lapse in care, acknowledging that the physician's order was not followed.
A resident with a history of cellulitis, hypertension, and muscle weakness, who was cognitively intact and required supervision for hygiene, did not receive a timely referral to podiatry for onychomycosis despite a wound consultant's recommendation and the resident's request. Staff interviews revealed that the need for podiatry care was known but not acted upon due to oversight, resulting in the resident having long, thick, discolored toenails.
A resident who was cognitively intact and able to participate in toileting with assistance was not provided with a scheduled toileting plan or bladder training, despite assessment findings and facility policy indicating these interventions were appropriate. Staff only provided a diaper and did not offer a bedpan or bedside commode, and no toileting program was attempted.
A resident with COPD was found receiving continuous oxygen therapy through tubing that was not labeled with the date of last change and appeared visibly soiled. Facility protocols and physician orders required regular changing and labeling of oxygen tubing, but these were not followed, resulting in the use of unclean equipment.
A resident with cognitive impairment and total dependence on staff was found with all four bed rails up, despite not using them for mobility or repositioning and being unable to remove them. Staff interviews and record review confirmed that alternatives to bed rails were not attempted prior to their use, and physician orders did not match the resident's abilities. Facility policy required alternatives to be tried before bed rails were used, but no documentation supported this was done.
A resident admitted with cellulitis, hypertension, and muscle weakness was not evaluated by a physician at least once every 30 days for the first 90 days after admission, as required. After the initial physician visit, only a PA conducted subsequent visits, and there was no documentation of physician visits for several months, despite the resident's desire to discuss ongoing health concerns.
A resident with severe cognitive impairment and multiple medical conditions did not have the prescribed Refresh Tears eye drops available in the medication cart. Instead, a nurse found only Polyvinyl Alcohol eye drops, which were not ordered for the resident. The nurse confirmed the correct medication had not been delivered and held the administration, in accordance with facility policy requiring verification of medication orders.
A resident with multiple diagnoses was prescribed Olanzapine for psychosis, and the consultant pharmacist recommended clarifying the behavioral indications for its use. Despite this, there was no documented follow-up by nursing staff with the physician to address or update the order, contrary to facility policy requiring action and documentation of pharmacist recommendations.
Surveyors found that two residents' medications were not managed according to policy: insulin pens for a resident with diabetes and other conditions were not discarded after use, and a bottle of valproic acid for another resident had an illegible label in the medication cart. An LPN confirmed these lapses, which were inconsistent with the facility's medication storage and labeling procedures.
A staff member failed to perform hand hygiene and change gloves between wound care treatments for a resident with multiple medical conditions, including diabetes and chronic respiratory failure. The staff member acknowledged not following proper procedures, which were outlined in the facility's infection control policies.
The facility did not make its most recent survey results easily accessible to residents and the public, as required. During an interview, the Administrator could not locate the survey binder and acknowledged it should be available for review. Facility policy confirms residents' right to examine survey results.
Multiple rooms were found to have less than the required 80 square feet of living space per resident, with three residents occupying rooms measuring between 210 and 214 square feet. Facility documentation and staff interviews confirmed the deficiency, and it was acknowledged that the limited space could impact care delivery and storage of personal and medical items.
A resident with a history of partial amputation and diabetes experienced verbal abuse from a CNA during a disagreement over a wheelchair's placement. The CNA raised her voice and yelled at the resident, causing distress. Staff confirmed the incident as verbal abuse, violating the facility's policy on resident rights.
Late Medication Documentation
Penalty
Summary
The nursing facility failed to ensure medications were documented timely for one resident. Resident 3 had diagnoses including hypertension, dementia, hemiplegia, hemiparesis following a CVA, and was admitted and later readmitted to the facility. The resident’s H&P indicated the resident was able to make decisions for activities of daily living, while the MDS showed the resident was rarely/never understood and sometimes understood others, and was dependent for multiple ADLs including oral hygiene, toileting hygiene, bathing, dressing, footwear, personal hygiene, rolling, and transfers. Resident 3’s care plan included interventions to administer medications as ordered for cardiac distress risk, dementia symptoms, and pain related to polyneuropathy. The order summary listed amlodipine, gabapentin, Namenda, and Plavix via G-tube. On the day reviewed, the covering nurse did not give the morning medications, and LVN 1 later administered the medications but documented them hours after administration: amlodipine was given at 8:52 a.m. and documented at 11:53 a.m., while Plavix, Namenda, and gabapentin were administered at 9:53 a.m. and documented at 11:53 p.m. and 11:54 a.m. LVN 1 stated the documentation was late and should have been completed right after the medications were given to prevent medication errors such as forgetting to document, omitting a medication, or giving it twice. The facility policy stated the person administering the medication records it on the MAR directly after it is given.
Failure to Timely Issue NOMNC Before End of Skilled Coverage
Penalty
Summary
The facility failed to inform and provide the Notice of Medicare Non-Coverage (NOMNC) to resident representatives at least 48 hours before the end of skilled nursing services for three sampled residents. For Resident 128, the record showed diagnoses including UTI, acute respiratory failure, and dysphagia; the MDS indicated cognition was intact and the resident needed moderate assistance with oral hygiene and personal hygiene. During interview and record review, the Business Office Manager Assistant stated the last covered day for skilled services had ended with skilled days remaining and that the NOMNC was given to the representative approximately 42 days after the resident was discontinued from skilled services. For Resident 136, the record showed diagnoses including UTI, acute kidney failure, and DM; the H&P stated the resident was able to make decisions for activities of daily living, and the MDS indicated cognition was intact with substantial assistance needed for toileting hygiene, lower body dressing, and personal hygiene. The BOMA stated the NOMNC was signed by the resident before the end of skilled coverage rather than being given at least 72 hours before skilled services ended. For Resident 164, the record showed diagnoses including HTN, COPD, and DM; the H&P stated the resident did not have the capacity to understand and make decisions, while the MDS indicated the resident was able to understand and be understood by others and needed substantial assistance with oral hygiene, toileting hygiene, and upper body dressing. The BOMA stated the NOMNC was given to the representative one day before the last covered day and that the facility did not follow Medicare guidelines to notify the representative at least 72 hours before the last day of skilled coverage.
Medication Timing and Disposal Documentation Deficiencies
Penalty
Summary
Medication administration was not carried out within the ordered timeframe for one resident. The resident had diagnoses including HTN, COPD, and DM, and the physician ordered diltiazem HCL 90 mg to be given before meals and at nighttime, with instructions to hold the dose if systolic blood pressure was less than 110 or heart rate was less than 70. The MAR showed the medication was administered at 9:00 a.m., 1:00 p.m., 5:00 p.m., and 9:00 p.m. During a medication observation, an LVN stated the medication should have been given at 6:30 a.m., 30 minutes before breakfast, and that it should be given before meals for better absorption. The facility policy stated medications are administered in accordance with prescriber orders, including any required time frame. The facility also failed to ensure two licensed nurses signed as witnesses when non-controlled discontinued medications were destroyed for five residents. Review of the Medication Disposition Records showed missing witness signatures for destroyed medications belonging to residents with significant medical conditions and impaired cognition or decision-making capacity, including anxiety disorder, HTN, hyperlipidemia, bacteremia, and other serious diagnoses. The records reviewed included destroyed Buspar, labetalol, hydralazine HCL, levofloxacin, gemfibrozil, and ondansetron HCL, with the documentation missing the second licensed nurse signature required as a witness. During interview, RN 2 stated there should be two signatures by licensed nurses when disposing or destroying non-controlled medications and that this was important to validate the total number of medications destroyed. The DON stated the facility's process required the signatures of two licensed nurses and acknowledged there was a risk for theft and drug diversion if the Medication Disposition Record was not completed accurately. The facility policies reviewed stated non-controlled medication destruction would occur in the presence of two licensed nurses and that medications would be disposed of in accordance with applicable regulations.
Unlabeled and Expired Food Items in Kitchen and Resident Room
Penalty
Summary
Food items were found not labeled and, in some cases, expired during observations in the kitchen. In the walk-in refrigerator, one pitcher of cranberry juice and one gallon of hamburger dill slices were not labeled, and a 32-ounce container of minced garlic had an expiration date of 5/15/2026. In the walk-in freezer, an opened bag of chicken patties was not labeled. On the spice rack, one pound of opened ground ginger and a 16-ounce lemon juice bottle were also not labeled. The Dietary Services Supervisor stated that not labeling food items could prevent staff from identifying the items or knowing whether they were expired, and that failing to discard expired food could result in foodborne illnesses. The facility policy titled Dating and Labeling required items to be properly covered, dated, labeled, and removed when expired or beyond the best buy date. Food items in one resident's room were also found not dated and labeled. Resident 20 was admitted and readmitted to the facility, had diagnoses including COPD, emphysema, and schizophrenia, and was documented as having the capacity to understand and make medical decisions with intact cognition. The resident's MDS indicated supervision was needed for personal hygiene, showers, and dressing. During observation, an opened jar of peanut butter and mayonnaise in the resident's room were not dated or labeled. The resident's IDT note documented that the resident was hoarding food items in drawers and on the bedside table. MDS staff and the ADON stated the food items should have been labeled and dated, and that the opened food items in the room had the potential to become contaminated and cause food borne illness. The facility policy on food from outside sources stated that outside food brought in by visitors and family was permitted and that staff would assist with safe and sanitary storage, with all outside foods properly dated and labeled.
Failure to Obtain and Document Informed Consent for Psychotherapeutic Medication
Penalty
Summary
The facility failed to obtain and document informed consent before administering Rexulti, a psychotherapeutic medication, to a resident with dementia and severe cognitive impairment. The resident’s H&P stated the resident did not have the capacity to understand and make decisions, and the MDS showed the resident required substantial assistance with multiple activities of daily living. A physician order dated 3/26/2026 directed Rexulti 1 mg by mouth each morning for agitation associated with dementia, and the MAR showed the medication was administered daily during June 2026. During interview and record review, the resident’s Psychotherapeutic Drug Informed Consent Form for Rexulti indicated the resident’s son was the representative and that he was notified and gave consent by phone with the NP. However, LVN 8 stated it was the NP’s responsibility to explain the benefits, side effects, and right to refuse treatment, and she could not confirm that the prescriber actually spoke with the son because she had left a message and he did not return the call. LVN 8 also stated she was not aware the son had died in January 2026 and stated the medication should not be given if consent was not verified. The facility policy required residents and/or their representatives to be fully informed of the benefits, risks, frequency/duration, possible side effects, and alternatives before psychotherapeutic drugs were started.
Call Light Not Within Reach for Resident With Right-Sided Contractures
Penalty
Summary
The facility failed to ensure the call light was within reach for one of four sampled residents, Resident 83. Resident 83’s face sheet showed diagnoses including COPD, hemiplegia, and muscle weakness. The H&P dated 2/12/2025 indicated Resident 83 was able to make decisions for ADLs, while the MDS dated 4/2/2026 indicated cognition was severely impaired and that the resident was dependent on staff for all ADLs and mobility. The care plan, revised on 7/3/2025, included an intervention to place the call light within reach and attend to needs promptly. During observation on 6/24/2026 at 9:24 a.m., Resident 83 was seen in bed with the right arm and hand contracted, and the call light was on the right side of the body. Resident 83 stated he could not reach the call light when he needed assistance. A CNA observed at 9:27 a.m. stated the call light was on the resident’s contracted side and not within reach, and said it should have been on the left side. MDS Nurse 2 later stated Resident 83 had contractures to the right side, the call light had to be on the left side and within reach, and if it was not within reach staff could not attend to him right away. The facility policy titled Answering the Call Light stated the call light was to be accessible to the resident when in bed.
Advance Directive Documentation Not Completed for Two Residents
Penalty
Summary
The facility failed to ensure that two sampled residents had completed Advance Healthcare Directive Acknowledgement documentation. For Resident 7, the face sheet showed admission with rheumatoid arthritis, osteoarthritis of the knee, and anemia. The H&P stated the resident could not make decisions, while the psychosocial assessment indicated no advance directive. The MDS showed the resident was able to understand and be understood by others, with intact cognition, but dependent on staff for several activities of daily living. During interview and record review, the Social Service Director reviewed the AHCD Acknowledgement Form and stated she had called the resident's representative but did not inform or offer the right to formulate an AHCD. The form did not show that written materials were provided, did not show the representative was informed of the right to formulate an AHCD, and had no representative signature. For Resident 144, the face sheet showed diagnoses including heart failure, presence of a cardiac pacemaker, and dementia. The H&P stated the resident did not have the capacity to understand and make decisions, and the AHDA indicated the resident was not capable of making decisions and that the facility did not document the resident's decision regarding advance directives. The MDS showed severely impaired cognition and substantial assistance needed for several ADLs. During interview and record review, the Social Service Director stated the resident's son usually made decisions, but the facility was informed that the son died and the document still needed the doctor’s signature to be legitimate. The facility policy stated that if a resident was incapacitated, information about the right to formulate an advance directive may be provided to the legal representative, and that information about whether an advance directive had been executed would be available in the medical record.
Failure to Complete Change of Condition Documentation After Chest Pain Event
Penalty
Summary
The facility failed to ensure a change of condition (COC) was completed for one resident after the resident complained of chest pain and 911 was called. The resident’s face sheet showed diagnoses of COPD, emphysema, and schizophrenia. The resident’s H&P dated 6/15/2026 indicated the resident had the capacity to understand and make medical decisions, and the MDS dated 5/16/2026 indicated cognition was intact. The MDS also showed the resident required supervision from staff for personal hygiene, showers, and dressing. During interview and record review, RN 1 stated that when the resident had a change of condition, a COC was to be completed even after 911 was called. RN 1 stated the COC for the resident was not done and that it would include an assessment of the change and notification of the physician and family. The facility policy titled, Change in a Resident's Condition or Status, stated the nurse would make detailed observations and gather relevant information before notifying the physician or healthcare provider, and that notifications would be made within 24 hours of a change in the resident’s medical condition or status.
Failure to Provide Written Transfer and Discharge Notice
Penalty
Summary
The facility failed to ensure that a written Notice of Proposed Transfer and Discharge Form was provided to the resident representative and sent to the local ombudsman for one resident who was transferred to a general acute care hospital for swelling of the right upper extremity. The resident’s face sheet showed admission and readmission to the facility, and the history and physical dated 1/3/2026 indicated the resident did not have the capacity to understand and make decisions. The resident’s diagnoses included HTN, COPD, and DM. During a concurrent interview and record review, RN 3 reviewed the resident’s Notice of Proposed Transfer and Discharge Form and stated there was no evidence that the facility provided a written notice to the resident’s representative or faxed the notice to the local ombudsman office. RN 3 stated it was not the facility’s practice to provide a written copy of the notice to the resident or representative, and the resident’s representative was not informed about the appeal process when the resident was transferred to the hospital. The SSD stated it was important to notify the local ombudsman when a resident was transferred to an acute hospital or discharged to a lower level of care, and to provide a written copy of the notice so the resident or representative would be aware of the right to appeal.
Missing Comprehensive Care Plans for Bipolar Disorder and Dementia
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans for two sampled residents. For one resident, the record showed diagnoses including bipolar disorder, epilepsy, and COPD, and the MDS dated 4/8/2026 indicated severely impaired cognition, dependence for toileting hygiene, lower body dressing, and personal hygiene, and an active bipolar disorder diagnosis. During a concurrent interview and record review on 6/25/2026, the MDS nurse stated there were no bipolar disorder care plans for this resident and that all resident information triggering in the MDS should have an individualized comprehensive care plan. For the second resident, the record showed diagnoses including encephalopathy, dementia, and mood disturbances, with dementia diagnosed on 6/6/2026. The H&P dated 6/6/2026 indicated the resident had the capacity to make needs known, and the MDS indicated intact cognition with set-up or clean-up assistance needed for toileting hygiene, showers, and dressing. Physician orders dated 6/6/2026 included Aricept and memantine for dementia, and orders dated 6/16/2026 included Zunveyl for dementia. During a concurrent interview and record review on 6/26/2026, the ADON could not locate a care plan for the resident's dementia diagnosis and stated the care plan should include the diagnosis so staff could monitor behavior. The MDS nurse also stated there was no care plan created for the dementia medications and that there should be a care plan for these medications. Facility policies reviewed stated comprehensive person-centered care plans are based on resident assessments, developed by an interdisciplinary team, and include measurable objectives, resident goals, desired outcomes, and responsible professional services.
Failure to Update Diabetic Ulcer Care Plan
Penalty
Summary
The facility failed to update the care plan for one of eight sampled residents with a diabetic ulcer. Resident 4 was initially admitted to the facility and later readmitted, and had diagnoses including respiratory failure, cerebral infarction, and Type 2 diabetes mellitus. The resident’s H&P dated 6/27/2025 indicated the resident did not have the capacity to make decisions. A physician order dated 6/15/2026 directed wound care for a diabetic ulcer, including cleaning with normal saline, applying betadine swab, covering with a dry dressing, and securing with kerlix every day for 21 days. A review of Resident 4’s MDS dated 3/16/2026 indicated the resident was dependent on staff to roll left and right. The care plan report titled Diabetic Ulcer, initiated on 9/19/2025, did not show a revised date. During interview and record review on 6/26/2026, the MDS nurse stated the care plan did not have a revision date and that without it, the facility could not determine whether the diabetic wound care plan interventions were effective and if the wound was healing. Facility policy stated the interdisciplinary team would review and update the care plan at least quarterly with the quarterly MDS assessment, and that revision of care planning was done quarterly or as needed when the patient’s condition or needs changed.
Unsafe Smoking Materials and Failure to Supervise Meals
Penalty
Summary
A pack of cigarettes and a single cigarette were observed on a resident’s bedside table in his room even though he had COPD, emphysema, schizophrenia, and was receiving oxygen therapy. His record showed he had the capacity to understand and make medical decisions and was cognitively intact, but the interdisciplinary team note documented unsafe behavior of smoking inside his room while on continuous oxygen therapy. The smoking and safety assessment indicated he used tobacco products and was to follow the facility’s smoking policy, which prohibited smoking in rooms or where oxygen was in use or stored. During interview and record review, staff acknowledged that cigarettes were not allowed in resident rooms and that smoking materials in the room were dangerous because the resident smoked and used oxygen. The assistant director of nursing stated the cigarettes created a fire hazard due to the oxygen in the room. The facility policy on smoking stated it was required to ensure resident safety and that there would be no smoking in any room or where oxygen was in use or stored. Resident 65, who had a history of aspiration pneumonia, traumatic subdural hemorrhage, metabolic encephalopathy, and major depressive disorder, had an H&P stating he lacked capacity to understand and make decisions. His MDS indicated he required supervision or touching assistance while eating, and the care plan identified him as at risk for aspiration due to dysphagia. Speech therapy notes stated he required a feeder to monitor meals and prompt safe swallow strategies, and the physician order required close supervision during meals due to high aspiration risk. Despite this, staff observed him with a meal tray in his room without staff present, and CNA 2 stated he could eat independently and did not require supervision. On another observation, the CNA placed the meal tray on the bedside table and left the room, and when the resident called out for help, no staff entered to assist. RN 4 stated the resident could not safely eat without supervision and that staff did not supervise lunch, which was inconsistent with the physician order and care plan.
Nasal cannula tubing not changed weekly
Penalty
Summary
The facility failed to ensure that Resident 128’s nasal cannula tubing was changed weekly according to policy. Resident 128 was initially admitted and later readmitted to the facility, and had diagnoses including emphysema, respiratory failure, and asthma. The resident’s H&P indicated the resident was able to make decisions for activities of daily living, and the MDS indicated cognition was intact. The MDS also showed the resident was dependent on staff for toileting hygiene, showers, and dressing. A physician order dated 6/2/2026 directed that the nasal cannula be changed every night shift on Sundays. During observation on 6/25/2026, Resident 128 was using a nasal cannula dated 6/17/2026 while receiving oxygen at 5 liters. During a concurrent interview and record review, the MDS nurse confirmed the tubing was dated 6/17/2026, stated it had to be changed every Sunday, and explained that weekly changes were required per policy to prevent bacteria accumulation. The facility policy titled Changing Disposable Equipment, dated 3/2019, indicated nasal cannulas were to be changed on Saturdays and as needed.
Delayed refill of pain medications
Penalty
Summary
The facility failed to ensure timely refills of Gabapentin and Duloxetine for one resident with diabetes, bilateral knee contractures, muscle weakness, and major depressive disorder. The resident’s H&P indicated she had the capacity to understand and make decisions, while the MDS later described her cognition as moderately impaired and noted she was dependent on staff for ADLs. During interview, the resident stated she had pain in both legs, described her neuropathy pain as very painful, rated her pain as 9/10, and said she had not received her morning doses of both medications that day. Record review showed the resident’s MAR documented that the morning doses of Duloxetine and Gabapentin were not administered because the medications were not available. During interview, the LVN stated the facility’s refill protocol was to request medication a week before it ran out, and that the pharmacy should have been notified when one week of medication remained. The LVN also stated the resident should not have run out of these medications and confirmed they were used for diabetic neuropathy and that failure to refill pain medication in a timely manner could result in prolonged pain and affect daily activities.
Improper Medication Storage and Discontinued Medication Left on Cart
Penalty
Summary
Drugs and biologicals were not stored in accordance with facility policy when a yellow banana was found inside medication storage 2 refrigerator during a concurrent observation and interview with LVN 5. LVN 5 stated staff food should not be stored in the medication refrigerator and explained that keeping staff food in the refrigerator could cause cross contamination with refrigerated medications. Discontinued ondansetron hydrochloride 4 mg for Resident 141 remained on medication cart one after the ordered 14-day course had ended. Resident 141 was admitted with diagnoses including cerebral infarction, UTI, and HTN, and the H&P and MDS indicated the resident had intact cognition and could understand and make medical decisions. During observation, one bubble pack with 8 remaining ondansetron tablets was still on the cart, and LVN 7 stated it should have been removed and placed in the nursing office bin for destruction. Aerosol nebulizers for Resident 20 were left on the bedside table instead of being stored in the medication cart. Resident 20 had diagnoses including COPD, emphysema, and schizophrenia, and the H&P and MDS indicated the resident had capacity and intact cognition. The self-administration assessment stated it was unsafe for Resident 20 to self-administer medications and that medications should not be kept at the bedside; MDSN 2 confirmed the resident was not to have medication at the bedside and stated the medication was to be stored in the medication cart.
Failure to Complete Ordered Lab Tests
Penalty
Summary
The facility failed to implement a physician's orders to obtain ordered laboratory tests for one resident with bipolar disorder, DM, and anemia. The resident's record showed orders for CBC, TSH, BMP, FT4, pre-albumin, iron panel, and Depakote level. During interview and record review, RN 3 stated the CBC, TSH, BMP, FT4, pre-albumin, and Depakote level were not completed and results were not available, and there was no documentation that the resident refused the blood tests. RN 3 also stated there was no documentation that licensed nursing staff made a follow-up call to the laboratory provider to determine what happened with the ordered tests or results. The resident's MDS indicated moderately impaired cognition and dependence on staff for eating, oral hygiene, and toileting hygiene, while the H&P stated the resident was able to make decisions for activities of daily living. The facility policy indicated staff were to process test requisitions and arrange for tests based on the resident's diagnostic and monitoring needs.
Incomplete documentation of lab orders and out-on-pass log
Penalty
Summary
Resident 2 had diagnoses including bipolar disorder, DM, and anemia. The resident’s H&P indicated the resident was able to make decisions for activities of daily living, while the MDS indicated moderately impaired cognition and dependence on staff for eating, oral hygiene, and toileting hygiene. On 4/14/2026, the physician ordered CBC, TSH, BMP, FT4, pre-albumin, iron panel, and Depakote level testing, but the resident’s Progress Notes did not contain documentation by the licensed nurse regarding the laboratory order. During concurrent interview and record review, RN 3 reviewed Resident 2’s Progress Notes and stated the medical record was incomplete because there was no note from the licensed nurse about the physician’s laboratory order. RN 3 stated the licensed nurse should document when receiving an order from the physician and said she did not know the reason the physician ordered the laboratory tests because there was no documentation in the Progress Notes. RN 3 stated complete documentation was important to prevent communication breakdown and support collaboration of care among facility staff. Resident 20 had diagnoses including COPD, emphysema, and schizophrenia. The resident’s H&P indicated the resident had capacity to understand and make medical decisions, and the MDS indicated intact cognition and need for supervision with personal hygiene, showers, and dressing, with oxygen therapy in place. The resident went out on pass, but the OOP log was incomplete: the date was not legible, no time of departure was documented, the return date was missing, and the return time was listed as 11:12 without indicating a.m. or p.m. The ADON stated the date was unclear, there was no time for departure, and the return information was incomplete.
Foam Siderail Used for Resident
Penalty
Summary
Provide and implement an infection prevention and control program was not ensured when a foam pool noodle used as a siderail was observed on Resident 85's upper bed siderails. Resident 85 was initially admitted to the facility and later readmitted, and had diagnoses including type 2 DM, schizoaffective disorder-bipolar type, hypertension, and COPD. The resident's H&P dated 2/5/2025 indicated the resident had the capacity to understand and make decisions, while the MDS dated 3/25/2026 indicated cognition was moderately impaired and that the resident required partial assistance from staff for oral hygiene, personal hygiene, and sitting to standing. During an observation on 6/23/2026, Resident 85's bed was noted to have foam padded siderails. On 6/25/2026, the Infection Prevention Nurse confirmed the foam siderails were in use for the resident and stated they were porous and could hold bacteria and viruses. The nurse also stated the risk of having foam siderails could result in a source of infection and harbor bacteria. The facility's policy and procedures for Infection Prevention and Control stated the goal was to maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public.
Staff Personal Belongings Stored in EBP Room in Violation of Infection Control Practices
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to the handling of staff personal belongings in the room of a resident on Enhanced Barrier Precautions (EBP). The resident was admitted with cirrhosis of the liver, pleural effusion, and muscle weakness, and had an EBP care plan initiated with interventions that included cleaning and disinfecting equipment and high-touch surfaces, performing hand hygiene during direct contact, and posting EBP signage. The resident’s MDS indicated clear speech, ability to express needs and wants, and understanding, with substantial/maximal assistance required for toileting, bathing, and personal hygiene. During an observation and concurrent interview with the Infection Preventionist Nurse in the resident’s room, surveyors observed a black purse, black bag, vitamin water bottle, beige purse, and a clear water container with lemon slices stored on top of the closet. The resident denied ownership of these items and could not recall who placed them there. The Infection Preventionist Nurse stated that staff should not store their personal belongings in a resident room on EBP, as this increased the risk of spreading germs and causing cross contamination among other residents and staff. Review of the facility’s Enhanced Barrier Precautions and Infection Control policies showed that EBP are used to reduce the spread of multidrug-resistant organisms and that infection control policies are intended to prevent and manage transmission of diseases and infections and apply to all personnel.
Failure to Keep Smoking Patio Door Closed Allows Smoke Into Facility
Penalty
Summary
The facility failed to ensure that the door to the smoking patio was kept closed, resulting in cigarette smoke entering the building. During an observation, the patio door was found open despite a sign instructing that it should remain closed, and cigarette smoke was detected in the hallway near several resident rooms. A CNA was observed entering from the patio and leaving the door open, acknowledging that the door should be closed to prevent smoke from entering and affecting residents. The Infection Prevention Nurse also confirmed that cigarette smoke in the building can be an annoyance and cause difficulty breathing for residents. Review of the facility's policy indicated that a homelike environment should include pleasant neutral scents, which was not maintained in this instance.
Failure to Provide Ordered Splint Application for Resident with Limited Mobility
Penalty
Summary
The facility failed to ensure that a resident with a physician's order for bilateral knee splint application received the prescribed restorative care. The order specified that the Restorative Nurse Assistant (RNA) was to apply splints to both knees for one hour, five times a week. Review of the resident's medical record and RNA task documentation over a 30-day period revealed that there was no documentation indicating the splints were applied as ordered. The RNA confirmed during interview and record review that there was no record of the splints being applied, and acknowledged the importance of the splints in maintaining form and preventing contractures. The resident involved had diagnoses including muscle weakness, an artificial hip joint, and a contracture of the left lower leg. The resident was dependent on staff for toileting, bathing, and dressing the lower body, and had intact cognition and decision-making capacity. The care plan reflected the physician's order for splint application to maintain function. The facility's policy required restorative nursing care to promote optimal safety and independence, but the lack of documentation and apparent failure to provide the ordered care constituted a deficiency.
Failure to Administer Medications as Ordered and Document Pain Assessments
Penalty
Summary
The facility failed to ensure that medications were administered as ordered by physicians for four sampled residents. For one resident with severe cognitive impairment and multiple diagnoses, including diabetes and hypertension, gabapentin was ordered to be administered three times daily at specific times. However, medication administration records showed that doses were given significantly late on multiple occasions, outside the facility's policy of administering medications within one hour of the scheduled time. Another resident with diabetes and a recent knee replacement did not receive metformin as scheduled, with one morning dose administered over an hour late and a nighttime dose reportedly missed due to unavailability from the pharmacy. This resident also experienced unmanaged pain, as pain assessments were not documented in the medication administration record, and pain medication was not provided according to the physician's orders. Interviews with staff confirmed that pain levels were not consistently assessed or documented, and that medication administration was delayed or omitted when medications were not available. Additional residents with chronic conditions such as diabetes, hypertension, and epilepsy also experienced late administration of scheduled medications, including metformin, gabapentin, and hydrochlorothiazide. Medication administration records and staff interviews confirmed that medications were not given within the required timeframes, and documentation was not completed as per facility policy. Facility policies reviewed indicated that medications should be administered within one hour of the scheduled time and that pain assessments and documentation are required, but these protocols were not followed for the residents involved.
Insulin Not Relabeled After Physician Order Change
Penalty
Summary
The facility failed to ensure that insulin medication for a resident with diabetes was properly labeled and stored according to current physician orders. Specifically, after a physician changed the resident's Novolin insulin order, the medication cart still contained insulin labeled with the previous dosing instructions. The label on the insulin pen reflected an outdated order, and the medication was not discarded or relabeled to match the new prescription. The nurse did not notify the pharmacy of the new order immediately, nor was a change of order label placed on the medication as required by facility policy. The resident involved had a history of diabetes and hypertension and was able to understand and make decisions. The resident required some assistance with daily activities but was generally able to communicate needs. The discrepancy was identified during an observation and interview with a nurse, who acknowledged that the medication should have been discarded or relabeled to prevent administration errors. The facility's policies required that only the pharmacy modify prescription labels and that outdated medications be removed and replaced when orders change, but these procedures were not followed in this instance.
Failure to Ensure Call Light Accessibility and Provide Oral Care
Penalty
Summary
Surveyors identified that staff failed to ensure call lights were placed within reach for two residents and failed to provide oral care for one resident. For one resident with muscle weakness and hypertension, documentation showed the resident required significant assistance with activities of daily living (ADLs), including being dependent for toileting, lower body dressing, and transfers. The care plan specified that the call light should be placed within reach. During observation and interview, the resident reported being unable to see or reach the call light, expressing frustration at not being able to contact staff when needed. A CNA confirmed the call light was not accessible due to the resident's contracture and position in bed, acknowledging that this was not in accordance with the care plan and facility policy. The same resident also reported not having received oral care and lacking a toothbrush or toothpaste. The CNA stated that oral care had not been provided that day, despite the resident having already eaten two meals, and acknowledged that oral care should be performed after each meal. The CNA attributed the missed care to the resident's recent room transfer. A second resident, with hemiplegia and hypertension, was also found to have the call light out of reach, as it was hanging off the bed. This resident was dependent on staff for all ADLs and unable to use the call light unless it was placed next to them. An LVN confirmed the call light was not accessible and stated it should always be within reach. Facility policies reviewed by surveyors required staff to ensure call lights are within reach to provide prompt assistance and to support residents with ADLs, including personal and oral hygiene.
Failure to Ensure Nurse Competency in Admission Assessment and Medication Management
Penalty
Summary
The facility failed to ensure that a registered nurse possessed the necessary competencies and skills to properly assess a newly admitted resident, resulting in the resident receiving unnecessary medication and experiencing a delay in wound treatment. Upon admission, the nurse transcribed an order for Seroquel at a higher dose than what was indicated in the hospital discharge records and entered a diagnosis of bipolar disorder that was not present in the resident's medical history. The medical doctor later confirmed that the resident did not have bipolar disorder and that the higher dose of Seroquel was not appropriate, as the original hospital order was for a lower dose and for a different indication. Additionally, the admitting nurse did not identify or document a sacrococcygeal pressure ulcer during the initial assessment, despite later findings of a significant unstageable pressure ulcer measuring 21.1 cm. The wound was not assessed by the wound care nurse until several days after admission, and treatment was not initiated until three days post-admission. The delay in assessment and treatment was corroborated by interviews with the treatment nurse and assistant director of nursing, who acknowledged that the skin assessment should have been completed immediately upon admission to prevent further injury. Family members expressed concern about the resident's increased sleepiness and lack of progress in therapy, which they attributed to overmedication. The facility's policies and procedures require registered nurses to accurately assess new admissions, follow physician orders, and document the general condition of residents upon admission, including skin condition. These requirements were not met in this case, leading to unnecessary medication administration and delayed wound care for the resident.
Failure to Ensure Drug Regimen Free from Unnecessary Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary drugs, specifically regarding the use of Seroquel, an antipsychotic medication. The clinical records did not contain a documented assessment to support the diagnosis of bipolar disorder, which was listed as the indication for Seroquel use. Review of the resident’s hospital and facility records showed that the original order for Seroquel was for acute agitation/delirium, but upon admission to the facility, the medication was continued for bipolar disorder without supporting documentation or evidence of such a diagnosis. The facility’s Minimum Data Set and psychiatric evaluation did not indicate the presence of behaviors or symptoms consistent with bipolar disorder or psychosis during the relevant period. Further review of the resident’s Medication Administration Record and behavior monitoring logs revealed that there were no documented episodes of the behaviors that would warrant the use of Seroquel for bipolar disorder. Interviews with therapy staff and the Director of Rehabilitation indicated that the resident initially was able to follow commands and participate in therapy, but later became lethargic and confused, which interfered with rehabilitation. Family members and staff expressed concerns that the resident was overmedicated, leading to increased sleepiness and decreased participation in therapy. The medical doctor confirmed that there was no diagnosis of bipolar disorder in the resident’s records and stated that he continued the Seroquel order from the hospital without verifying the indication. The facility’s policy required that psychotropic medications be used only with a clear clinical indication and after ruling out other causes for behaviors, but this was not followed in the resident’s case. The lack of proper assessment, documentation, and monitoring led to the resident receiving an antipsychotic medication without adequate justification.
Failure to Provide and Properly Set Pressure-Relieving Mattresses for At-Risk Residents
Penalty
Summary
The facility failed to provide appropriate pressure ulcer prevention and care for several residents as ordered by their physicians and as outlined in facility policy. Specifically, three residents who were at risk for pressure ulcers due to immobility or other medical conditions were not provided with low air loss (LAL) mattresses as ordered. Observations and interviews confirmed that these residents were lying on regular mattresses despite having physician orders and care plans indicating the need for LAL mattresses to prevent pressure injuries. Staff interviews revealed a lack of awareness or follow-through regarding the implementation of these orders. Additionally, two residents who were provided with LAL mattresses did not have the mattresses set to the correct weight settings as required. In both cases, the mattress settings were significantly higher than the residents' actual weights, which staff acknowledged was not in accordance with manufacturer instructions or facility policy. Staff interviews confirmed that the incorrect settings could compromise the effectiveness of the mattresses in preventing pressure ulcers. The facility's own policies and procedures, as well as the manufacturer's operational manual, require that appropriate support surfaces be selected and maintained based on individual resident risk factors and that LAL mattresses be set according to the resident's weight. Despite these requirements, the facility did not ensure that the necessary equipment was provided or properly set for residents at risk for pressure ulcers, as evidenced by direct observation, record review, and staff interviews.
Failure to Provide Ordered Restorative Nursing Services Seven Days a Week
Penalty
Summary
The facility failed to ensure that two residents received Restorative Nurse Assistant (RNA) services as ordered by their physicians, specifically the application of bilateral elbow splints seven days a week. Both residents had physician orders and care plans indicating the need for daily application of elbow splints to prevent contractures and maintain range of motion. However, a review of RNA task forms revealed that the splints were not applied every day as required, with several days missed for each resident during the review periods. One resident, with diagnoses including hypertension, dysphagia, and respiratory failure, was dependent on staff for activities of daily living and had a care plan and physician order for daily bilateral elbow splint application. The RNA task form showed that the splints were not applied on a daily basis as ordered. Interviews with staff confirmed that the services were not provided every day, and staff acknowledged the importance of consistent splint application to prevent contractures. The second resident, diagnosed with traumatic brain injury, dysphagia, and respiratory failure, was also dependent on staff and had similar orders and care plan requirements for daily splint application. The RNA task form for this resident also indicated missed days. Staff interviews confirmed the inconsistency in providing the ordered restorative care. Facility policies and job descriptions reviewed during the survey supported the expectation that restorative nursing care should be provided as ordered and in accordance with residents' care plans.
Failure to Prevent Accident Hazards and Ensure Safe Supervision
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for three residents. One resident, who had multiple diagnoses including multiple sclerosis, COPD, acute kidney failure, and a seizure disorder, was observed to have two vape devices with cannabis symbols on her bedside table on multiple occasions. The resident reported using the vapes weekly in her room and keeping them on her bedside table. Facility staff, including an LVN and the Staff Development Assistant, acknowledged that they had not noticed the vapes during their daily rounds and recognized the potential risks, including negative exposure to other residents, possible contraindications with medications, and the risk of burns or injury to the resident herself. The facility's policy indicated that vape devices, while not considered smoking devices for ignition risk, still posed health and safety risks, including the potential for explosion or fire due to the battery. Another resident, with diagnoses including seizures, encephalopathy, and dysarthria, was found to have a left bed rail pad that was hanging off the bed rail during multiple observations. This resident was dependent on staff for most activities of daily living and was at risk for pressure ulcers and had a seizure disorder. Physician orders specified that the resident should have a low bed with padded bilateral upper half side rails and a floor mat to decrease potential injury. Both an LVN and the Assistant Director of Nursing confirmed that the left bed rail was not fully padded as required, and facility policy emphasized the importance of padding side rails for residents with seizure disorders to prevent injury during seizure activity. A third resident, with diagnoses including COPD, hypertension, type 2 diabetes, and muscle weakness, was found to have a personal lighter at his bedside, despite being a supervised smoker. The resident stated he was able to keep his lighter in his room, and an LVN confirmed that supervised smokers were not allowed to have lighters in their rooms due to the risk of burns or fire. Facility policy specified that residents without independent smoking privileges may not keep any smoking items, including lighters, except under direct supervision.
Failure to Complete Physician-Ordered Laboratory Tests
Penalty
Summary
The facility failed to provide timely and complete laboratory services as ordered for two residents. For one resident with diagnoses including malnutrition, schizophrenia, and bipolar disorder, the physician ordered a Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), and Ammonia level. Review of the resident's records and interview with a Licensed Vocational Nurse revealed that these lab tests were not completed, and there were no results available. The nurse confirmed that the labs were ordered to monitor the resident due to her medications, but the required tests were not performed. For another resident with encephalopathy, generalized edema, and dependent on staff for all functional abilities, there was a physician's order for weekly pre-albumin blood draws to monitor protein levels. Record review and interview with a Registered Nurse showed that the weekly pre-albumin labs were not performed as ordered, with only sporadic draws documented over several months. The facility's policy stated that clinical laboratory services are to be provided to meet residents' needs, but these orders were not consistently carried out.
Deficient Food Storage Labeling and Ice Machine Cleaning Practices
Penalty
Summary
The facility failed to maintain safe and sanitary food storage and preparation practices in the kitchen. During an observation in the dry storage room, an opened box of whole wheat spaghetti pasta was found without a label indicating the date it was opened. The Dietary Service Supervisor (DSS) confirmed that all opened food items in dry storage should be labeled with the date they were opened, in accordance with the facility's policy. The DSS acknowledged that not labeling food items with an open date could result in residents consuming expired food. Additionally, during an observation in the kitchen area, the outside compartment of the ice machine was found to be dirty with a thick hard water deposit. The DSS stated that dietary staff were responsible for cleaning the outside compartment of the ice machine once a week, but there was no log maintained to document this cleaning. The facility's policy required dietary staff to clean and sanitize the outside of the ice machine daily and as needed. The DSS recognized the importance of cleaning the ice machine for infection control purposes.
Failure to Offer and Document Influenza Vaccination for Two Residents
Penalty
Summary
The facility failed to ensure that two residents were offered the influenza vaccine for the 2024-2025 flu season, as required by facility policy and procedure. Interviews with the Infection Prevention Nurse (IPN) revealed that there was no documentation in the residents' medical records indicating that the flu vaccine was either offered, administered, or declined for these residents. Both the electronic health records and the California Immunization Registry were reviewed, and neither resident had evidence of receiving or declining the vaccine for the specified season. Resident 152 had a history of respiratory failure, ventilator dependence, and pneumonia, and was assessed as unable to make decisions or participate in a mental status interview. Resident 441 had diagnoses including respiratory failure and COPD, was also ventilator dependent, and similarly assessed as unable to make decisions. Both residents were dependent on staff for all functional abilities, and their care plans indicated a high risk for infection with interventions to offer and administer vaccines as needed. However, there was no documentation in their care plans, interdisciplinary team meetings, or other records to show that the flu vaccine was offered or declined. Facility policies required that all residents be offered vaccines unless medically contraindicated or already immunized, and that refusals be documented in the medical record. Despite these requirements, the facility was unable to provide documentation that the two residents were offered the flu vaccine or that any declination was recorded, constituting a failure to follow established vaccination protocols.
Failure to Assess and Document Bed Rail Use and Alternatives
Penalty
Summary
The facility failed to ensure that a comprehensive and accurate assessment was completed for a resident regarding the use of four bed rails. The resident, who had diagnoses including metabolic encephalopathy, dementia, and schizophrenia, was admitted and readmitted to the facility and was documented as lacking the capacity to understand and make decisions. The Minimum Data Set (MDS) indicated the resident was dependent on staff for activities of daily living such as showering, toileting hygiene, and dressing. Observations on two separate days showed all four bed rails were up while the resident was in bed, and the resident was not using the bed rails for mobility or repositioning, nor was the resident able to remove the bed rails independently. Interviews with facility staff revealed that the need for all four bed rails had not been properly assessed, and alternatives to bed rails, as required by facility policy, had not been attempted or documented prior to their use. The facility's policy specified that alternatives such as roll guards, foam bumpers, lowering the bed, and concave mattresses should be considered before installing bed rails. Record review confirmed there was no documentation of attempted alternatives or a comprehensive assessment regarding the use of bed rails for this resident.
Inaccurate MDS Assessment for Depression Diagnosis
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessment was completed accurately for one resident by not coding the resident's diagnosis of depression under MDS section I5800 (Active Diagnoses). The resident's admission record and history and physical indicated a diagnosis of depression, and the resident was prescribed Sertraline HCL, an antidepressant, for symptoms including crying, yelling, and self-biting. Despite this, the MDS assessment did not reflect the depression diagnosis, as confirmed by the MDS nurse during a review and interview. The resident was noted to have severely impaired cognitive skills and was totally dependent on staff for several activities of daily living. The facility's policy required staff completing any portion of the MDS to certify its accuracy, but this was not followed in this instance. As a result, incorrect data was transmitted to CMS, and the omission had the potential to affect the resident's plan of care and delivery of services.
Failure to Resubmit PASARR Screening for Resident with Mental Illness Diagnoses
Penalty
Summary
The facility failed to complete and resubmit the Preadmission Screening and Resident Review (PASARR) Level I screening for a resident who had diagnoses of bipolar disorder and major depressive disorder (MDD). The initial PASARR Level I screening, completed by another facility, indicated that the resident had no serious mental illness diagnoses and that the case was closed, with no Level II evaluation required. However, upon admission, the resident's diagnoses of bipolar disorder and MDD were documented in the admission record and history and physical, indicating the presence of mental illness. Despite this information, the facility did not conduct a new PASARR Level I screening to reflect the resident's current diagnoses, which would have triggered a Level II evaluation and referral to the state mental health authority. The facility's policy and the PASRR reference manual both require that a new screening and referral be made if a significant change in mental condition is identified. The failure to resubmit the PASARR Level I screening and refer the resident for further evaluation resulted in the resident not being assessed for appropriate mental health services.
Failure to Revise Care Plan for Use of Low Air Loss Mattress
Penalty
Summary
The facility failed to ensure that a resident's care plan was revised to specifically address the use of a low air loss (LAL) mattress, which is a specialized device used to prevent and treat pressure ulcers. The resident in question had significant medical conditions, including metabolic encephalopathy, hemiplegia, and cerebral infarction, and was assessed as being at risk for developing pressure ulcers. The resident was dependent on staff for activities of daily living and lacked the capacity to make decisions. The care plan in place addressed the risk for skin breakdown and included general interventions such as assessing risk and using pressure-relieving devices as needed, but did not specify the type of device to be used. During a review of the care plan and interviews with facility staff, it was confirmed that the care plan had not been updated to reflect the use of the LAL mattress for this resident. The Assistant Director of Nursing acknowledged that the care plan lacked specificity regarding the pressure-relieving device, which was necessary for consistent and individualized care. Facility policy required that care plans be revised as residents' conditions changed, but this was not done in this case.
Failure to Complete Ordered Weekly Weights for Resident with Weight Loss
Penalty
Summary
A resident with diagnoses of malnutrition, diabetes mellitus, and congestive heart failure was readmitted to the facility and had a physician's order for weekly weights for four weeks due to an eight-pound weight loss in one month. The resident's care plan and change of condition documentation both reflected the need for weekly weights and ongoing monitoring, as well as the requirement to report significant changes to the physician. Despite these orders and care plan interventions, the last recorded weight for the resident was documented prior to the initiation of the weekly weight order, and no subsequent weekly weights were completed as required. During an interview and record review, a Licensed Vocational Nurse confirmed that the weekly weights were not performed according to the physician's order. The facility's policy on weight assessment and intervention also required monitoring of resident weights for undesirable or unintended weight loss or gain. The failure to obtain and document weekly weights as ordered resulted in inadequate monitoring of the resident's weight loss.
Failure to Provide Compression Stockings per Physician Order
Penalty
Summary
A deficiency occurred when a resident with a history of bilateral lower extremity edema, cellulitis, hypertension, and generalized muscle weakness did not receive compression stockings as ordered by the physician. The resident was cognitively intact and able to make decisions, and the physician's order specified daily application of compression stockings to both lower extremities. During an observation, the resident was found without compression stockings and reported not having them for two weeks, stating that the previous stockings were too long and wide. The resident also indicated that nursing staff were aware of the lack of appropriate stockings during this period and expressed concern about ongoing swelling. Interviews with the treatment nurse and DON confirmed that the resident had not received the prescribed compression stockings for two weeks due to the old stockings being ill-fitting and new ones not being delivered. The treatment nurse acknowledged that the physician's order for daily application was not followed and that untreated edema could result in hospitalization. Facility policy indicated that incorrectly sized stockings could cause harm, but the resident was left without any compression stockings for an extended period, contrary to the physician's order.
Failure to Provide Timely Podiatry Referral for Foot Care
Penalty
Summary
A resident with a history of cellulitis in both lower limbs, hypertension, and generalized muscle weakness was admitted to the facility and was cognitively able to make decisions. The resident required supervision for personal hygiene and dressing. Documentation showed that a wound consultant recommended a referral to podiatry for onychomycosis, a fungal infection causing thickened, discolored toenails. Despite this recommendation and the resident's own request to see a foot doctor for the condition, the referral was not made. Observation confirmed the resident had long, thick, brownish-yellow toenails on both feet. Interviews with staff revealed that the treatment nurse was aware of the need for podiatry care and had informed the ADON, but the ADON did not follow through with the referral, citing oversight. The DON confirmed that podiatry care is a service provided by the facility and acknowledged the need for prompt assessment and treatment. The facility's policy indicated that residents should receive foot care in accordance with professional standards, but this was not followed in this case.
Failure to Implement Scheduled Toileting Program for Cognitively Intact Resident
Penalty
Summary
The facility failed to provide a scheduled toileting plan or bladder training for one resident, despite assessment findings indicating the resident was a good candidate for such interventions. The resident was cognitively intact, aware of the need to toilet, and able to participate in toileting activities with one-person assistance. Documentation showed that the resident required substantial assistance with toileting hygiene and lower body dressing, but no trial of a toileting program had been attempted. The resident expressed willingness to use a bedpan or bedside commode to avoid urinary infections, but reported that staff only provided a diaper and did not offer these alternatives. Interviews with staff confirmed that the resident was not offered a bedpan or bedside commode, and the facility's own assessment tool indicated the resident would benefit from scheduled toileting or bladder retraining. The facility's policy required staff to provide appropriate services and interventions, such as scheduled toileting, based on assessment results. However, no such program was implemented for the resident, contrary to both the assessment findings and facility policy.
Failure to Label and Change Oxygen Tubing as Ordered
Penalty
Summary
A deficiency occurred when a resident with chronic obstructive pulmonary disease (COPD) was observed receiving continuous oxygen therapy through tubing that was not labeled with the date it was last changed. The oxygen tubing appeared cloudy and contained clear, thick fluid near the nasal area. According to a licensed vocational nurse, oxygen tubing should be changed daily and labeled accordingly, while the physician's order specified that the nasal cannula or mask should be changed every seven days or as needed when soiled. The resident's care plan also indicated that oxygen tubing should be changed weekly or as needed. Despite these protocols, the tubing in use was not labeled and showed visible signs of soiling.
Failure to Attempt Alternatives Before Installing All Four Bed Rails
Penalty
Summary
The facility failed to ensure that appropriate alternatives were attempted before installing all four bed rails for one resident. The resident in question had diagnoses including metabolic encephalopathy, dementia, and schizophrenia, and was assessed as lacking capacity to make decisions. Observations on two separate days showed the resident lying in bed with all four bed rails up, despite not using the rails for mobility or repositioning and being unable to remove them easily. The resident was dependent on staff for activities of daily living and was not receiving ADL assistance at the time of observation. A review of the physician's orders indicated that all four bed rails were to be up and locked for ADL changes, mobility, positioning, and as an enabler, and this was considered a non-restraint. However, staff interviews revealed that the resident was not able to use the bed rails for mobility and that the physician's orders did not match the resident's abilities. Documentation was not found to show that alternatives to bed rails were attempted prior to their use. Facility policy required that alternatives such as roll guards, foam bumpers, or lowering the bed be tried before bed rails were used, but there was no evidence this was done for the resident.
Failure to Ensure Timely Physician Visits After Admission
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident was evaluated by a physician at least once every 30 days for the first 90 days following admission, as required. The resident, who was admitted with diagnoses including cellulitis of both lower limbs, hypertension, and generalized muscle weakness, was only seen by her physician once since admission. Clinical records confirmed that after the initial physician visit, subsequent visits were conducted by a Physician Assistant rather than the physician, and there was no documentation of physician visits for the required months. During interviews, the resident expressed concern about not seeing her physician and wanted to discuss her ongoing high blood pressure. Facility leadership, including the ADON and DON, acknowledged that the physician had not complied with the required visit schedule and that documentation of physician visits was missing for several months. The facility's policy also specified that the attending physician must visit patients at least once every 30 days for the first 90 days after admission, which was not followed in this case.
Failure to Provide Prescribed Eye Drops as Ordered
Penalty
Summary
The facility failed to ensure that the correct prescribed eye drops were available in the Sub-Acute Medication Cart according to the physician's orders for a resident. The resident, who had a history of respiratory failure, aphasia, dysphagia, and brain damage, was noted to have severely impaired cognitive skills and was dependent on staff for activities of daily living. The physician had ordered Refresh Tears Ophthalmic Solution 0.5% for the resident. During a medication administration observation, a nurse was found to be removing Polyvinyl Alcohol 1.4% eye drops from the medication cart, which did not match the physician's order and was not prescribed for the resident. The nurse stated that the correct eye drops had not been delivered by the pharmacy and acknowledged that the Polyvinyl Alcohol drops required physician clarification, as there was no order for them. The resident's eye drops were held, and the nurse indicated that the situation could result in a medication error. Facility policy requires that medication labels and orders be checked for accuracy prior to administration.
Failure to Act on Pharmacist's Medication Review Recommendation
Penalty
Summary
The facility failed to act in a timely manner on the consultant pharmacist's recommendation regarding a resident's medication regimen. Specifically, a resident with diagnoses including psychosis, bipolar disorder, and diabetes mellitus was started on Olanzapine for psychosis manifested by constant worrying about a medical condition. The consultant pharmacist reviewed the medication regimen and recommended that the physician clarify and update the order for Olanzapine with appropriate behavioral indications. However, there was no documentation that the nursing staff followed up with the physician to address this recommendation or to clarify the behavioral manifestations justifying the use of the psychotropic medication. The resident's clinical records did not show any action taken by the licensed nursing staff to discuss or implement the pharmacist's recommendation, despite the psychiatrist evaluating the resident shortly after the recommendation was made. The facility's policy required that recommendations from the consultant pharmacist be acted upon and documented by staff or the prescriber, but this was not done. As a result, the resident was at risk for receiving unnecessary medication due to the lack of timely follow-up and documentation.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Surveyors identified that insulin pens belonging to a resident with diagnoses including hemiplegia, type 2 diabetes, COPD, and epilepsy were found opened and not discarded in the medication storage room. The resident required maximal assistance with activities of daily living and had moderately impaired cognitive skills. During observation, a licensed vocational nurse confirmed that the insulin pens should have been discarded and acknowledged that failure to do so could result in an infection control issue. Additionally, a bottle of valproic acid prescribed to another resident with epilepsy, type 2 diabetes, schizophrenia, and aphonia was found in the medication cart with an illegible label. This resident had severely impaired cognitive skills and required moderate assistance with daily activities. The same nurse confirmed that all medications should have legible labels and that an illegible label could lead to medication errors and uncertainty about medication ownership. The facility's policy required medications and biologicals to be stored safely, securely, and properly, in accordance with manufacturer or supplier recommendations.
Failure to Perform Hand Hygiene During Wound Care
Penalty
Summary
Licensed staff failed to perform proper hand hygiene during wound care for one resident. Specifically, a staff member removed the dressing from the resident's right great toe, cleaned the wound, and applied a new dressing without washing his hands between steps. The same staff member then proceeded to treat another wound, an abrasion on the left heel, without changing gloves or washing hands between the two wound care treatments. During an interview, the staff member acknowledged not removing gloves or washing hands after treating each wound and stated awareness of the correct procedure. The resident involved had multiple medical conditions, including chronic respiratory failure, transient ischemic attack, and diabetes mellitus, and was dependent on staff for all activities of daily living. The resident was also at risk for developing pressure ulcers. Facility policy and procedures reviewed indicated that hand hygiene is the primary means to prevent the spread of infections and that gloves do not replace hand washing. The observed actions were not in accordance with these policies.
Survey Results Not Accessible to Residents and Public
Penalty
Summary
The facility failed to ensure that the results of its last recertification survey were placed in a location that was easily accessible and viewable by residents and the public. During an observation and interview in the main lobby, the Administrator was unable to locate the binder containing the most recent survey results and acknowledged that it should be available for anyone to review. A review of the facility's policy and procedure on Resident Rights confirmed that residents have the right to examine survey results.
Resident Rooms Below Minimum Square Footage Requirement
Penalty
Summary
The facility failed to ensure that residents in rooms 1, 2, 3, 4, 5, 7, 8, 9, 10, 11, 12, and 13 had at least 80 square feet of living space per resident, as required. Observations showed that these rooms each contained three occupied beds, and a review of the Client Accommodation Analysis confirmed that the floor space in these rooms ranged from 210 to 214 square feet, which is less than the required 240 square feet for three residents. A Room Variance Waiver request letter also acknowledged that these rooms did not meet the minimum space requirement. During an interview, the Administrator confirmed awareness of the room size issue and noted that, although there had been no complaints, the limited space could affect staff's ability to provide care and store necessary items.
Verbal Abuse Incident Involving CNA and Resident
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a Certified Nursing Assistant (CNA). The incident involved a disagreement between the resident and CNA regarding the placement of a roommate's wheelchair, which was obstructing the resident's passage. The resident, who had a history of partial amputation, functional quadriplegia, and diabetes mellitus, expressed that the wheelchair was blocking his way out of the room. The CNA responded by raising her voice, which escalated into yelling, causing the resident to feel upset. The incident was documented in the resident's progress notes and change of condition report, indicating that the CNA's voice became progressively louder during the disagreement. Interviews with staff members, including a Licensed Vocational Nurse (LVN) and a Registered Nurse (RN), confirmed that the CNA yelled at the resident, which was considered verbal abuse. The LVN noted that the CNA should have explained the situation calmly, while the RN stated that the CNA's behavior was verbally abusive and inappropriate. The facility's policy on abuse and mistreatment of residents emphasizes the right of residents to be free from verbal abuse. The policy defines verbal abuse as the use of language that includes disparaging and derogatory terms within hearing distance of residents. The incident was reported to the facility's administration, and the CNA was suspended and subsequently terminated for her conduct, which violated resident rights and the facility's code of conduct.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
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What surveyors actually found near you
We read the 7,875 citations issued within 25 miles in the last 12 months — including the 26 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Los Angeles
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Crenshaw Nursing Home | 0 mi | ★★★★★ | 22 | 0 |
| Miracle Mile Healthcare Center, Llc | 1.4 mi | ★★★★★ | 47 | 0 |
| Pavilion On Pico Healthcare & Wellness Centre, Lp | 1.4 mi | ★★★★★ | 27 | 0 |
| West Pico Terrace Healthcare & Wellness Centre Lp | 1.4 mi | ★★★★★ | 15 | 0 |
| Western Convalescent Hospital | 1.8 mi | ★★★★★ | 34 | 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 October 2026) and official state health department websites.