Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Los Feliz Healthcare & Wellness Center, Lp during CMS and state inspections, most recent first.
Failure to remove an IV catheter after completion of IV antibiotic therapy. A resident with impaired cognition, DM, and HTN received ceftriaxone IV for a back abscess, but the IV remained in place after the last dose was given. During observation, staff noted the dated IV site still present; the LVN, ADON, and DON all acknowledged the IV should have been removed after therapy ended.
Failure to Protect a Resident from Visitor Abuse: A resident with intact cognition and decision-making capacity was verbally abused and spat on by a visitor during an argument in the activity area and hallway. The visitor admitted to using profanity, making derogatory remarks, threatening immigration-related action, and spitting in the resident’s face. An RN tried to de-escalate the situation but did not remove the visitor, who later left on her own, contrary to the facility’s visitation policy for alleged abuse.
Failure to Timely Report Physical Abuse Involving a Visitor: A resident with intact cognition and supervision needs was involved in a confrontation with a visitor in the activity room and hallway. The visitor admitted to spitting on the resident’s face and making derogatory threats, while the resident and another resident described the spitting and attempted pushing. The ADM treated the event as verbal abuse and the abuse report was faxed to SSA after the two-hour reporting window for physical abuse had passed.
Failure to Report and Investigate Allegation of Physical Abuse: A resident with hemiplegia, dementia, and impaired cognition had a bruise and scratch on the face, and the RP reported the resident said he hit me and demonstrated being struck. The RP notified RN 1, and the DON later observed the resident demonstrate the alleged assault, but the facility did not report the allegation to the SSA or Ombudsman and did not conduct a thorough investigation, despite its Abuse Prevention and Management policy requiring immediate reporting and investigation.
Failure to Report Alleged Physical Abuse Within Required Timeframe: A resident with impaired cognition, dementia, and right-sided hemiplegia was observed with a bruise to the right jaw, and the RP reported the resident said she was punched in the face. RN and leadership were notified, but the allegation was not reported within the required timeframe because staff believed it may not have been abuse and thought the bruise may have been from a prior fall; the facility policy required suspected physical abuse to be reported to the proper authorities within two hours.
Failure to Report and Investigate Allegation of Abuse: A resident with dementia, right-sided hemiplegia, and dependence for several ADLs had a bruise and scratch on the cheek after the RP reported that the resident said an unidentified staff member hit her. The RP notified an RN, then spoke with the DON and Admin, who contacted law enforcement, but the Admin did not investigate and the DON did not report the allegation to CDPH because she believed no abuse had occurred.
An LVN documented multiple meds as given on a resident’s MAR after the resident had already been transferred to a GACH. The resident had Alzheimer’s disease, hydrocephalus, venous insufficiency, and PVD, and the SBAR and transfer form showed the resident left the facility earlier that day for bilateral eye swelling and pain. The LVN stated the resident was not in the facility and that she signed off the meds by accident, while the DON confirmed the MAR entries were inaccurate and should have reflected that the resident was in the hospital.
Two residents who were incontinent and required staff assistance for toileting and hygiene reported that an assigned CNA failed to provide timely incontinence care and refused or ignored their requests to be changed, leaving one resident in a soaked brief and wet bedding for about an hour and another resident sitting in a soiled brief after an episode of diarrhea. In both cases, nursing staff documented that the CNA did not respond appropriately to call lights or direct requests, and other CNAs not assigned to these residents ultimately provided the needed care. Staff interviews and records confirmed that answering call lights, changing soiled briefs, and maintaining resident dignity and comfort are required CNA duties under facility policy.
A resident with hemiplegia, hemiparesis, and overactive bladder, who was fully dependent for toileting and personal hygiene, requested a diaper change and was being provided peri-care when a CNA entered the room without knocking and approached a gap in the privacy curtain while the resident’s lower body was exposed. The CNA providing care reported that the second CNA entered under the pretense of getting gloves and appeared in a 1–2 foot opening in the curtain, prompting the caregiver to tell her to leave. The resident confirmed that a second person appeared at the curtain gap, began talking to the CNA, and that she was still being changed and exposed, causing her embarrassment. Staff interviews and facility documents indicated that staff are expected to knock, close curtains, and protect resident privacy during care, and that cell phone recording is prohibited due to privacy concerns.
A resident with multiple medical conditions and high assistance needs developed diarrhea and later tested positive for C. difficile, prompting the decision to move the resident to a private room under contact isolation. An LVN documented in the electronic record that the resident had been placed in a private room earlier in the day, even though the room was still being cleaned and the actual transfer did not occur until later, as corroborated by a CNA. The DON stated that nurses must only chart what has actually occurred, and facility policy requires that events be documented as they happen and never in advance, making this entry an inaccurate medical record.
A resident with diabetes and other complex conditions refused a fasting blood sugar check and later had a critically high blood glucose reading. Staff did not notify the physician as required by orders and facility policy, and documentation of the refusal and missed insulin dose was lacking. The physician was only informed after the resident became unresponsive and was being transferred to the hospital.
A resident with diabetes and other complex conditions experienced critically high blood glucose and hypotension, but nursing staff did not notify the physician as required by orders and facility policy. Instead, 911 was called and the physician was only notified after the resident was being transported to the hospital. The resident also missed 14 hours of prescribed tube feeding. These failures resulted in delayed care and the resident's transfer to an acute care hospital with serious complications.
A resident dependent on enteral feeding did not receive the prescribed Glucerna 1.5 regimen due to a failure to initiate the feeding as ordered. Despite having the necessary supplies and physician orders, staff did not start the feeding, resulting in the resident missing 14 hours and 770 ml of nutrition. Facility policy required feedings to be administered as ordered, but this was not followed.
A resident with diabetes and other complex conditions did not receive a scheduled insulin dose after refusing a fasting blood sugar check, despite prior blood sugar readings indicating the medication should have been given. Staff did not obtain an alternative blood sugar measurement at the scheduled time, resulting in missed medication administration and subsequent deterioration in the resident's condition.
A resident with multiple complex medical conditions did not have accurate and complete clinical records due to nursing staff failing to document required progress notes when medications were not administered and not accurately updating the MAR after the resident was discharged to a hospital. The DON and involved LVNs confirmed that documentation was incomplete, which did not meet professional standards and facility policy.
A resident's medical record was incomplete at discharge, as the RN did not complete or sign the Discharge Planning Review Form, and the resident's refusal to sign was not documented. LPNs also failed to document the level of care provided and the resident's health status at discharge, resulting in missing required information in the progress notes.
A resident with severe cognitive impairment and multiple diagnoses was exposed during a shower when the privacy curtain was not fully closed, as observed by staff. Facility policy requires staff to maintain resident privacy during personal care, but this was not followed, resulting in a lapse in dignity and privacy.
A resident with a history of CVA, epilepsy, depression, and hemiplegia, who required significant assistance with daily activities, was found to have their call light placed out of reach. Staff confirmed the call light should have been accessible, as required by the care plan and facility policy, but it was left at the top of the mattress, making it inaccessible for the resident to request help.
A resident with multiple medical conditions and moderate cognitive impairment did not receive necessary transportation to a scheduled pulmonology appointment due to the facility's lack of advance planning and absence of a transportation policy. The Social Services Director did not arrange transportation ahead of time, resulting in no wheelchair-accessible transport being available on the day of the appointment, and the DON confirmed the lack of procedures for such arrangements.
A resident with multiple medical conditions and moderate cognitive impairment had a scheduled pulmonology appointment, but the facility failed to document transportation arrangements and whether the appointment was completed. The absence of this documentation was confirmed by the Social Services Director and was not in accordance with facility policy or professional standards.
The facility did not reconcile or maintain accountability logs for six eKITs containing controlled medications across three medication rooms, and failed to ensure the availability of tramadol for a resident with a physician's order for pain management. As a result, a resident with a history of spinal conditions did not receive prescribed tramadol for moderate to severe pain, and staff confirmed that required shift-to-shift reconciliation of controlled substances was not performed.
Several residents with cognitive and physical impairments experienced deficiencies in their living environment, including a bed control cord with exposed wires, a broken baseboard with exposed nails, and floor mats in disrepair. Staff were aware of these issues but did not promptly report them to maintenance, resulting in unsafe and non-homelike conditions contrary to facility policy.
Several residents were subjected to physical restraints, such as pillows tightly tucked under fitted sheets and the use of bolsters or bed placement against the wall, without proper physician orders, informed consent, restraint assessments, or care plan documentation. These actions restricted residents' freedom of movement and were implemented for staff convenience or safety without following required protocols.
Licensed nursing staff failed to rotate subcutaneous insulin injection sites for two residents receiving insulin therapy, despite physician orders and facility policy requiring site rotation. Documentation showed repeated use of the same injection areas over multiple days, and staff interviews confirmed that proper rotation was not consistently performed.
Surveyors found that multiple residents were exposed to accident hazards due to improper placement of heavy objects on fall mats, uncovered electrical outlets, broken baseboards with exposed nails, unsecured smoking materials, and medications left at bedside. Staff interviews and direct observations confirmed that these actions were not in accordance with facility policies, and several residents had cognitive or physical impairments that increased their vulnerability to these hazards.
A resident with hemiplegia and high fall risk was found using padded bilateral upper bedrails without a physician's order, informed consent, or a care plan, despite facility policy requiring these steps. Staff confirmed the bedrails were used for mobility and fall prevention, but records lacked necessary documentation and the only assessment recommended against their use.
Two residents experienced medication errors when an LPN failed to administer a prescribed pain medication due to unavailability and gave a multivitamin with minerals instead of the ordered formulation. These actions resulted in a medication error rate above 5%, as confirmed by the DON and facility records.
Two residents receiving subcutaneous insulin did not have their injection sites rotated as required by prescriber orders and facility policy, resulting in repeated administration in the same areas. This failure was confirmed by facility leadership and documented in medication administration records, constituting significant medication errors.
Surveyors found that kitchen staff failed to maintain sanitary conditions by not wiping down sticky containers of thickened lemon water and almond milk, not labeling an opened container of apple juice with the date it was opened, and leaving a bottle of brown coloring with dried drippings. The Dietary Supervisor and DON confirmed these actions were not in line with facility policy requiring proper labeling and cleaning of food containers.
Staff failed to consistently label and date food items brought in by family or visitors and stored in the resident-designated refrigerator, including condiments such as ranch dressing, mayonnaise, and salsa. Interviews with dietary, nursing, and administrative staff confirmed that the facility's policy requires labeling with the resident's name and date, and timely disposal, but these procedures were not followed, resulting in unlabeled and potentially expired food being stored.
Staff failed to follow infection control protocols by placing a resident's personal items on the floor, not labeling a urinal bottle, leaving mobile linen carts open in hallways, and using permeable covers on linen carts. These actions resulted in potential contamination of resident care items and clean linens, contrary to facility policy and infection prevention standards.
A resident with multiple diagnoses was given seven medications by an LVN who did not inform the resident of the medication names or their purposes prior to administration. The LVN, unable to communicate in the resident's preferred language, also failed to request a translator as required by facility policy. This resulted in the resident not being fully informed about their care and not having the opportunity to make choices regarding their medication regimen.
A resident with diabetes, a foot ulcer, and limited mobility was found to have their call light on the floor and out of reach, despite care plan and facility policy requiring it to be accessible. Staff interviews confirmed the expectation that call lights remain within reach, and the deficiency was observed during a survey.
A resident with hemiplegia and high fall risk had their bed placed against the wall as a restraint without a corresponding care plan or physician's order. Facility staff confirmed that this intervention was not documented in the care plan, leading to potential miscommunication among the IDT and failure to meet policy requirements for comprehensive, person-centered care planning.
A resident with dementia and major depressive disorder, who was dependent on staff and valued participation in religious services, was not consistently informed about or brought to these services. Staff interviews revealed gaps in communication and documentation, and the facility had not implemented its policy for tracking activity attendance, resulting in the resident missing preferred activities and incomplete records.
Two residents were transferred to the hospital without proper documentation of their change in condition, as required by facility policy. In both cases, essential forms and details such as SBAR/Change of Condition, vital signs, and notifications to providers and representatives were missing or incomplete, resulting in a lack of clear communication about the residents' status and care prior to transfer.
A resident with an indwelling urinary catheter was found to have a loop in the catheter tubing, preventing free urine flow into the drainage bag. Staff and the DON confirmed that catheter tubing should be kept free of kinks or loops, in accordance with facility policy and standard practice. The resident had a history of obstructive uropathy and required significant assistance with daily living activities.
A resident with a gastrostomy tube, severe cognitive impairment, and total dependence on staff was found to have a medication syringe that was not properly rinsed after use, as required by physician orders, care plan, and manufacturer guidelines. The syringe was observed with residual liquid and powder, and the ADON confirmed this failure to rinse could lead to GI complications.
A resident with a midline catheter was found with a loose, soiled dressing that was not labeled with the date of the last change, despite facility policy requiring such labeling. Nursing leadership confirmed that the lack of a date could prevent staff from knowing when the dressing was last changed, which did not meet professional standards for IV care.
A resident with ESRD who required regular hemodialysis did not receive timely physician follow-up after missing a dialysis session, and a dialysis emergency kit was not available at the bedside as required. Facility staff confirmed the absence of the kit and lack of physician notification, despite policies mandating these actions for dialysis care.
Staff failed to label an opened multi-dose epoetin alfa vial with the date of first use and expiration, contrary to manufacturer and facility policy, and did not remove it from use. Additionally, an IV antibiotic prepared from the emergency kit was not labeled with the resident's name or rate of administration. These deficiencies were confirmed by nursing staff and the DON, and were identified through observation and record review.
A resident with moderate cognitive impairment and multiple medical conditions experienced a toothache that was verbally reported by a family member, but the Social Services Director did not document the complaint or ensure a timely, specific dental referral. When the resident was seen by the dentist, the dental record lacked the chief complaint, and there was no follow-up with the family to confirm resolution, resulting in a failure to address the dental issue as required by facility policy.
A resident with a terminal prognosis and multiple complex diagnoses was admitted to hospice care, but the facility failed to assign a qualified hospice coordinator to oversee and coordinate care between hospice and facility staff. The Medical Records Director, who was designated as the hospice coordinator, was only responsible for record-keeping and was not involved in care coordination or the interdisciplinary team. This resulted in incomplete hospice documentation and a lack of proper coordination of hospice services for the resident.
A resident with multiple health conditions was found to have a bed control cord with frayed and exposed wires, which had previously been inadequately repaired with tape. Staff observed the hazard but did not report it immediately, and maintenance staff acknowledged that the repair did not meet facility policy or equipment manual standards. Facility policies require immediate reporting and proper repair of such hazards to maintain a safe environment.
Two residents' activity records were inaccurately documented when activity assistants used another staff member's login to chart attendance and services, resulting in records showing staff signatures on days they were not present. This practice was confirmed by staff interviews and was not in accordance with facility policy, which requires only authorized staff to document in medical records and prohibits signing for others.
A resident's patio was cluttered with facility and residents' belongings, including trash bags, mattresses, and a wheelchair covered by a tarp, affecting their homelike environment. The resident, with conditions like rheumatoid arthritis and major depressive disorder, expressed concerns about potential rodents and limited space. The Environmental Director and DON acknowledged the issue, which violated the facility's policy for a safe and comfortable environment.
A resident's medical records were inaccurately documented when a complaint of a possible infection on a dialysis access port was recorded with the wrong date, leading to an incorrect timeline of events. The error was acknowledged as a typographical mistake by an LVN, highlighting a failure to ensure accurate documentation as per the facility's policy.
The facility failed to ensure call lights were within reach for four residents, leading to a deficiency in accommodating their needs. One resident with muscle weakness had the call light placed on the side of his contracted arm, making it inaccessible. Another resident with impaired vision and cognition had the call light on the floor, while a third resident's call light was positioned at the head of the bed, out of reach. A fourth resident with dementia had the call light hanging on the bed rail, touching the floor. The facility's policy to keep call cords within reach was not followed.
Two residents in the facility were subjected to the use of bed rails and bed placement against the wall without proper assessment, physician orders, or informed consent. Both residents had the capacity to understand and make decisions, yet the facility failed to document safety assessments or educate the residents or their representatives on the risks and benefits of such restraints. This oversight violated the facility's policy, which mandates that restraints be used only when necessary and with appropriate documentation.
The facility failed to develop comprehensive care plans for residents, including those using physical restraints and receiving medications like vancomycin and Risperdal. This led to inadequate monitoring and documentation, potentially compromising resident safety and care.
Failure to Remove IV Catheter After IV Antibiotic Completion
Penalty
Summary
The facility failed to remove an IV catheter for Resident 2 after the resident completed the ordered IV antibiotic course. Resident 2 was admitted with diagnoses including metabolic encephalopathy, DM, and HTN, and the H&P stated the resident did not have the capacity to understand and make decisions. The MDS later indicated the resident’s cognitive skills for daily decisions were severely impaired and that the resident was dependent on staff for all ADLs. A physician order dated 5/18/2026 directed ceftriaxone sodium 1 gram IV in the morning for a back abscess for three days. The IV administration record showed the first dose was given on 5/19/2026, the second on 5/20/2026, and the third and last dose on 5/21/2026. During observation on 6/12/2026, the resident still had a gauze 24 IV noted and dated 5/19/2026. LVN 1 stated the IV should be changed every three days, the ADON stated the IV should be changed every 72 hours and that there was no physician order to continue it, and the DON stated the night RN should have removed the IV after the last antibiotic dose on 5/21/2026.
Failure to Protect a Resident from Visitor Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse and verbal abuse during an altercation with a visitor who was the family member of another resident. The resident had been admitted with diagnoses including abnormalities of gait and mobility, metabolic encephalopathy, and cognitive communication deficits, and later assessments documented that he had the capacity to understand and make decisions, intact cognition, and the ability to understand and be understood. On the evening of the incident, the resident was in the Facility Recreational Room with another resident when the visitor entered and began yelling at both residents. The resident reported that the visitor used profanity, threatened to call immigration authorities, and made derogatory comments toward him. The interaction escalated as the resident and the visitor continued arguing while walking down the hallway toward the resident’s room. The resident stated that the visitor turned around and spat directly into his face, covering his face and glasses with saliva, and attempted to hit him before a CNA intervened. Another resident stated she saw the visitor spit on the resident’s face and saw the visitor attempt to push him. The visitor acknowledged that she spit on the resident, threatened to call immigration authorities, and used a derogatory slur toward him because she did not like how he was speaking to her. The RN who witnessed part of the event stated she tried to de-escalate the situation by having the resident and the visitor go into the Facility Recreational Room, but she did not ask the visitor to leave the facility. The RN stated the visitor left when she was done visiting with the other resident and that she did not see the visitor leave. The Administrator stated the visitor was not removed after the alleged abuse and that the facility did not have footage showing the visitor was monitored. The facility’s Visitation Rights policy stated that a visitor who is abusing, exploiting, or coercing a resident will be denied access or given limited and supervised access until an investigation clears the allegations, but that did not occur during the incident described.
Failure to Timely Report Physical Abuse Involving a Visitor
Penalty
Summary
The facility failed to report a physical abuse incident to the State Survey Agency within two hours after a visitor spat on Resident 1. Resident 1 was admitted with diagnoses including abnormalities of gait and mobility, metabolic encephalopathy, and cognitive communication deficits, and later assessments documented that he had the capacity to understand and make decisions, intact cognitive function, and required supervision or touching assistance with several activities of daily living. The facility’s own records described the event as a verbal altercation with an allegation that the visitor spit on Resident 1’s face, and the care plan identified Resident 1 as at risk for emotional distress related to the altercation. Resident 1 stated that while he was in the facility recreational room with Resident 4, Visitor 1 entered, yelled at him, threatened him, and later turned in the hallway and spat in his face and on his glasses. Resident 1 stated that Certified Nursing Assistant 1 intervened when Visitor 1 attempted to hit him, and that he then went to the nurses’ desk and wanted to contact police. Resident 4 gave a similar account, stating that Visitor 1 spat at Resident 1 in the hallway and attempted to push him before CNA 1 stopped her. Visitor 1 acknowledged that she spat on Resident 1 and stated she also made derogatory comments and threats toward him. The Administrator stated he was the abuse coordinator and was aware of the disagreement, but believed the event was verbal abuse and thought the facility had 24 hours to report it. The Director of Staff Development stated he submitted the abuse report to SSA by fax at 1:26 a.m. on 5/23/2026 and said he was not aware of the spitting allegation when he submitted it. The facility’s policy required written reporting of known or suspected physical abuse to SSA within two hours of observation, knowledge, or suspicion, and the policy defined physical abuse to include acts such as hitting, slapping, punching, and kicking.
Failure to Report and Investigate Allegation of Physical Abuse
Penalty
Summary
The facility failed to implement its written Abuse Prevention and Management policy when it did not report an allegation of physical abuse involving a resident to the State Survey Agency and did not conduct a thorough investigation. The resident was admitted with diagnoses including right-sided hemiplegia, dementia, and depression, and the MDS dated 4/13/2026 indicated moderately impaired cognition, maximal assistance with oral hygiene, lower body dressing, and personal hygiene, and dependence for toileting and showers. The H&P dated 1/8/2026 indicated the resident did not have the capacity to understand and make decisions. According to the resident’s RP, on 3/31/2026 the RP observed a bruise and scratch on the right side of the resident’s cheek that had not been present the previous evening. The RP stated the resident said, "he hit me," and demonstrated being struck on the right side of the face. The RP reported the incident to RN 1 that morning, and the DON later observed the resident demonstrate how she had been hit. The RP also spoke with the DON and Administrator, and the facility contacted law enforcement to interview the resident regarding the allegation. During interview, the DON stated the facility did not report the allegation to the SSA because she believed no abuse had occurred, and stated the facility should have reported it because the state agency would investigate whether abuse occurred. The DON further stated the facility did not follow its Abuse Prevention and Management policy because it did not report the allegation to the Ombudsman or SSA and did not conduct a thorough investigation.
Failure to Report Alleged Physical Abuse Within Required Timeframe
Penalty
Summary
The facility failed to report an allegation of physical abuse within two hours when Resident 2 was reported to have been punched in the face. Resident 2 was admitted with diagnoses including right-sided hemiplegia, dementia, and depression, and the MDS indicated moderately impaired cognition with dependence or maximal assistance for several activities of daily living. The H&P stated Resident 2 did not have the capacity to understand and make decisions. On 3/31/2026, the COC documented a bruise to the right jaw, and the resident’s RP reported seeing a bruise and scratch on the right cheek that morning after not seeing any bruising the prior evening. The RP stated Resident 2 said, "he hit me," and demonstrated being struck on the right side of the face. The RP reported the incident to RN 1 the same morning, and RN 1 notified the DON and Admin because the allegation involved physical abuse. RN 1 stated he did not submit a report because he was not sure it was abuse. The DON stated the facility did not report the allegation because she believed no abuse had occurred and thought the bruise was from a fall on 3/29/2026, while the Admin stated he did not consider the allegation to be abuse and did not investigate it. The facility policy stated known or suspected physical abuse must be reported to the local Ombudsman and CDPH within two hours of observation, knowledge, or suspicion.
Failure to Report and Investigate Allegation of Abuse
Penalty
Summary
The facility failed to thoroughly investigate and submit a written report of an allegation of abuse to CDPH within five working days after a resident’s responsible party reported that an unidentified staff member hit the resident on the right side of the cheek. The resident had been admitted with diagnoses including right-sided hemiplegia, dementia, and depression, and the MDS indicated moderately impaired cognition with dependence for toileting and showers and maximal assistance for oral hygiene, lower body dressing, and personal hygiene. The H&P stated the resident did not have the capacity to understand and make decisions. The responsible party stated he observed a bruise and scratch on the resident’s right cheek during a morning visit and that the resident said, “he hit me,” while demonstrating how she had been struck. He reported the incident to an RN the same morning and later spoke with the DON and Administrator, who contacted law enforcement to interview the resident. The Administrator stated he did not consider the allegation to be abuse and did not investigate it, and the DON stated the facility did not report the allegation to CDPH because she believed no abuse had occurred. The facility’s policy required the administrator or designee to provide a written report of the findings of the investigation within five working days of the incident.
Inaccurate MAR Documentation After Resident Transfer
Penalty
Summary
The facility failed to maintain accurate clinical records for one resident when an LVN documented medications as administered on the MAR after the resident had already been transferred to a GACH. The resident was admitted with Alzheimer’s disease, hydrocephalus, venous insufficiency, and peripheral vascular disease. The record also showed the resident had been assessed as able to understand and be understood on the MDS, while the H&P later indicated the resident did not have the capacity to understand or make medical decisions. The resident’s orders included famotidine, fluticasone propionate, Culturelle, and Lasix. On the day of the event, the SBAR documented bilateral upper eyelid swelling and that the MD was notified with new orders to transfer the resident to GACH 1 for bilateral eye swelling and pain. The SNF to Hospital Transfer Form showed the resident was transferred to GACH 1 at 11:20 a.m. that day. Despite the transfer, the May 2026 MAR showed the LVN documented famotidine, Culturelle, fluticasone propionate, and Lasix as administered later that afternoon and evening. During interview, the LVN stated the resident was not in the facility when she came on duty and that she must have signed off the medications by accident. The DON reviewed the MAR and stated the LVN signed off medications as given when the resident was not in the facility, and that the entry should have indicated the resident was in the hospital. The facility policy required medication administration records to be factual and accurately reflect the services provided and the resident’s condition.
Failure to Provide Timely Incontinence Care and Respond to Resident Requests
Penalty
Summary
The deficiency involves failures by a certified nursing assistant (CNA 1) to provide timely incontinence care and respond appropriately to resident requests for assistance, resulting in residents remaining in soiled diapers and wet bedding. One resident with bilateral osteoarthritis of the knees and hips and morbid obesity, who required moderate assistance for toileting hygiene and maximal assistance for transfers, pressed the call light around 9 p.m. because her diaper and bed sheets were wet and needed to be changed. Approximately 30 minutes later, CNA 1, who was assigned to this resident, entered the room, turned off the call light, and left without providing care, despite the resident verbally stating she needed to be changed. The resident waited an additional 20–30 minutes, then called the front desk to request help, and ultimately remained in a soaked diaper and wet bed for about an hour before another CNA, not assigned to her, changed her diaper and bedding. Nursing staff and another CNA corroborated the resident’s account. RN 1 reported that the resident called the front desk stating she needed a CNA, and after paging CNA 1, CNA 2 later informed RN 1 that the resident was not being changed. When RN 1 went to the room, she observed the resident to be soaking wet with a very wet bed sheet. RN 1 stated the resident reported that CNA 1 had come in, turned off the call light, turned her back, and left after being told the resident needed to be changed. RN 1 then located CNA 1 in the conference room looking at her cell phone; during the ensuing interaction, CNA 1 became offended, stated she was going home, and left the facility before the end of the shift, requiring another CNA to provide the incontinence care. LVN 1 recalled that CNA 1 was paged twice for this resident, saw the call light remain on, and later learned from the resident that CNA 1 had ignored her request to be changed. CNA 2 reported that during rounds she found the resident waiting to be changed, and about 50 minutes later, after an overhead page, the resident told her that CNA 1 had turned off the call light and left; CNA 2 observed that the resident’s bed was wet. A second deficiency event involved another resident with bilateral hip osteoarthritis, prostate cancer, and type 2 diabetes, who was dependent for toileting hygiene and required substantial assistance for bathing and lower body dressing. This resident, who used a wheelchair due to muscle weakness and was incontinent, reported having an episode of diarrhea that soiled his diaper and stated he asked CNA 1 to clean him, but she said no. LVN 1, stationed at the nursing desk, witnessed the resident approach and ask that CNA 1 be called to change his soiled diaper. After calling CNA 1 overhead twice, LVN 1 instructed CNA 1 to change the resident when she arrived. In the resident’s presence, CNA 1 gave excuses that she had been on break and was busy, then asked the resident, “Do you want me to change you, yes or no?” The resident became frustrated and requested another CNA, and LVN 1 arranged for another CNA, not assigned to him, to provide the cleaning and changing. RN 1 later learned from LVN 1 that the resident had asked CNA 1 to be changed earlier and that CNA 1 had responded no. In interviews, CNA 1 denied recalling either resident and minimized resident complaints, while the DON and other staff confirmed that answering call lights and providing timely incontinence care are standard CNA responsibilities, and that residents are to be treated with dignity and respect in accordance with facility policy and job descriptions.
Failure to Maintain Resident Privacy During Peri-Care
Penalty
Summary
The deficiency involves a failure to ensure personal privacy for a resident during intimate care. The resident, who had hemiplegia and hemiparesis following a cerebral infarction, syncope, and overactive bladder, was dependent on staff for toileting hygiene, bathing, dressing, and personal hygiene according to the MDS. The resident had documented capacity to understand and make decisions. On the evening in question, the resident activated the call light requesting a diaper change, and a CNA responded to provide incontinence and peri-care. While the CNA was in the process of changing the resident’s soiled diaper, with the old diaper already removed and the resident’s lower body exposed, another CNA entered the room without knocking. According to the CNA providing care, the second CNA came into the room under the pretense of getting gloves and appeared at a 1–2 foot gap in the privacy curtain while the resident was still exposed. The CNA providing care told the second CNA to leave so she could continue changing the resident, and later reminded the second CNA that residents need privacy. The resident reported seeing a second person appear at the gap in the curtain while she was still being changed and exposed, and stated that this person began talking to the CNA who was providing care. The resident stated she felt embarrassed by the exposure and asked the CNA providing care to be mindful and not let anybody come in while she was being changed, noting that some CNAs usually knock and ask permission but the second person did not knock. Interviews with other staff, including another CNA and the DON, confirmed that facility practice and expectations require staff to knock, introduce themselves, close curtains, and provide privacy during peri-care, and that video recording with cell phones is not allowed due to the possibility of violating residents’ privacy. The facility’s Resident Rights policy and CNA job description also state that residents have rights to privacy and confidentiality and that CNAs must provide personal hygiene care in a manner that maintains resident dignity and comfort.
Inaccurate Advance Documentation of Isolation Room Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s medical record was accurately documented in accordance with facility policy. The resident had a history that included cerebral ischemia, spinal stenosis, and paroxysmal atrial fibrillation, and had been recently re-admitted after treatment for a urinary tract infection. An MDS assessment indicated the resident required maximal assistance with eating, personal hygiene, and upper body dressing, and was dependent for toileting hygiene and bathing. These details establish the resident’s clinical status and functional dependence at the time of the events. On the day in question, the resident experienced several episodes of diarrhea, and a stool sample was collected and later tested positive for C. difficile. Following receipt of the positive test result, nursing staff determined the resident needed to be moved to a private room and placed on contact isolation. LVN 1 stated that the new private room still needed to be cleaned before the resident could be transferred and reported that the actual transfer occurred around midday. CNA 1 similarly recalled that housekeeping had to clean the new room first and that the transfer occurred shortly before CNA 1’s lunch break at approximately 11:30 a.m. However, review of the electronic medical record showed that an Infection Note dated the same day was entered at 9:07 a.m., indicating that the resident had already been placed in a private room. When questioned, LVN 1 acknowledged that the note was likely completed before the transfer actually occurred and that the documentation was inaccurate at the time it was entered. The DON confirmed that licensed nurses are expected to chart what they have actually done and not to document events in advance, referencing the facility’s policy on Completion & Correction, which states that entries must be recorded as events occur and that an event is never to be documented before it happens. This sequence of actions resulted in an inaccurate medical record for the resident.
Failure to Notify Physician of Critical Blood Sugar Refusal and Elevated Glucose
Penalty
Summary
The facility failed to notify the medical doctor when a resident with multiple complex diagnoses, including type 2 diabetes mellitus, hypertension, gastrostomy, and chronic kidney disease, refused a fasting blood sugar (FSBS) check and subsequently had a critically elevated blood glucose reading. The resident, who lacked capacity to make healthcare decisions, was admitted with orders for regular FSBS monitoring and specific instructions to notify the physician if blood sugar exceeded 250 mg/dL. On the morning in question, the resident refused the FSBS at 6 a.m., and this refusal was not communicated to the physician as required by both facility policy and physician orders. Later that day, the resident was found to have a blood glucose level of 379 mg/dL and was noted to be difficult to arouse, with vital signs indicating hypotension. Despite the elevated blood sugar and the physician order to notify for readings above 250 mg/dL, staff did not contact the physician at that time. Instead, emergency services were called when the resident became unresponsive, and the physician was only notified after the resident was being transported to the hospital. Documentation was lacking regarding both the refusal of the FSBS and the missed insulin dose, and there was no evidence that the physician was informed of these events in a timely manner. Interviews with nursing staff and facility leadership confirmed that the physician should have been notified immediately of the resident's refusal and the subsequent high blood sugar, as per facility policy and standard practice. Staff acknowledged that failure to notify the physician could result in a delay of care. The facility's policies on medication administration, diabetic care, and blood glucose monitoring all require prompt physician notification for refusals and for blood sugar readings outside specified parameters, but these procedures were not followed in this case.
Failure to Notify Physician and Administer Care for Critically Elevated Blood Glucose
Penalty
Summary
A deficiency occurred when nursing staff failed to follow physician orders and facility policy regarding the management of a resident with type 2 diabetes mellitus, hypertension, gastrostomy, and chronic kidney disease. The resident was admitted with orders for blood glucose monitoring every six hours, with instructions to notify the physician if blood sugar exceeded 250 mg/dL. On the day in question, the resident's blood sugar was found to be 379 mg/dL, and later, upon transfer to the hospital, was recorded as greater than 500 mg/dL, with laboratory results showing a glucose level of 1,443 mg/dL. Despite these critical findings, the nursing staff did not notify the physician as required by the orders and facility policy. Interviews with the LVN and RN involved revealed that neither contacted the physician when the resident's blood sugar was elevated and the resident became unresponsive with hypotension. Instead, they called 911 and only notified the physician after the resident was already being transported to the hospital. The staff acknowledged that physician notification could have resulted in additional orders, such as insulin or fluids, but this step was omitted. The facility's policies on medication administration, diabetic care, and blood glucose monitoring all required physician notification for out-of-range blood glucose values, which was not followed in this case. Additionally, a review of the resident's medication administration record and feeding orders revealed that the resident missed 14 hours of prescribed tube feeding, which the Assistant Director of Nursing confirmed could contribute to unstable blood sugar and other complications. The failure to initiate the feeding as ordered and the lack of timely physician notification for both the elevated blood sugar and the resident's change in condition resulted in a delay in care and treatment for the resident, who was ultimately transferred to an acute care hospital with diagnoses including diabetic ketoacidosis and hyperkalemia.
Failure to Provide Prescribed Enteral Feeding to Resident
Penalty
Summary
A deficiency occurred when a resident who was dependent on enteral feeding did not receive the prescribed diet as ordered by the attending physician. The resident, admitted with diagnoses including type 2 diabetes mellitus, hypertension, gastrostomy, and chronic kidney disease, had a physician's order for Glucerna 1.5 to be administered via gastrostomy tube at a rate of 55 ml per hour for 20 hours daily, totaling 1,100 ml and 1,650 kcal per 24 hours. The order specified the feeding should be on at 2 p.m. and off at 10 a.m., or until the dose was completed, with allowances to hold feedings during ADL care, showers, and transfers. Upon review of the Medication Administration Record (MAR) and Medication Admin Audit Report, it was found that the feeding was not initiated as ordered. The MAR indicated the feeding was signed off as 'off' at 10 a.m., but there was no documentation that the feeding had been started prior to this time. The Assistant Director of Nursing (ADON) confirmed that the feeding should have been set up immediately upon admission, as the facility had the necessary supplies and equipment available. The ADON also noted that the nurse did not sign that the feeding was started, resulting in the resident missing 14 hours of prescribed feeding. As a result of this omission, the resident did not receive 770 ml of the prescribed enteral nutrition. The facility's policy and procedure for enteral feeding, last reviewed in April 2025, required that enteral feedings be administered via pump as ordered by the physician. The failure to initiate the prescribed feeding regimen led to the resident not receiving the required nutrition and hydration as ordered.
Failure to Administer Insulin and Perform Blood Glucose Monitoring as Ordered
Penalty
Summary
The facility failed to ensure that a resident received medications as prescribed, specifically regarding the administration of insulin and blood glucose monitoring. On the morning in question, the resident refused a fasting blood sugar (FSBS) check at 6 a.m., and as a result, did not receive the scheduled dose of Novolin N FlexPen insulin, which was to be administered unless the blood sugar was below 100. The Medication Administration Record (MAR) indicated the FSBS was refused and the insulin was not given, with documentation codes reflecting these actions. The resident had a complex medical history, including type 2 diabetes mellitus, hypertension, gastrotomy, and chronic kidney disease. The resident's records indicated inconsistent capacity to make healthcare decisions, and the Minimum Data Set (MDS) noted that the resident sometimes understood and was sometimes understood. Despite the refusal of the FSBS, previous blood sugar readings at 12:04 a.m. and 11:56 a.m. were 121 and 109, respectively, both above the threshold for holding insulin. Facility policy required medications to be administered according to physician orders and blood glucose testing to be performed as ordered. Later that day, the resident experienced a significant change in condition, including hypotension and an elevated blood sugar level of 379, leading to hospital transfer. The Assistant Director of Nursing (ADON) confirmed that staff should have obtained another blood sugar check at 6 a.m. to ensure accurate assessment and appropriate insulin administration, as the available blood sugar readings did not meet the criteria for withholding the medication.
Failure to Maintain Accurate Clinical Records and Documentation
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for one resident by not ensuring that nursing staff properly documented medication administration and related progress notes. Specifically, a Licensed Vocational Nurse (LVN) documented a code '9' on the Medication Administration Record (MAR), which indicates that a progress note should be present to explain why a medication was not given. However, no such progress note was found in the resident's record, resulting in incomplete documentation. Additionally, after the resident was discharged to a general acute care hospital, another LVN did not accurately document in the MAR, further contributing to the inaccuracy of the resident's medical records. The resident involved had multiple complex medical conditions, including type 2 diabetes mellitus, hypertension, a gastrostomy tube, and chronic kidney disease. The resident's care plan included numerous orders such as enteral feeding, medication administration via g-tube, pain monitoring, and regular assessments for side effects and symptoms related to their diagnoses and treatments. The MAR for this resident showed that tasks and medication administrations were signed off as completed, but the required supporting documentation, such as progress notes for exceptions or withheld medications, was missing. Interviews with facility staff, including the Director of Nursing (DON) and the LVNs involved, confirmed that the documentation was incomplete and did not meet professional standards. The DON acknowledged that the absence of accurate documentation could result in an incomplete record and hinder continuity of care, as subsequent staff would not have a clear understanding of the resident's condition or the reasons for any deviations from the care plan. The facility's own policy required complete, legible, and accurate entries in the medical record, which was not followed in this instance.
Incomplete Discharge Documentation and Medical Record Deficiency
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident by not ensuring that the Discharge Planning Review Form was completed and signed by a registered nurse, and by not documenting the resident's refusal to sign discharge documents. The resident, who had diagnoses including anxiety disorder, gastroesophageal reflux disease, and acute respiratory failure with hypoxia, was admitted with intact cognition. Upon discharge, the Discharge Planning Review Form lacked both the licensed nurse's and the resident's signatures, and the resident's refusal to sign was not documented in the medical record. Additionally, licensed nurses did not document the level of care provided, the resident's health status, or the medical records given to the resident on the day of discharge. Progress notes for the resident did not reflect these required details, and the Director of Nursing confirmed that the medical records were incomplete and that documentation of the resident's discharge status was neither timely nor complete. The facility's policy required that progress notes reflect the resident's current status and be documented in a timely manner, which was not followed in this case.
Resident Privacy Not Maintained During Shower
Penalty
Summary
A deficiency occurred when a resident's privacy was not maintained during a shower. Observation revealed that the privacy curtain in the shower room was not fully closed, leaving a gap that exposed the resident while being assisted with bathing. The Licensed Vocational Nurse present acknowledged that the curtain should have been closed to ensure the resident's safety and privacy. The Director of Nursing confirmed that staff are expected to pull the privacy curtain when a resident is undressed in the shower room and that this lapse could cause embarrassment and emotional distress for the resident. The resident involved had a history of dementia, depression, and stroke, and was assessed as having severely impaired cognitive functioning. The resident required moderate assistance with showers and was able to make needs known regarding activities of daily living. Facility policy requires staff to promote and protect resident privacy, including bodily privacy during personal care. The failure to fully close the privacy curtain during the resident's shower did not align with these requirements.
Call Light Not Within Reach for Dependent Resident
Penalty
Summary
A deficiency occurred when staff failed to ensure that a call light was within reach for a resident with significant medical needs. The resident had a history of cerebrovascular accident (CVA), epilepsy, depressive disorder, and hemiplegia, and required maximal to moderate assistance with activities of daily living such as toileting, dressing, and hygiene. The resident's care plan specifically directed staff to keep the call light within reach due to these limitations. During an observation, the call light was found placed at the top of the mattress above the resident's pillow, out of the resident's reach. A CNA confirmed that the resident would not be able to access the call light in that position and acknowledged it should have been placed within reach to allow the resident to call for assistance. The DON also confirmed that call lights are required to be within reach, as per facility policy, and that failure to do so could delay necessary care.
Failure to Arrange Transportation for Clinic Appointment
Penalty
Summary
The facility failed to ensure that a resident received medically-related social services necessary to achieve the highest possible quality of life by not arranging transportation for a scheduled clinic appointment. The resident, who had a history of cerebral infarction, hemiplegia, heart failure, asthma, and depression, was dependent on staff for daily activities and had moderately impaired cognitive functioning. A physician's order required the resident to attend a follow-up appointment with a pulmonologist, with specific instructions for preparation and transportation. Despite the scheduled appointment and the need for wheelchair-accessible transportation, the Social Services Director did not arrange transportation ahead of time, relying instead on a transportation agency that only accepted same-day requests. On the day of the appointment, no wheelchair-accessible transportation was available, and the facility did not utilize a private transportation agency that could have been scheduled in advance. The Director of Nursing confirmed that there was no facility policy or procedure for arranging transportation, and acknowledged that this failure could potentially delay care and worsen the resident's condition.
Failure to Document Clinic Appointment Arrangements and Outcomes
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident by not documenting the arrangements for a scheduled clinic appointment and the outcome of that appointment. The resident, who had a history of cerebral infarction, hemiplegia, heart failure, asthma, and depression, was noted to have moderately impaired cognitive functioning and was dependent on staff for certain activities of daily living. A physician's order indicated a scheduled follow-up appointment with a pulmonologist, including specific instructions for preparation and required documentation to accompany the resident. Upon review, it was found that while the appointment was noted in the resident's records, there was no documentation regarding the transportation arrangements made for the appointment or whether the appointment was completed. The Social Services Director confirmed the lack of documentation for both the transportation and the appointment outcome. The Director of Nursing stated that each discipline is responsible for updating resident records and that such documentation should have been present. Facility policy also requires all disciplines to document relevant resident progress and events in the medical record according to professional standards.
Failure to Reconcile Controlled Medication Kits and Ensure Availability of Prescribed Pain Medication
Penalty
Summary
The facility failed to reconcile and account for six medication emergency kits (eKITs) containing controlled medications (CMs) in three medication rooms for the month of June 2025. During observations and interviews, it was found that none of the eKITs in Medication Room Stations 1, 2, and 3 had accountability logs for reconciliation of CM inventory at every shift change, as required by facility policy and federal and state regulations. Multiple licensed nurses confirmed that the eKITs were not reconciled at every shift, and the Director of Nursing (DON) acknowledged that the required accountability and reconciliation logs were not maintained for these kits during the specified period. Additionally, the facility did not have an available supply of tramadol, a controlled medication prescribed for moderate to severe pain, which affected a resident who was not administered the medication as ordered. On the morning of June 3, 2025, a licensed vocational nurse (LVN) was observed administering other medications to the resident but did not administer tramadol because it was not available in the medication cart or anywhere in the facility. The LVN instead administered Tylenol, which was only prescribed for lower pain levels, and acknowledged this as a medication error. The resident had reported a pain level of 5, which required tramadol according to the physician's order. Review of the resident's records indicated a history of spondylosis and cervical disc degeneration, with tramadol prescribed for pain levels between 5 and 10. The Medication Administration Record confirmed that tramadol was not administered as ordered. Facility policies reviewed indicated that medications, especially controlled substances, must be administered as prescribed and reconciled at each shift change, but these procedures were not followed, resulting in the deficiencies identified.
Failure to Maintain Safe and Homelike Environment Due to Equipment and Environmental Disrepair
Penalty
Summary
Multiple deficiencies were identified related to the facility's failure to maintain a safe, clean, and homelike environment for several residents. For one resident with epilepsy, cognitive communication deficit, and mood disorder, the bed control cord was found to have exposed and frayed wires, partially wrapped with black tape, which was not an appropriate repair. The resident and staff were aware of the issue, but it was not reported promptly to maintenance, and the improper repair was not followed up with a replacement as required by facility policy and equipment manuals. Another resident with hemiplegia, hemiparesis following a stroke, depression, muscle weakness, and a history of falls was found to have a broken baseboard in their room, with two exposed metal nails sticking out. Staff were aware of the broken baseboard but did not report it to maintenance due to being busy. The presence of the broken baseboard and exposed nails was acknowledged by staff as unsafe and not consistent with a homelike environment. Additionally, two residents with significant cognitive and physical impairments, both at risk for falls, were found to have floor mats in disrepair. One resident's floor mat had a linear tear with foam padding exposed, while another's had multiple scratches. Staff and leadership acknowledged that these conditions did not provide a homelike environment and that such issues should have been reported to maintenance for replacement. Facility policies and procedures required prompt reporting and repair of such environmental hazards, but these were not followed in these instances.
Failure to Ensure Residents' Right to Be Free from Physical Restraints
Penalty
Summary
The facility failed to ensure that residents were free from the use of physical restraints unless required for medical treatment, as evidenced by multiple observations, interviews, and record reviews involving four residents. For two residents, staff placed pillows tightly tucked under the fitted sheet on both sides of the bed, which restricted the residents' freedom of movement. These actions were performed for staff convenience and without a physician's order, informed consent, physical restraint assessment, or inclusion in the care plan. Both the Director of Staff Development and the Director of Nursing confirmed that this practice was not permitted, as it prevented residents from moving freely and could be considered a restraint. Another resident was found to be using a low air loss mattress with built-in bilateral upper and lower bolsters for trunk control and postural positioning. However, there was no documentation of a physician's order, informed consent, physical restraint assessment, or care plan for the use of these bolsters. The MDS Coordinator and DON acknowledged that the use of bolsters in this manner could be considered a restraint, as it restricted the resident's movement, and that the required assessments and documentation had not been completed. A fourth resident's bed was placed against the wall to prevent falls, but this intervention was implemented without a physician's order, informed consent, restraint assessment, or care plan. Staff interviews confirmed that these steps were necessary to ensure the safe use of such interventions and to honor the resident's right to informed consent. The facility's own policies required that before any restraint is used, alternative methods must be attempted and documented, and that a comprehensive assessment, physician's order, informed consent, and care plan must be in place, none of which were completed in these cases.
Failure to Rotate Insulin Injection Sites for Two Residents
Penalty
Summary
Licensed nursing staff failed to rotate subcutaneous insulin injection sites for two residents who were prescribed insulin for diabetes management. For one resident, medical records showed repeated administration of insulin in the same areas, such as the left lower quadrant of the abdomen and the right arm, over multiple days. The resident had diagnoses including type 2 diabetes mellitus, muscle weakness, and mild protein-calorie malnutrition, and was cognitively intact and able to make medical decisions. The order summary for this resident specifically instructed staff to rotate injection sites, but documentation revealed that this was not consistently done. For the second resident, who had type 2 diabetes mellitus with chronic kidney disease and mild protein-calorie malnutrition, similar failures were observed. The resident's records indicated that insulin was administered multiple times in the same area, such as the right or left arm and the abdomen, without proper rotation as required by the physician's orders. This resident had moderately impaired cognition and was also prescribed a sliding scale insulin regimen that included instructions to rotate injection sites. The care plan for this resident included an intervention to administer medications as ordered, but the rotation of injection sites was not consistently documented. Interviews with the Director of Staff Development and the Assistant Director of Nursing confirmed that licensed staff did not always rotate insulin administration sites for these residents. Both staff members acknowledged that site rotation is necessary to prevent complications and that the facility's policy and the prescribing information for Novolog insulin require rotation of injection sites. The facility's policy also outlined the main sites for insulin injection and emphasized the importance of rotating within those areas.
Failure to Maintain a Safe Environment and Prevent Accident Hazards
Penalty
Summary
Surveyors identified multiple deficiencies related to accident hazards and inadequate supervision in the facility, affecting several residents with varying degrees of cognitive and physical impairment. In several instances, floor mats intended to reduce injury from falls were obstructed by heavy objects such as overbed tables and visitor chairs, as observed in the rooms of residents with documented fall risks and impaired cognition. Staff interviews confirmed that these items should not have been placed on the mats, as this could compromise their effectiveness in preventing injury during a fall. Additionally, a bedside table was found on top of a fall mat in another resident's room, with staff acknowledging this practice was unsafe. Other environmental hazards were also documented, including an uncovered electrical outlet behind a resident's bed and a broken baseboard with exposed nails in another resident's room. Staff admitted to being aware of these hazards but failed to report them, and maintenance personnel confirmed that such conditions were unsafe and not in compliance with facility policy. The presence of these hazards was corroborated by direct observation and staff interviews, and facility policies reviewed by surveyors required immediate reporting and correction of such issues to maintain a safe environment. Additional deficiencies included improper storage of cigarettes and medications. A resident was found with a pack of cigarettes in their possession, contrary to facility policy requiring secure storage of smoking materials. Medications, including topical creams and eye drops, were left at the bedside of two residents without proper physician orders or secure storage, in violation of facility procedures. Staff interviews confirmed that these practices were not in line with established protocols and posed risks as outlined in the facility's own policies and procedures.
Failure to Obtain Required Authorization and Documentation for Bedrail Use
Penalty
Summary
The facility failed to obtain a physician's order, informed consent, a bedrail assessment supporting use, and a care plan for the application of padded bilateral upper bedrails for a resident with hemiplegia, hemiparesis, muscle weakness, and cognitive communication deficit following a cerebral infarction. The resident was admitted with high fall risk and required assistance with mobility and activities of daily living, using both a walker and wheelchair. Despite the resident's capacity to make medical decisions and intact cognition, there was no documentation of a physician's order or informed consent for the use of bedrails. Observation confirmed that the resident's bed had bilateral upper padded bedrails in use, and staff interviews revealed that the bedrails were being used to facilitate mobility in bed and as a fall intervention. However, review of the resident's records showed the absence of a physician's order, informed consent, and a care plan addressing the use of bedrails. The only bedrail assessment present recommended against their use, yet the bedrails remained in place. Interviews with facility staff, including the Director of Staff Development and the Assistant Director of Nursing, confirmed that required procedures were not followed. Facility policy required a detailed healthcare provider order, informed consent, and care planning for bedrail use, but these steps were not completed. The lack of proper assessment, documentation, and consent for the use of bedrails constituted the deficiency identified by surveyors.
Medication Error Rate Exceeds Acceptable Threshold Due to Missed and Incorrect Medication Administration
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required, with two medication errors identified out of 31 observed opportunities, resulting in a 6.45% error rate. One error involved a resident who did not receive tramadol as prescribed for moderate to severe pain because the medication was not available in the facility at the time of administration. Instead, the resident was given Tylenol, which was only indicated for lower pain levels, despite the resident reporting a pain level of 5. The nurse acknowledged that tramadol should have been available and administered according to the physician's order and facility policy. Another error occurred when a different resident received a multivitamin with minerals, contrary to the physician's order for a multivitamin without minerals. The nurse administering the medication admitted to not following the five rights of medication administration and recognized this as a medication error. The Director of Nursing confirmed that the correct form of the multivitamin was not given and that this could potentially affect the resident's health, especially considering the resident's medical condition, which included a left lower leg wound. Record reviews confirmed that both residents had clear physician orders for their respective medications, and the facility's policies required strict adherence to these orders, including ensuring medication availability and verifying the correct medication before administration. The failures were observed during medication passes and confirmed through interviews with the involved nurse and the Director of Nursing, as well as through review of the residents' medical records and the facility's policies and procedures.
Failure to Rotate Insulin Injection Sites Results in Medication Errors
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors by not rotating subcutaneous insulin injection sites as required by prescriber orders, manufacturer specifications, and accepted professional standards. For two residents with diabetes mellitus, staff repeatedly administered insulin injections in the same anatomical areas over an extended period, as documented in the Location of Insulin Administration Reports. This practice was confirmed through record reviews and interviews with facility leadership, who acknowledged that injection site rotation was not consistently performed. One resident, admitted with type 2 diabetes mellitus, muscle weakness, and mild protein-calorie malnutrition, had intact cognition and was able to make medical decisions. The resident's orders specified the use of a sliding scale for Novolog insulin and explicitly required rotation of injection sites. However, records showed that insulin was frequently administered in the same areas, particularly the right arm, over multiple dates. Facility staff, including the Director of Staff Development and Assistant Director of Nursing, confirmed that this failure to rotate sites constituted a medication error and could lead to complications such as bruising, skin injury, and impaired insulin absorption. A second resident, also with type 2 diabetes mellitus and diabetic chronic kidney disease, had similar orders for insulin administration with instructions to rotate injection sites. Despite this, documentation revealed repeated use of the same injection sites, including the right and left arms and the abdomen. Interviews with facility staff again confirmed that the lack of site rotation was a medication error. Facility policies and manufacturer guidelines reviewed during the survey also emphasized the importance of rotating injection sites to prevent adverse effects and ensure proper medication administration.
Failure to Maintain Sanitary Food Storage and Labeling Practices
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen regarding safe and sanitary food storage and preparation practices. During an inspection, opened containers of thickened lemon water and almond milk were found to be sticky to the touch, and an opened container of apple juice was not labeled with the date it was opened. Additionally, an opened bottle of brown coloring for gravy was observed with dried dark brown drippings on the side. The Dietary Supervisor confirmed that kitchen staff should have wiped containers clean after each use and labeled all opened items with the date to ensure proper food safety and sanitation. Interviews with the Dietary Supervisor and the Director of Nursing confirmed that the facility's policy requires all food items to be labeled and dated when opened, and that containers should be wiped clean after each use. The policy also states that opened products should be stored in containers with tight-fitting lids and labeled accordingly. The observed failures to follow these procedures had the potential to compromise food safety for residents receiving meals from the kitchen.
Failure to Enforce Food Labeling and Storage Policy for Resident Food Brought by Visitors
Penalty
Summary
The facility failed to enforce its policy regarding the labeling and storage of food items brought in by family members or visitors for residents. During observations and interviews, it was found that multiple food items, including condiments such as ranch dressing, mayonnaise, and red salsa, were stored in the resident-designated refrigerator without being labeled with the resident's name or the date the items were opened and placed in the refrigerator. Staff interviews confirmed that the established procedure requires all such items to be labeled with the resident's name and date, and to be discarded after 48 hours, but this was not consistently followed. The deficiency was identified during kitchen inspections and interviews with dietary, nursing, and administrative staff, all of whom acknowledged the requirement for proper labeling and timely disposal of perishable food items. The facility's policy, last reviewed in January 2024, clearly states that food brought in by visitors must be labeled and stored appropriately to prevent the risk of food-borne illness. However, the observed failure to label and date these items as required placed residents at risk for consuming expired or spoiled food.
Failure to Maintain Infection Control Practices for Resident Items and Linen Storage
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observed deficiencies in resident care and environmental management. In one instance, a resident with chronic obstructive pulmonary disease, protein-calorie malnutrition, and dementia was found lying in a low bed with a glass of water and a desk phone placed on the floor beside the bed. Additionally, the resident's urinal bottle was not labeled with the resident's name or room number. Staff interviews confirmed that placing personal items on the floor could lead to contamination and that urinals should be labeled to prevent cross-contamination between residents. Further observations revealed that staff repeatedly left mobile linen carts open in the hallway after obtaining supplies, with the carts facing resident rooms. Staff members acknowledged that leaving the carts open exposed clean linens to environmental contaminants, and that clean linens were touched with gloves and PPE after providing resident care, increasing the risk of contamination. Facility policy required that linen carts be covered at all times to prevent contamination, but this was not consistently followed. Additionally, some mobile linen carts were covered with mesh or permeable materials, which staff recognized as inadequate for protecting linens from environmental contaminants. Although there was an effort to replace these covers with non-permeable materials, not all carts had been updated. Facility policies reviewed indicated the importance of proper labeling, storage, and handling of resident care items and linens to prevent infection, but these procedures were not consistently implemented.
Failure to Inform Resident of Medication Names and Indications During Administration
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) administered seven medications to a resident without informing them of the names and indications of each medication prior to administration. The resident, who had diagnoses including type 2 diabetes mellitus and hypertension, was observed swallowing the medications without being told what they were or their purposes. The LVN later acknowledged not providing this information and stated that the resident spoke Spanish, while the LVN did not, and failed to request a translator as required by facility policy. This omission was confirmed during interviews with both the LVN and the Director of Nursing (DON), who stated that the process of informing residents about their medications is essential for resident rights and decision-making. Facility policy and procedures reviewed indicated that staff are required to explain the type of medication being administered and to accommodate residents' communication needs. The failure to inform the resident of the medication names and indications, and to provide translation services, resulted in the resident not being fully informed about their care and not having the opportunity to make choices regarding their medication regimen.
Call Light Not Kept Within Reach for Resident with Limited Mobility
Penalty
Summary
The facility failed to ensure that a resident's call light was kept within reach, as required by the resident's care plan and facility policy. During an observation, the call light was found on the floor beside the resident's bed, making it inaccessible. The resident had a history of type 2 diabetes mellitus with a foot ulcer, obesity, and physical deconditioning, which limited mobility and increased dependence on staff for activities of daily living. The resident was cognitively intact and able to communicate needs, and the care plan specifically directed staff to keep the call light within reach and encourage its use for assistance. Interviews with facility staff, including an LVN, the Director of Staff Development, and the Assistant Director of Nursing, confirmed that it was the responsibility of all staff to ensure call lights were accessible to residents at all times. Staff acknowledged that the call light should not have been on the floor and that environmental checks should include verifying the call light's placement. Review of facility policy also indicated that call cords must be placed within the resident's reach. The failure to keep the call light accessible constituted a deficiency in accommodating the resident's needs and preferences.
Failure to Develop and Implement Care Plan for Physical Restraint Intervention
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident who was subject to a physical restraint intervention. Specifically, the resident, who had diagnoses of hemiplegia, hemiparesis following cerebral infarction, and muscle weakness, was admitted with high fall risk and required assistance with mobility and activities of daily living. The resident's bed was placed against the wall as a fall prevention measure, which the Director of Staff Development (DSD) identified as a form of restraint that limited the resident's freedom to exit the bed from both sides. Despite this intervention, there was no corresponding care plan documented in the resident's electronic medical record addressing the use of the bed as a restraint. Further review of the resident's records, including the admission record, history and physical, Minimum Data Set (MDS), and order summary, confirmed the absence of a physician's order or care plan for the restraint intervention. Interviews with facility staff, including the DSD and Assistant Director of Nursing (ADON), revealed that the lack of a care plan led to potential miscommunication among the interdisciplinary team and could result in substandard care. The facility's policy required that a comprehensive care plan be developed within seven days of the baseline assessment, but this was not completed for the restraint intervention used for this resident.
Failure to Provide Resident-Centered Activities and Maintain Accurate Activity Records
Penalty
Summary
The facility failed to provide resident-centered activities for a resident with dementia, major depressive disorder, and generalized muscle weakness. The resident was dependent on staff for transfers and had expressed, through assessment and care planning, a strong preference for participating in religious services, specifically Christian mass, which was considered very important to her. Despite this, the resident was not consistently informed about or brought to religious services, and there was a lack of communication regarding cancellations or alternative activities when the service was not held. Interviews with staff revealed inconsistencies in how residents were notified about activities, with responsibility for informing residents sometimes falling between activity staff and CNAs. On the day in question, the activity assistant did not conduct room visits due to being the only assistant present, and the CNA reported that the resident preferred to stay in bed but did not specifically address the resident's desire to attend religious services. The resident herself stated she had not been told about the religious service and would have attended if invited, emphasizing the importance of these services to her spiritual well-being. Additionally, the facility did not follow its own policy and procedure regarding documentation and tracking of resident participation in activities. The activity director acknowledged that the policy requiring attendance tracking for each activity had not been implemented, resulting in incomplete records of which residents participated in which activities. This lack of documentation and communication contributed to the resident not receiving her preferred activities and the facility not maintaining accurate records as required.
Failure to Document Change of Condition Prior to Hospital Transfer
Penalty
Summary
The facility failed to ensure that a change of condition was properly documented and communicated for two residents who were transferred to a general acute care hospital (GACH). For one resident with diagnoses including cognitive communication deficit, type 2 diabetes mellitus, and generalized muscle weakness, there was no eInteract Change of Condition/SBAR form completed by the licensed nurse at the time of transfer for a urinary tract infection. The Minimum Data Set Coordinator confirmed that the required documentation, which should detail the events leading to the transfer and the interventions provided, was missing. The Director of Nursing also stated that the SBAR/Change of Condition form is essential for communicating the resident's status and the care provided during such incidents. Another resident, with a history of acute osteomyelitis, neuropathic bladder, and paraplegia, was transferred to the hospital on two occasions. On one occasion, the progress notes only indicated the transfer for critical laboratory results without documenting vital signs, primary diagnosis, code status, nursing observations, or notifications to the primary physician and resident representative. On another occasion, although an SBAR/Change of Condition was created for worsening edema, it was not updated to reflect the actual transfer, and the provider notified was not documented. The Director of Staff Development and Assistant Director of Nursing both acknowledged that the required documentation was incomplete or missing, which is necessary to ensure safe transfer and accurate communication of the resident's condition and care. The facility's policy requires that any change in a resident's condition be documented in detail, including the incident, assessments, notifications, and updates to the care plan. However, in both cases, the facility did not follow its own procedures, resulting in incomplete records of the residents' changes in condition and the care provided prior to hospital transfer. This lack of documentation could lead to delays in care and inadequate communication among healthcare providers and resident representatives, as noted in the findings.
Failure to Maintain Catheter Tubing Free of Kinks or Loops
Penalty
Summary
A deficiency was identified when a resident with an indwelling urinary catheter was observed to have a loop in the catheter tubing, which prevented urine from flowing freely into the drainage bag. During the observation, a CNA confirmed that the tubing contained urine and white sediment, and acknowledged that staff are responsible for ensuring the catheter bag is below the bladder, covered for privacy, and that the tubing is free from kinks or loops. The facility's policy also requires that catheter tubing be kept free from kinking and that the collection bag remain below the bladder level. The resident involved had a history of obstructive uropathy, pneumonia, and type 2 diabetes mellitus, and required varying levels of assistance with activities of daily living due to impaired cognition and lower extremity impairment. Physician orders specified monitoring the catheter and drainage bag for issues such as sediment, foul odor, hematuria, and bladder distention every shift. Both the CNA and the DON confirmed that the presence of a loop or kink in the catheter tubing is contrary to standard practice and facility policy, as it can impede urine flow.
Failure to Properly Rinse Medication Syringe for Enteral Feeding
Penalty
Summary
A deficiency occurred when a licensed nurse failed to properly rinse a medication syringe after administering medication via a gastrostomy tube to a resident. The resident, who was non-verbal, had severely impaired cognition, and required total assistance with all activities of daily living, was observed to have a medication syringe stored in a plastic bag with yellow liquid at the bottom and a yellowish white dried powdery substance stuck to the side. The facility's care plan and physician's orders required that syringes be rinsed thoroughly after each use to prevent complications, and the manufacturer's guidelines also specified thorough rinsing after each use. During an interview, the Assistant Director of Nursing confirmed that the syringe should have been rinsed well before being placed back in the storage bag, as failure to do so could place the resident at risk for gastrointestinal problems. The observation and record review confirmed that the nurse did not follow established protocols for syringe care, resulting in the potential for complications associated with enteral feeding.
Failure to Label IV Dressing with Date of Last Change
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including obstructive uropathy, pneumonia, and type 2 diabetes, was observed with a midline catheter dressing that did not indicate the date of the last dressing change. The resident required substantial assistance with activities of daily living and had physician orders for regular flushing of the IV lumen and dressing changes every 48 hours. Facility policy required midline dressings to be changed every seven days or as needed if soiled, loose, or leaking, and to be labeled with the date and time of the last change. During observations, the resident was found with a loose and soiled transparent dressing on the upper arm, which the resident reported became loose after a shower. Interviews with the ADON and DON confirmed that the dressing was not labeled with the date of the last change, contrary to facility policy and professional standards. Both nursing leaders acknowledged that the absence of labeling could prevent staff from knowing when the dressing was last changed, potentially increasing the risk of infection at the insertion site.
Failure to Ensure Timely Physician Notification and Emergency Preparedness for Dialysis Resident
Penalty
Summary
The facility failed to provide dialysis care and services consistent with professional standards of practice for a resident with end stage renal disease (ESRD) who was dependent on hemodialysis. The resident had medical orders for hemodialysis three times weekly, as well as instructions to keep the dialysis site dressing dry and intact, and to monitor for signs of infection, bleeding, drainage, and pain. Despite these orders, the facility did not follow up with the resident's attending physician when the resident missed a scheduled dialysis appointment. Review of nursing progress notes and interviews with the Director of Nursing (DON) confirmed that there was no physician follow-up documented after the missed dialysis session. Additionally, the facility failed to ensure that a dialysis emergency kit was readily available at the resident's bedside. During an observation and interview, it was noted that the dialysis kit, which is intended to provide immediate care in case of emergencies such as bleeding, was missing from the resident's room. Both the resident and the LVN confirmed that the kit had not been present for at least two weeks, and a search of the room and closet did not locate it. The DON confirmed that each dialysis resident should have a kit at the bedside and described its contents and purpose. Facility policies and procedures required that residents who require dialysis receive services consistent with professional standards and that nursing staff keep the physician informed of any changes in condition. The policies also specified that staff should be trained in emergency care for dialysis residents, including management of hemorrhage. The failure to follow up with the physician after a missed dialysis session and the absence of a dialysis kit at the bedside constituted deficiencies in the provision of safe and appropriate dialysis care.
Failure to Properly Label and Store Medications
Penalty
Summary
Facility staff failed to ensure that drugs and biologicals were labeled and stored in accordance with professional standards and manufacturer requirements. In one instance, an opened multi-dose vial of epoetin alfa for a resident was found in the medication room refrigerator without a date indicating when it was first used or when it would expire. The manufacturer's instructions specified that multi-dose vials should be discarded no later than 21 days after first use, and facility policy required the date of opening and expiration to be recorded on the vial. Both the RN and the DON confirmed that the vial was not labeled as required and should have been removed from use, as its effectiveness could not be guaranteed. Additionally, the facility failed to properly label intravenous (IV) ertapenem administered to another resident. The IV bag containing ertapenem, which was prepared from the emergency medication kit, was not labeled with the resident's name or the rate of administration. Facility policy and standard nursing practice require that all medications, especially those from emergency kits, be labeled with the resident's name, medication name, dose, route, date, and rate of administration to ensure safe and accurate medication delivery. The nurse responsible for administering the ertapenem acknowledged that the labeling was incomplete due to being in a hurry, and the DON confirmed that this was not in accordance with facility policy. Both deficiencies were identified through direct observation, interviews with nursing staff and the DON, and review of facility policies and manufacturer instructions. The lack of proper labeling and storage had the potential to result in the use of expired or ineffective medication and could have led to medication administration errors, as the required information to verify the correct resident and administration details was missing.
Failure to Timely Address and Document Dental Complaint
Penalty
Summary
The facility failed to promptly provide dental services for a resident who was admitted with diagnoses including dysphagia, GERD, and anxiety disorder. The resident had moderate cognitive impairment but was able to make decisions and communicate needs. A family member verbally reported the resident was experiencing a toothache to the Social Services Director (SSD), but the SSD did not document the chief complaint or ensure a timely and specific referral to the dentist. When the resident was eventually seen by the dentist, the dental record did not indicate the reason for the referral or the resident's chief complaint. The dentist documented no pain, no swelling, and no visible pathology, but there was no evidence that the toothache complaint was addressed. The SSD acknowledged that the dental referral log and dental records lacked documentation of the chief complaint, and she was unsure if the resident was evaluated for the reported toothache. Additionally, the SSD did not follow up with the family member to confirm whether the dental issue had been resolved. Interviews with other staff, including the Director of Staff Development and Assistant Director of Nursing, confirmed that the process for referring and following up on dental complaints was not followed as required by facility policy. The lack of documentation and follow-up had the potential to result in unresolved pain and discomfort for the resident.
Failure to Designate Qualified Hospice Coordinator for Resident Care
Penalty
Summary
The facility failed to designate a qualified hospice coordinator responsible for coordinating care between hospice representatives and facility staff for a resident receiving hospice services. The Medical Records Director (MRD) was assigned as the hospice coordinator, but interviews and record reviews revealed that the MRD's role was limited to ensuring hospice medical records were complete and updated, and he was not involved in coordinating care or participating in the interdisciplinary team (IDT). The MRD's background was in medical billing and quality assurance in home health, and the job description for the Health Record Coordinator did not include hospice coordination responsibilities. A review of the resident's records showed that the resident was admitted with diagnoses including malignant neoplasm of the cervix, palliative care, and cerebral infarction, and was on hospice care with a terminal prognosis. The resident was mostly dependent on mobility and activities of daily living, and had a condition with a life expectancy of less than six months. The care plan indicated the need for cooperative work with the hospice team to meet the resident's needs, but there were missing signatures and incomplete documentation in the hospice binder, which was not updated and could not be located at the time of review. Interviews with facility staff, including the Case Manager and Assistant Director of Nursing (ADON), confirmed that there was no specific individual assigned as hospice coordinator, and that the MRD, who was designated as such, did not have the clinical background or involvement in care coordination required for the role. The facility's policy required collaboration between hospice and facility staff, but the lack of a qualified hospice coordinator led to deficiencies in the coordination and documentation of hospice care for the resident.
Failure to Maintain Safe Bed Equipment for Resident
Penalty
Summary
The facility failed to maintain resident care equipment in safe operating condition by not ensuring that a resident's bed frame control was in good repair. Specifically, the bed control cord for a resident with epilepsy, cognitive communication deficit, and mood disorder was found to have frayed and exposed wires. The resident, who required substantial assistance with daily activities and was dependent on staff for mobility, reported the issue, noting that black tape had previously been applied to the cord but that exposed wires remained visible and the repair was inadequate. Observations confirmed that the bed control cord had exposed and frayed wires, sometimes with and sometimes without black tape. Staff interviews revealed that a CNA noticed the exposed wires but did not report the issue immediately due to being busy, acknowledging that it should have been reported to maintenance right away. The Maintenance Assistant admitted to previously repairing the cord with tape but was unaware of further issues, while the Maintenance Director stated that taping over exposed wires was not an appropriate repair and that the bed or control should have been replaced if a proper repair could not be made. The facility's policies and procedures, as well as the bed frame manual, require that equipment be maintained in a safe and operable manner, with repairs performed only by authorized personnel and damaged electrical components not to be used. The Director of Nursing confirmed that the facility's policy was not followed in this instance, as equipment issues are to be reported immediately to ensure a safe and homelike environment for residents.
Inaccurate Activity Documentation Due to Shared Staff Logins
Penalty
Summary
The facility failed to maintain accurate and complete medical records in accordance with accepted professional standards for two residents reviewed under the Activities care area. Specifically, activity documentation did not accurately reflect which activity staff member provided services to the residents. For both residents, records indicated that an activity assistant had signed for days when she was not present, and other staff members used her login credentials to document activities, rather than having their own access. One resident, admitted with dementia, major depressive disorder, and generalized muscle weakness, was dependent on staff for transfers and had a care plan emphasizing participation in religious services. Documentation for this resident showed that the activity assistant was recorded as providing services on days she was not working. The assistant confirmed she did not sign on those dates, indicating inaccurate recordkeeping. Another resident, with diagnoses including dementia, schizoaffective disorder, and COPD, also had activity records showing the same assistant's signature on days she was not present. Interviews revealed that other activity assistants did not have their own electronic charting access and used the assistant's login to document care. The DON confirmed that each staff member should have individual access to ensure accurate and validated documentation, and that signing for others is not accurate and poses confidentiality risks. Facility policies required that only authorized staff document in medical records and that staff may not sign for another person.
Cluttered Patio Compromises Resident's Homelike Environment
Penalty
Summary
The facility failed to provide a safe, comfortable, and homelike environment for a resident when their patio was cluttered with belongings from multiple residents, including four clear trash bags with facility curtains, three facility mattresses, and a wheelchair, all covered with a blue tarp. This situation was observed during an interview with the resident, who expressed concerns about the clutter and potential presence of rodents under the tarp, which discouraged them from using the patio. The resident had been admitted with diagnoses including contracture of muscles, rheumatoid arthritis, and major depressive disorder, and required substantial assistance with daily activities. The Environmental Director confirmed that the items had been on the patio for a week and included residents' belongings and facility items. The Director of Nursing acknowledged the resident's complaint and admitted that the patio was cluttered, limiting space for residents and creating an unattractive environment. The facility's policy emphasized providing a safe, clean, and homelike environment, which was not upheld in this instance, as the patio's condition was not addressed despite the resident's complaint.
Inaccurate Documentation of Resident's Change of Condition
Penalty
Summary
The facility failed to ensure that medical records were complete and accurately documented for a resident who was transferred to a General Acute Care Hospital (GACH) due to a complaint of a possible infection on the dialysis access port. The incident occurred when the resident complained at 11:50 p.m. on 9/4/2024, but the Change of Condition (COC) Evaluation form documented the complaint as occurring on 9/5/2024. This discrepancy resulted in inaccurate information in the resident's clinical record, as the attending physician was notified on 9/5/2024 at 1 a.m., which was recorded as 22 hours and 50 minutes before the documented complaint time. The Director of Nursing (DON) acknowledged that the documentation error was due to a typographical mistake by LVN 1, who admitted to the error and emphasized the importance of double-checking documentation before closing it. The facility's policy on Alert Charting Documentation, last reviewed on 5/23/2024, was intended to ensure timely and accurate documentation of residents experiencing a change in condition. However, the failure to adhere to this policy led to an inaccurate timeframe of events in the resident's clinical records.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that the call lights were within reach for four residents, leading to a deficiency in accommodating the needs and preferences of these residents. Resident 52, who was admitted with end-stage renal disease, cerebrovascular disease, aphasia, and muscle weakness, was observed with a call light placed on the side of his contracted arm, making it inaccessible. Despite the care plan indicating the need for the call light to be within reach, the call light was not positioned correctly, as confirmed by a CNA and the DON. Resident 8, who has severely impaired vision and cognition, was found with the call light on the floor, unclipped from the bed sheets. The CNA confirmed that the resident's habit of playing with the call light often resulted in it being out of reach, which could prevent the resident from calling for help. Similarly, Resident 179, who preferred to lay with her head at the foot of the bed, had her call light positioned at the head of the bed, making it inaccessible. The CNA acknowledged the importance of having the call light within reach to ensure the resident could call for assistance. Resident 14, who has generalized muscle weakness and vascular dementia, was observed with the call light hanging on the bed rail and touching the floor, out of reach. The CNA and DON both confirmed that the call light should have been within reach to allow the resident to request assistance. The facility's policy, which mandates that call cords be placed within the resident's reach, was not followed in these instances, leading to the deficiency.
Failure to Ensure Proper Use of Bed Rails and Restraints
Penalty
Summary
The facility failed to ensure that two residents, identified as Residents 118 and 378, were free from the use of physical restraints without proper assessment and documentation. Resident 118 was admitted with conditions including surgical amputation, muscle weakness, and unsteadiness of the feet. Despite having the capacity to understand and make decisions, the resident's bed was placed against the wall with both upper bed rails up, without a physician's order or informed consent. The facility's records showed contradictory recommendations regarding the use of side rails, and there was no documentation of a safety assessment or education provided to the resident or their representative about the risks and benefits of bed rail use. Similarly, Resident 378, who was admitted with hepatic encephalopathy, seizures, and muscle weakness, also had their bed placed against the wall with both upper bed rails up. Like Resident 118, there was no physician's order, informed consent, or documentation of a safety assessment for the use of bed rails and bed placement. The facility's policy required a physician order and informed consent for the use of restraints, which was not adhered to in these cases. The facility's failure to conduct proper assessments and obtain necessary consents for the use of bed rails and bed placement against the wall posed potential risks to the residents, including restriction of movement, physical harm, and psychosocial harm. The facility's policy emphasized the need for restraints to be used only when necessary and with proper documentation, which was not followed in these instances.
Deficiencies in Care Planning and Monitoring
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for several residents, leading to deficiencies in care. For two residents, the facility did not create care plans addressing the use of physical restraints, such as bed rails and bed placement against the wall, despite their high risk for falls. Observations revealed that both residents had their upper bed rails up and beds placed against the wall, yet there were no care plans to guide staff on these interventions. Interviews with nursing staff and the Director of Nursing confirmed the absence of care plans, which are essential for standardizing care and ensuring resident safety. Another resident, who was receiving vancomycin hydrochloride for a serious bacterial infection, did not have a care plan developed for the use of this medication. The resident had a stage four pressure ulcer and required intravenous antibiotics, but the lack of a care plan meant that staff were not adequately informed about the resident's treatment needs. The Director of Nursing acknowledged that a care plan should have been created when the antibiotic order was received to prevent delays in care. Additionally, the facility failed to monitor and document the use of Risperdal for a resident with delusions. The resident's medication administration record lacked documentation for monitoring delusions, side effects of Risperdal, and alternative therapies. Interviews with nursing staff and the Director of Nursing revealed that there was no care plan for managing the resident's delusions or monitoring the effectiveness and side effects of Risperdal. This oversight could lead to unnecessary medication use and potential harm to the resident.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Los Angeles
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Skyline Healthcare Center - La | 0 mi | ★★★★★ | 11 | 0 |
| Hollywood Presbyterian Medical Center D/p Snf | 1.5 mi | ★★★★★ | 22 | 0 |
| Glendale Healthcare Center | 1.7 mi | ★★★★★ | 10 | 0 |
| Leisure Glen Post Acute Care Center | 1.7 mi | ★★★★★ | 3 | 0 |
| Garden Crest Rehabilitation Center | 1.8 mi | ★★★★★ | 16 | 0 |
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