Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Manchester Healthcare Center during CMS and state inspections, most recent first.
Failure to review and act on the consultant pharmacist's MRR recommendations resulted in no evidence that physician notification or plan of care changes were completed for multiple residents. The DON stated the facility could not show that the recommendations from the pharmacist's review were reviewed and acted upon, despite the facility policy requiring the DON to follow up with the attending physician and document responses to irregularities reported by the pharmacist.
A resident with a g-tube, severe cognitive impairment, and no capacity to make decisions was visibly exposed during g-tube medication administration when an LVN opened the window curtain and failed to close the privacy curtain. The resident was exposed to outside view during care, and the LVN and DON both stated privacy and dignity should be protected during medication administration.
Incomplete informed consent for Depakote: A resident with bipolar disorder, schizophrenia, and dementia received Depakote for psychotropic use, but the consent form lacked the resident's and/or RR's signature and did not show LPN verification that informed consent had been obtained before the medication was started. The DON reviewed the record and confirmed the consent was incomplete, while the MAR showed the resident received multiple doses of the medication.
Damaged Wall Next to Resident Bed: A resident with major depressive disorder, dysphagia, and muscle weakness had a wall area beside the bed with chipped and peeling paint plus cracked, missing plaster exposing the underlying material. The Maintenance Supervisor measured the damaged section at 22 inches by 6 inches and stated it should have been repaired to keep the room in good condition and support a clean, safe, and home-like environment.
Unnecessary Psychotropic Use and Missing GDR Documentation: The DON and record review showed PRN psychotropic orders for two residents lacked stop dates, despite the facility policy limiting PRN psychotropics to 14 days unless the attending physician re-evaluated the resident. For another resident with major psychiatric diagnoses and severely impaired cognition, the record lacked documented non-pharmacological interventions for behavioral symptoms, and there was no documented GDR for fluoxetine or olanzapine since 6/2025. The MARs also showed little to no documented target behaviors for the meds being given.
Inaccurate MDS Medication Coding: A resident with paranoid schizophrenia, MDD, DM, and convulsions had an MDS that incorrectly showed no antipsychotics, antidepressants, anticonvulsants, or hypoglycemic agents, even though the MAR showed these meds were given during the MDS reference period. The MDSC acknowledged the MDS did not accurately identify the resident's medications, despite the resident being severely cognitively impaired and dependent for all ADLs.
Inaccurate PASARR Screening for Resident with Schizophrenia: The facility failed to ensure a resident’s PASARR Level I Screening accurately reflected an existing psychiatric diagnosis. The resident had paranoid schizophrenia, was cognitively intact, and required total assistance with ADLs. The SW stated the schizophrenia diagnosis should have been marked yes on the screening, and the DON stated PASARR must be accurate for proper recommendation and resident placement.
PASRR screening was not completed for a resident with major depressive disorder and paranoid schizophrenia upon admission. The resident's MDS showed intact cognitive skills, moderate ADL assistance needs, and active mental health diagnoses. During record review, the DON confirmed there was no evidence of a PASRR Level I screening, and stated it should have been completed because of the resident's depression and schizophrenia diagnoses.
Failure to Develop Comprehensive Person-Centered Care Plans: The facility did not develop or implement complete person-centered care plans for three residents. One resident with major depressive disorder, paranoid schizophrenia, anxiety, and Buspirone use had no care plan for those needs. Another resident with epilepsy, impaired cognition, weakness, and a history of falls and convulsions had no care plan for fall or seizure risk. A third resident with depression and PTSD had a care plan that mentioned depression but did not address PTSD-related assessments or interventions.
A resident with legal blindness, depression, muscle weakness, and dysphagia had long, untrimmed fingernails with debris under the nail beds despite a care plan directing staff to keep the nails short. The resident required moderate ADL assistance, stated he could feel his nails were long and wanted staff to cut them, and was observed eating with his hands while the nails remained dirty and untrimmed. The IP stated nail care should be assessed daily and provided by CNA or licensed nursing staff when needed.
Two residents with g-tubes had enteral feeding bottles at their bedsides labeled with the other resident’s name. In addition, an LVN administered eight medications through one resident’s g-tube without first verifying placement and patency, despite the resident’s care plan and physician order requiring that check before medication administration. The DON stated this was inconsistent with professional standards of nursing practice.
Incorrect LALM Weight Setting: A resident with hemiplegia, impaired cognition, and dependence for personal care was ordered a low air loss mattress based on weight, but the mattress was observed set for a higher weight range than the resident’s recorded weight. The TN stated that an overly firm setting can increase PU risk, and the facility policy addressed prevention of pressure ulcer development.
A resident with hemiplegia, osteoarthritis, and convulsions did not have required quarterly fall risk evaluations completed, and staff stated the resident’s fall risk status may have changed without being identified. Another resident with epilepsy, weakness, difficulty walking, severely impaired cognition, and a history of falls was identified by the physician as high risk for repeat falls, but an LVN stated there were no care plans for fall risk or convulsions. Facility policy required quarterly fall risk evaluations and comprehensive care planning for resident needs.
A resident with PTSD and aphagia did not have a Trauma Care Evaluation completed. The resident reported nightmares, difficulty sleeping, and being startled by loud noises, while the DSD found no TCE in the chart and stated he could not obtain much information about trauma triggers from the resident. The DON stated staff should have assessed the resident’s PTSD.
Missing EBP Signage and PPE Outside Resident Room: A resident with a gastrostomy tube and impaired cognition had EBP indicated under facility policy, but staff did not post EBP signage or place PPE outside the room. The IPN stated EBP applied to residents with indwelling medical devices, including gastrostomy tubes, and that signage and PPE were to be available outside the room for care activities.
Insufficient Resident Room Square Footage: The facility failed to ensure multiple resident rooms provided at least 80 sq ft per resident. The ADM stated there were no active room waivers and did not provide a waiver request letter during interview, while the Client Accommodation Analysis showed several 2-bed rooms at 77.5 sq ft per resident and one 3-bed room at 74 sq ft per resident. A later Room Waiver Request listed the same rooms.
A resident with encephalopathy, DM, altered mental status, and HTN was identified on admission as having a recent history of wandering and a significant actual risk for wandering and elopement, but no individualized care plan or preventative interventions were developed or documented despite facility policy. The MDS showed the resident required supervision for transfers and ambulation, yet staff and the DON did not treat the resident as an elopement risk, and exit doors—while alarmed—were only intermittently monitored during rounds with no staff assigned to continuously observe the exit near the rehab area. One evening, staff heard an exit door alarm, later found the resident missing from his room, conducted internal and external searches, and contacted hospitals, but the resident was not located until two days later when found at a recovering unit in a GACH and brought back by the Administrator.
Two residents with cognitive and physical impairments were observed smoking without required staff supervision, despite care plans and facility policy mandating supervision during smoking sessions. Both residents had documented needs for assistance and supervision, but staff failed to provide oversight at the time of the incidents.
A resident with severe cognitive impairment and no decision-making capacity was administered psychotropic medications after staff obtained informed consent directly from the resident, rather than from a responsible party, contrary to facility policy and physician assessment.
A resident with a diagnosis of schizophrenia and prescribed antipsychotic medication was admitted without an accurate Level I PASRR screening, as the screening failed to identify the serious mental illness or psychotropic medication use. The DON confirmed the inaccuracy and that the discrepancy should have been caught and corrected prior to admission.
A resident with paranoid schizophrenia, severe cognitive impairment, and a history of aggression did not have a care plan addressing their psychiatric diagnosis or aggressive behaviors. Despite staff awareness of the need for such care planning, and facility policy requiring comprehensive care plans, no interventions or monitoring were documented for these issues.
A resident with severe cognitive impairment and high risk for pressure ulcers did not receive a physician-ordered low-air-loss mattress after being moved to a new room. The mattress remained in the previous, now unoccupied, room, and staff confirmed the omission was due to oversight during the transfer. The order for the mattress was still active, and staff acknowledged the resident should have had the mattress in place.
A resident with schizoaffective disorder, epilepsy, and hypertension received Olanzapine for several months without a written informed consent documented in the clinical record. The DON confirmed that facility policy required informed consent for psychotropic medications, but the necessary documentation was missing, and the resident or conservator was not given the opportunity to make an informed decision.
A resident with schizoaffective disorder, epilepsy, and hypertension was admitted and prescribed Zyprexa for behavioral symptoms, but the facility did not develop a care plan with interventions or goals addressing the mental health diagnosis, associated behaviors, or use of psychotropic medication. The DON confirmed the absence of such care plan elements, despite facility policy requiring comprehensive, person-centered care plans for all residents.
A resident with schizoaffective disorder, epilepsy, and hypertension eloped from the facility, and the responsible LVN notified the physician by phone but did not complete the required SBAR communication tool due to being preoccupied with the search. The DON confirmed that the SBAR should have been completed to ensure clear communication and accurate documentation, as required by facility policy.
A resident with a history of hypertension, diabetes, hemiplegia, and epilepsy experienced an acute change in mental status and severely elevated blood pressure. Nursing staff did not promptly assess or intervene according to emergency protocols, delaying the call to 911 and transfer to the hospital for over three hours. The resident was later found to have suffered an intracerebral hemorrhage and died after being transferred to acute care. The facility failed to follow its own emergency care policies and did not provide timely assessment or intervention.
A resident with diabetes and other complex conditions received insulin orders written in milliliters instead of units, and nursing staff failed to clarify the order or verify the correct dosage before administration. The MAR showed the incorrect dosage was documented as given on multiple occasions, and blood glucose levels were not consistently recorded in the electronic medical record, contrary to facility policy.
Licensed nurses failed to administer medications within one hour of the scheduled time, did not ensure availability of a prescribed transdermal patch, and did not monitor or document side effects and vital signs as ordered for three residents with complex medical and psychiatric conditions. These actions resulted in missed or late doses, lack of required monitoring, and a resident reporting emotional distress due to not receiving prescribed medication.
Two residents with significant physical and cognitive impairments who depended on staff for ADLs had their call lights go unanswered for at least 12 minutes, despite staff walking past their rooms. Staff interviews confirmed that prompt response to call lights is expected, and the DON stated that delays could make residents feel neglected. Facility policy requires call lights to be answered as soon as possible.
Two residents with cognitive impairments and mental health conditions, both assessed as moderate risk for wandering and elopement, did not have care plans developed to address their elopement risk. Despite documented behaviors and assessments indicating the need, staff failed to implement required care planning interventions, as confirmed by the DON.
Staff were observed opening both the front and back exit doors without using keys, and the alarms on these doors were not activated. Interviews revealed that staff were either unaware of the alarm status or had intentionally left doors unlocked and unmonitored, contrary to facility policy. The DON confirmed that all exit doors should be locked and alarmed to prevent elopement and ensure resident safety.
The facility failed to maintain proper nail hygiene for three residents, leading to long and dirty fingernails, which posed a risk for infections. Residents with conditions such as cerebral infarction, heart failure, and dementia were observed with untrimmed nails. CNAs acknowledged the oversight, and the DON confirmed that nail care is a CNA responsibility per facility policy.
A resident with cerebral cyst and hemiplegia waited 3 hours for assistance to get out of bed, despite requesting help from a CNA. The delay, acknowledged by staff, caused the resident anxiety and sadness, violating their right to a dignified existence and self-determination.
The facility failed to maintain complete ADL documentation for two residents, leading to potential miscommunication about care provided. One resident, dependent on staff for ADLs due to conditions like cerebral cyst and hemiplegia, had multiple undocumented personal hygiene care instances. Another resident, requiring substantial assistance due to cerebral infarction, also had missing documentation. Staff interviews confirmed the omissions, highlighting the importance of accurate record-keeping.
The facility did not make their last recertification survey results easily accessible to residents and the public. An LVN found the survey results behind the nurse's station in a non-transparent file rack, which was not visible to visitors. The facility's policy stated that residents have the right to examine survey results.
The facility failed to ensure that four out of five sampled employees had completed orientation skills checklists upon hire, which are essential for verifying staff competency. The Director of Staff Development (DSD) found that the files of three CNAs and one LVN were incomplete, with missing signatures and dates on their checklists. Without these completed checklists, the competency of the staff could not be confirmed, potentially leading to substandard care for residents.
The facility did not post the Nursing Hours Per Patient Day (NHPPD) information in a visible area for residents and the public. An LVN confirmed the absence of the NHPPD posting at the nurse's station, which is required to inform about staffing adequacy. The Director of Staff Development stated that NHPPD should be updated daily and visible to the public. The facility's policy mandates that nurse staffing data be posted prominently.
The facility failed to ensure monthly Medication Regimen Reviews (MRRs) by a licensed pharmacist for four residents, risking drug interactions and overmedication. Residents with conditions such as hypertension, diabetes, dementia, and schizophrenia did not have MRRs completed from October to December 2024. The DON acknowledged the absence of these reviews, which are crucial for identifying potential drug interactions and ensuring appropriate medication management.
The facility failed to maintain cleanliness and proper food storage in the pantry and kitchen, risking cross-contamination and pest attraction. Observations included a whitish granule substance on the floor, an improperly stored open package of dried milk, and a leaking package of ground turkey in the freezer. The Dietary Supervisor acknowledged these issues, emphasizing the need for cleanliness to prevent contamination.
The facility did not submit PBJ data to CMS for the fourth quarter of 2024, as required. The Administrator was unaware of this oversight, and the DON stated that the payroll department was responsible but not informed. This data is crucial for CMS to verify staffing levels for safe patient care.
The facility failed to label medications with opened dates and lacked routine room temperature monitoring, risking medication effectiveness. An LVN confirmed the absence of a temperature log, and vials of Aplisol, lorazepam, and Admelog insulin were found without opened date labels, potentially leading to the use of expired medications. This oversight affected residents with conditions like anxiety, diabetes, and heart failure.
A resident was transferred to a general acute care hospital for abdominal pain without a physician's order. The resident, who was cognitively intact and had conditions such as seizures and hemiplegia, was transferred without following the facility's policy requiring a physician's discharge order. An LVN confirmed the absence of the necessary order during a record review and interview.
A resident with a history of seizures and hemiplegia was transferred to a GACH for abdominal pain without a completed Change in Condition Form. An LVN confirmed the lack of documentation explaining the transfer, contrary to facility policy requiring assessment and documentation of condition changes.
The facility failed to transmit MDS assessments for two residents to CMS within the required 14-day period. One resident, with hypertension and congestive heart failure, required set-up assistance, while another, with anemia and failure to thrive, was totally dependent on staff. The delay in transmission was confirmed by the MDSN and acknowledged by the DON, potentially affecting resident care and facility reimbursement.
A resident with severe cognitive impairment and schizophrenia did not receive a required PASRR Level II assessment due to an oversight by the Medical Records Director, who failed to follow up on a duplicate PASRR. This deficiency could result in the resident not receiving necessary mental health services.
A facility failed to develop a care plan for a resident with a PICC line, which was necessary for monitoring and intervention. The resident had a PICC line in the right upper arm, but no care plan was in place to address its management. The DON confirmed that registered nurses are responsible for tasks such as changing dressings and checking for swelling, but these were not documented. This oversight was identified during a review of the resident's medical records.
A facility failed to monitor a resident's vital signs every shift as ordered by the physician. The resident, who was cognitively intact and had diagnoses including seizures and shortness of breath, had an order for vital signs to be checked every shift. However, records showed multiple instances of missing entries, with some days having only one or two recordings instead of the required three. An LVN confirmed the oversight and highlighted the importance of monitoring vital signs to ensure timely interventions.
A resident with severe vision impairment and a history of optic atrophy and macular degeneration did not receive necessary vision care services. Despite the resident's requests for new prescription eyeglasses and a consultation with an eye doctor, the facility failed to document a referral to an optometrist. The Social Service Designee acknowledged the oversight, which contradicted the facility's policy on referrals and resident rights.
A resident with long, thick toenails did not receive necessary podiatry care, despite requesting it and the facility offering such services. The resident experienced discomfort and was unable to wear socks. The oversight was due to a failure in referral by the previous Social Service Designee, contrary to the facility's policies.
A resident with a PICC line for antibiotics was not properly monitored or maintained by the facility. The DON was unaware of the PICC line's presence, and the dressing was found soiled and unchanged. RNs failed to perform necessary tasks such as changing the dressing, flushing the line, and checking for complications, posing a risk of infection or infiltration.
Failure to Review and Act on Pharmacist Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to review and act on the Medication Regimen Review (MRR) completed for all residents on 12/10/2025. The consultant pharmacist identified recommendations for 24 of the 44 residents reviewed, but during an interview on 3/26/2026, the DON stated there was no evidence available to show that the MRR recommendations were reviewed and acted upon. The DON stated that timely review and intervention were important to ensure residents' physicians were notified of the pharmacist's recommendations and that modifications to the plan of care were made timely. The facility's policy and procedure titled Drug Regimen Review, dated 10/1/2023, stated the facility was to maintain residents' highest practicable level of well-being and prevent or minimize adverse consequences related to medication therapy through oversight by a licensed pharmacist, attending physician, medical director, and the DON. The policy stated the DON was responsible for following up with the attending physician as indicated, the attending physician was to respond to irregularities reported by the pharmacist, and this documentation was to occur within 30 days of issuance of the MRR.
Privacy Not Maintained During G-Tube Medication Administration
Penalty
Summary
The facility failed to keep the privacy curtain and window closed during medication administration for Resident 14. Resident 14 was admitted and later readmitted to the facility and had diagnoses including a g-tube, paranoid schizophrenia, major depressive disorder, and diabetes mellitus. The resident’s MDS dated 1/17/2026 indicated severely impaired cognitive skills for daily decision making, and the resident was dependent for ADLs. A later H&P dated 3/16/2026 stated the resident did not have the capacity to understand and make decisions. During an observation on 3/24/2026 at 8:30 a.m., LVN 2 was observed administering medications via g-tube at the resident’s bedside. LVN 2 opened the window curtain, exposing the resident to outside view, and did not close the privacy curtain. The resident was visibly exposed during the medication administration process. During interview, LVN 2 stated the window and privacy curtains should not have been opened during medication administration because it exposed the resident to others and outside view, and that privacy, dignity, and confidentiality should be protected during g-tube medication administration. The DON stated staff were expected to protect resident privacy and dignity during all care and treatment, including g-tube medication administration, and that the privacy curtain and window curtain should remain closed during care.
Incomplete informed consent for Depakote
Penalty
Summary
The facility failed to ensure informed consent was fully completed before Depakote was administered to one resident. The resident was admitted and readmitted to the facility with diagnoses including bipolar disorder, schizophrenia, and dementia. The MDS dated 1/11/2026 indicated the resident had moderately impaired cognitive skills for daily decision making, required maximum assistance with ADLs, and received antipsychotic medication. A physician order dated 1/6/2026 directed Depakote 750 mg by mouth twice daily for bipolar disorder and stated informed consent was obtained, and the MAR showed the resident received 153 doses between 1/1/2026 and 3/24/2026. During a concurrent interview and record review on 3/24/2026, the DON reviewed the informed consent for psychotropic medication dated 1/6/2026 and found it did not include the resident's and/or representative's signature. The form also did not show that licensed nursing staff verified with the resident and/or representative that the physician had obtained informed consent before Depakote was started. The DON stated the consent was incomplete and that licensed staff should have ensured it was fully completed prior to administration. The facility policy required the attending physician to obtain informed written consent, the facility to verify consent before administration, and the consent form to be signed by the resident or representative and the physician, or by a licensed nurse if the resident or representative signature could not be obtained.
Damaged Wall Next to Resident Bed
Penalty
Summary
The facility failed to ensure the wall next to Resident 10’s bed was maintained in good repair. Resident 10 was admitted to the facility with diagnoses including major depressive disorder, dysphagia, and muscle weakness. The Minimum Data Set dated 1/7/2026 indicated Resident 10’s cognitive skills for daily decision making were intact and that the resident required moderate assistance from staff for activities of daily living. During an observation on 3/23/2026 at 11:45 a.m., an area on the wall adjacent to the right side of Resident 10’s bed, between the bed and bedside cabinet, was observed with chipped and peeling paint and cracked and missing plaster exposing the underlying material beneath the painted surface. The area remained unrepaired. During a concurrent observation and interview on 3/25/2026 at 9:15 a.m., the Maintenance Supervisor measured the damaged area at 22 inches long and 6 inches wide and stated the wall was damaged and should have been repaired to maintain the room in good condition. The Maintenance Supervisor also stated resident rooms should be maintained in a manner that supports a clean, safe, and home-like environment. The facility’s Maintenance Services policy stated the maintenance department was responsible to maintain all areas of the building and grounds in a safe and operable manner at all times.
Unnecessary Psychotropic Use and Missing GDR Documentation
Penalty
Summary
The facility failed to ensure three sampled residents were free from unnecessary psychotropic medication use. For one resident with major depressive disorder, paranoid schizophrenia, and anxiety, the physician order dated 2/18/2026 directed olanzapine 10 mg every 8 hours as needed for psychosis, but the order did not include a stop date. For another resident with dysphagia, hypertension, and muscle weakness, the physician order dated 2/19/2026 directed Restoril 15 mg every 24 hours as needed for inability to sleep, and it also did not include a stop date. During review with the DON, the facility policy titled Psychotherapeutic Drug Management was reviewed, and the DON stated PRN psychotropic orders were limited to 14 days and could not be renewed unless the attending physician evaluated the resident in person for appropriateness. For a third resident with major depressive disorder, schizophrenia, bipolar disorder, and severely impaired cognition, the record showed olanzapine was administered from 1/28/2025 to 9/17/2025 for bipolar disorder and fluoxetine from 1/28/2025 to 11/24/2025 for depression. The record also showed olanzapine was later ordered from 9/18/2025 to 11/24/2025 for auditory hallucinations. The DON stated non-pharmacological interventions were to be implemented for residents receiving psychotropics and that less restrictive measures should be used to manage behaviors and identify causes of the behaviors. The DON stated this resident did not have non-pharmacological interventions ordered or documented as provided from 2/2/2025 to 11/24/2025. The record review also showed that the resident’s MARs for January and February 2026 did not document the behaviors for which fluoxetine or olanzapine were being given, except for one episode on 1/7/2026 of uncontrollable crying, yelling, and screaming without cause during care. The DON stated there was no documented evidence of a GDR for the resident’s fluoxetine and olanzapine since 6/2025, and that GDR attempts were to be documented and care planned.
Inaccurate MDS Medication Coding
Penalty
Summary
The facility failed to accurately code Section N of the MDS for one of 12 sampled residents, Resident 14. Resident 14 was admitted and re-admitted to the facility with diagnoses including paranoid schizophrenia, major depressive disorder, type 2 diabetes mellitus, and convulsions. The MDS dated [DATE] indicated that Resident 14 had severely impaired cognitive skills for daily decision making, was dependent on staff for all ADLs, and was not receiving antipsychotics, antidepressants, anticonvulsants, or hypoglycemic agents. A review of Resident 14's MAR for 3/1/2026 to 3/31/2026 showed that Resident 14 did receive antipsychotics, antidepressants, anticonvulsants, and hypoglycemic agents within the MDS reference date. During interview, the MDSC stated the MDS did not accurately identify the medications Resident 14 was receiving and that accurate identification was important because the MDS guided the plan of care. The facility policy titled RAI Process stated that all information recorded within the MDS assessment must reflect the resident's status at the time of the Assessment Reference Date.
Inaccurate PASARR Screening for Resident with Schizophrenia
Penalty
Summary
The facility failed to ensure that one sampled resident’s PASARR Level I Screening was completed accurately to indicate an existing psychiatric condition. Resident 6 was admitted on 7/08/2021 and later re-admitted with diagnoses including paranoid schizophrenia. The resident’s MDS dated 2/10/2026 indicated the resident was cognitively intact and dependent on staff for all ADLs. During interview and record review on 3/24/2026, the SW reviewed Resident 6’s admission record and PASARR Level I Screening dated 11/12/2025 and stated the diagnosis of schizophrenia should have been checked as yes on the screening. The SW stated completing the PASARR Level I screening correctly was important to meet the resident’s needs and identify whether a PASARR II was needed. The DON stated on 3/25/2026 that PASARR should be accurate for proper recommendation and appropriate resident placement. The facility policy stated it conducts Level I PASARR screening for all admissions and readmissions, and that individuals seeking admission to a Medi-Cal-certified SNF must have a PASRR determination prior to acceptance.
PASRR Screening Not Completed for Resident With Mental Health Diagnoses
Penalty
Summary
PASRR screening for mental disorders or intellectual disabilities was not completed for one sampled resident upon admission. The resident had diagnoses of major depressive disorder and paranoid schizophrenia, and the admission record showed the resident was originally admitted to the facility and later readmitted. The resident's MDS dated 2/25/2026 indicated cognitive skills for daily decision making were intact, the resident required moderate assistance with ADLs, and major depressive disorder and paranoid schizophrenia were active diagnoses. During a concurrent interview and record review on 3/26/2026 at 9:30 a.m., the DON reviewed the resident's medical records and found no indication that a PASRR Level I screening had been completed upon admission to determine whether the resident had a mental illness requiring PASRR review. The DON stated a PASRR Level I screening should have been completed for the resident because of the diagnoses of depression and schizophrenia, and that the facility failed to ensure the screening was completed upon admission. The facility policy stated that all residents are screened for mental illness or intellectual disability, PASRR must be completed prior to admission, and the facility performs PASRR Level I screenings for all residents, including those currently residing with mental illness or intellectual disability.
Failure to Develop Comprehensive Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for three sampled residents. For Resident 1, the admission record listed diagnoses of major depressive disorder, paranoid schizophrenia, and anxiety, and the resident was also receiving Buspirone. A review of the medical record with the DON showed there was no care plan addressing the resident’s mental health diagnoses or the use of Buspirone. The DON stated a care plan should have been developed to address the resident’s identified mental health diagnoses and medication use, with specific interventions to guide staff care and services. For Resident 32, the admission record listed epilepsy, generalized muscle weakness, and difficulty walking. The MDS indicated severely impaired cognitive skills for daily decision making and substantial to maximal assistance needs for hygiene and mobility. Physician progress notes documented that the resident lacked coordination and was at high risk for repeat falls requiring hospitalization. During interviews, the resident reported a fall a few months earlier but could not explain how it occurred, and LVN 2 stated the resident was at risk for falls and had a history of convulsions, but did not have a care plan addressing either condition. For Resident 5, the admission record listed depression and PTSD, and the MDS indicated intact cognition. The H&P stated the resident had the capacity to make medical decisions. The care plan referenced worsening depression as evidenced by a history of PTSD, but it did not address assessments or interventions related to PTSD. The resident stated she had PTSD for many years and did not want it in her medical record. The SW confirmed there was no documentation of a comprehensive care plan for PTSD, and the DON stated the importance of a PTSD care plan was to ensure the resident received proper treatment.
Failure to Maintain Resident Fingernail Hygiene
Penalty
Summary
The facility failed to maintain the fingernails of one resident in a clean and neat condition. Resident 18 was admitted with legal blindness, depression, muscle weakness, and dysphagia. The resident’s MDS dated 3/19/2026 indicated intact cognitive skills for daily decision making and moderate assistance was required for ADLs. The care plan dated 3/12/2026 directed staff to keep the resident’s fingernails short. During an observation on 3/23/2026, Resident 18’s fingernails were observed long and untrimmed with dark brown debris underneath the nail bed. During a later observation and interview on 3/25/2026, the resident was seen eating lunch using his hands, and the fingernails were again observed long with black substance underneath them. The resident stated he was blind, could feel that his nails were long, and wanted staff to cut them. The IP stated nail care should be assessed daily and that residents needing help with cleaning or trimming nails should be assisted by CNAs or licensed nurses. The facility policy stated residents’ nails are to be maintained in a clean, trimmed, and hygienic condition.
Incorrectly Labeled Enteral Feeding Bottles and Failure to Verify G-Tube Placement
Penalty
Summary
Resident 3 and Resident 14 both had gastrostomy tubes and enteral feeding bottles at their bedsides that were incorrectly labeled with the other resident’s name. Resident 3’s bedside feeding bottle was labeled with Resident 14’s name, and Resident 14’s bedside feeding bottle was labeled with Resident 3’s name. Resident 14’s record also showed severe cognitive impairment and dependence on staff for all activities of daily living, and a physician order required the enteral feeding bottle to be labeled with the resident’s name. Resident 14 also had a physician order and care plan directing staff to check g-tube placement before medication administration. During observation, an LVN administered eight medications through Resident 14’s g-tube without first verifying placement and patency. The resident’s history and physical stated the resident did not have the capacity to understand and make decisions. During interview, the LVN stated the medications were given through the g-tube without checking placement and patency first. The DON stated nursing staff were expected to confirm g-tube placement and patency prior to administering medications through the g-tube, and that doing so without verification was unsafe and inconsistent with professional standards of nursing practice.
Incorrect LALM Weight Setting
Penalty
Summary
The facility failed to ensure that a low air loss mattress was set to the correct weight setting for one resident. The resident was admitted with diagnoses including hemiplegia following a cerebral infarction and had moderately impaired cognition, required substantial to maximum assistance with toileting hygiene, and was dependent on staff for personal hygiene and rolling left and right in bed. The resident’s MDS also identified the resident as being at risk for developing pressure ulcers. The physician ordered the resident to be placed on a low air loss mattress with the setting based on weight. The resident’s recorded weight was 133 lbs., but during observation the mattress dial was set for a weight range of 150 lbs. to 180 lbs. During interview, the Treatment Nurse stated that low air loss mattresses are used to prevent pressure ulcers and maintain skin integrity, and that if the weight setting is too high the mattress becomes too firm and increases the risk for a pressure ulcer. The facility policy on Support Surface Guidelines stated the facility was to provide care and services to promote prevention of pressure ulcer development.
Failure to complete fall risk evaluations and care plan fall and seizure risks
Penalty
Summary
Accident hazards were not adequately identified and care planned for two residents. Resident 14 was admitted and re-admitted to the facility with diagnoses including hemiplegia following a stroke, osteoarthritis, and convulsions. Her MDS dated 3/4/2026 indicated severely impaired cognitive skills for daily decision making, dependence on staff for all ADLs, and substantial to maximal assistance needed for bed mobility and all other mobility. During interview, the DSD stated fall risk evaluations were to be completed on admission, quarterly, annually, and as needed, but Resident 14 had not had a fall risk evaluation since 1/28/2025. The DSD also stated her fall risk status could have changed since 1/8/2025 and that she could be at an unidentified risk for falls and injury. Resident 32 was admitted with diagnoses including epilepsy, generalized muscle weakness, and difficulty walking. His MDS indicated severely impaired cognition and that he required substantial to maximal assistance for personal hygiene and mobility in and out of bed. Physician progress notes dated 2/6/2026, 2/9/2026, and 2/23/2026 stated he lacked coordination and was at high risk for repeat falls requiring hospitalization. During interview, Resident 32 stated he had a fall a few months ago but could not explain how it occurred. An LVN stated Resident 32 was at risk for falls and had a history of convulsions, and that both conditions required care plans; however, he did not have care plans for fall risk or convulsions. The facility policy stated a comprehensive care plan was to include services needed to attain or maintain the resident's highest practicable well-being, and the fall risk evaluation was to be completed quarterly and used to develop a person-centered care plan.
Failure to Complete Trauma-Care Evaluation for Resident with PTSD
Penalty
Summary
The facility failed to ensure a trauma-care evaluation was completed for one sampled resident with a history of trauma. The resident’s admission record showed diagnoses including PTSD and aphagia, and the H&P indicated the resident was able to make decisions for activities of daily living. The MDS dated 2/20/2026 indicated the resident was independent in showering, bed mobility, dressing, transfer, hygiene, and eating. During interview, the resident stated she had been diagnosed with PTSD as a teenager and reported nightmares, difficulty sleeping, and being startled by loud noises. The DSD reviewed the record and stated there was no Trauma Care Evaluation in the chart, and that he could not get much information regarding trauma and triggers from the resident. The DSD stated he should have contacted the resident’s psychiatrist to obtain information regarding the resident’s PTSD, and that trauma-related care training for staff was combined with behavior training but did not specifically include trauma-based care strategies. The DON stated facility staff should have assessed the resident’s PTSD and that possible re-traumatization would harm the resident’s psychosocial well-being.
Missing EBP Signage and PPE Outside Resident Room
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when the facility did not ensure enhanced barrier precautions (EBP) signage and PPE were placed outside the room of one resident. Resident 3 was admitted with a gastrostomy tube and had diagnoses including presence of a gastrostomy. The resident’s MDS indicated moderately impaired cognitive skills for daily decision making and dependence on staff for toileting hygiene, personal hygiene, and rolling left and right in bed. A physician order directed enteral feeding at 65 ml per hour every shift. During observation, there were no indicators or signage posted outside Resident 3’s room showing that EBP precautions were required, and no PPE was available outside the room. The Infection Preventionist Nurse stated that EBP was implemented for all residents with indwelling medical devices, including gastrostomy tubes, that signage was to be posted outside the room to alert staff, and that PPE was to be made available outside the room for use during care activities. The facility policy titled Standard and Enhanced Precautions stated that EBP was indicated for residents with gastrostomy tubes and was to be implemented for the duration of the resident’s stay.
Insufficient Resident Room Square Footage
Penalty
Summary
The facility failed to ensure that each resident had at least 80 square feet of living space in multiple rooms, including Rooms 101, 102, 103, 104, 105, 107, 109, 111, 112, 114, 115, 117, 201, 202, 203, 204, 205, 207, 209, 211, 212, 214, 215, and 217. During interview, the Administrator stated the facility did not have any active room waivers and did not provide a room waiver request letter at that time. A review of the Client Accommodation Analysis showed that the listed rooms measured 155 square feet with 2 beds, providing 77.5 square feet per resident, and one room measured 215 square feet with 3 beds, providing 74 square feet per resident. A later review of a Room Waiver Request document showed the facility requested a room waiver for the same rooms. During observations and interviews from 3/23/2026 to 3/26/2026, no concerns were observed related to the reduced living space, and staff and residents reported no complaints or concerns.
Failure to Care Plan and Supervise High-Risk Wanderer Resulting in Elopement
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement an individualized care plan with specific interventions for a resident who was identified on admission as having a significant actual risk for wandering and elopement. The resident was admitted with diagnoses including encephalopathy, diabetes mellitus, altered mental status, and high blood pressure. The admission nursing assessment documented a recent history of wandering and a significant actual risk for wandering and elopement. The facility’s own policies required that residents at risk for wandering and elopement have preventative interventions documented in the medical record and that a person-centered care plan be developed based on assessed needs, but no such care plan was created for this resident. The resident’s MDS dated 1/6/2026 indicated that he could make his needs known and understand others, and that he required supervision for transfers and walking 50 feet with two turns, and partial/moderate assistance for walking 10 feet. He did not use a wheelchair. Despite the documented risk for wandering and elopement, interviews and record review confirmed that there were no individualized interventions in the care plan to prevent the resident from leaving the facility unsupervised. The DON later stated that the resident was not considered at risk for elopement before the incident, which conflicted with the admission assessment that identified a significant actual risk. On the evening of 1/30/2026, staff discovered that the resident was not in his room between approximately 8:30 p.m. and 8:45 p.m. Staff searched rooms, common areas, closets, restrooms, and outside the facility, and also drove along the street and called nearby hospitals but could not locate him. An RN supervisor reported hearing an exit door alarm near the rehab room around 8:00 p.m., checking the parking lot, and not seeing anyone outside; shortly thereafter, a CNA reported that the resident was missing. The facility’s exit doors were not locked but were equipped with alarms, and monitoring of these doors was done only during staff rounds, with no staff assigned to continuously monitor the exit near the rehab room. The resident was later found two days later at a recovering unit in a general acute care hospital and was returned to the facility by the Administrator.
Failure to Supervise Residents During Smoking Sessions
Penalty
Summary
Facility staff failed to provide required supervision for two residents who were assessed as needing supervision while smoking. During observations, both residents were seen smoking cigarettes on the patio without staff present, despite their care plans and smoking assessments indicating the need for supervision. The Activity Director confirmed that these residents should not be left unsupervised while smoking, as per facility policy. The Director of Nursing also acknowledged that supervision should be provided by Activity Department staff or assistants. Resident 2 had diagnoses including paranoid schizophrenia, major depressive disorder, and generalized anxiety disorder, with moderate cognitive impairment and a need for partial/moderate assistance with activities of daily living. Resident 3 had muscle weakness, dysphasia, and right hip pain, requiring setup or cleanup assistance with hygiene and dressing. Both residents' care plans and the facility's smoking policy required staff supervision during smoking sessions, but this was not followed at the time of the observations.
Failure to Obtain Valid Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain proper informed consent for the administration of psychotropic medications to a resident with severe cognitive impairment and no decision-making capacity. Record review showed that the resident, who had diagnoses including paranoid schizophrenia, restlessness, agitation, and emotional lability, was assessed as having significant cognitive impairment and was determined by a physician to lack the capacity to understand or make medical decisions. Despite this, informed consent for the administration of Vistaril and trazodone was documented as being obtained directly from the resident. Interviews with the Director of Nursing confirmed that staff should not have obtained consent from the resident, given the lack of decision-making capacity. Facility policy required that the risks and benefits of psychotropic medications be explained prior to use, and that consent be obtained from the resident or a responsible party. The failure to follow these procedures resulted in the administration of psychotropic medications without valid informed consent.
Failure to Ensure Accurate PASRR Screening for Mental Illness
Penalty
Summary
The facility failed to ensure an accurate Level I Preadmission Screening and Resident Review (PASRR) was completed for one resident. Upon review of the resident's admission record, it was found that the resident had a diagnosis of schizophrenia and was prescribed aripiprazole, an antipsychotic medication. The resident's Minimum Data Set (MDS) also indicated severe cognitive impairment and a need for assistance with most activities of daily living. However, the Level I PASRR screening completed prior to admission did not identify the resident's serious mental illness or the use of psychotropic medication. During interviews and record reviews, the Director of Nursing (DON) acknowledged that the PASRR was inaccurate and should have been reviewed and corrected before admission. The facility's policy required all applicants to be screened for mental illness to ensure coordination with appropriate state agencies if indicated. The discrepancy in the PASRR was not identified or addressed prior to the resident's admission, resulting in the deficiency.
Failure to Care Plan Psychiatric Diagnoses and Aggressive Behaviors
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan addressing the psychiatric diagnoses and associated behaviors for a resident diagnosed with paranoid schizophrenia. The resident's admission record and Minimum Data Set (MDS) indicated diagnoses of paranoid schizophrenia, restlessness, agitation, emotional lability, and severe cognitive impairment. Despite these documented conditions and the resident's known behaviors of aggression and striking out at others, there was no care plan in place to address these psychiatric issues or the manifesting behaviors. Interviews with facility staff, including an LVN and the DON, confirmed that care planning for psychiatric diagnoses and related behaviors is required to prevent incidents and protect other residents. A review of the resident's care plans since admission revealed that none addressed the schizophrenia diagnosis or the aggressive behaviors. The facility's own policy and procedure on care planning required a comprehensive care plan for each resident, but this was not followed in this case.
Failure to Provide Ordered Low-Air-Loss Mattress for Pressure Ulcer Prevention
Penalty
Summary
A deficiency occurred when a resident, who was at high risk for developing pressure ulcers due to generalized muscle weakness and severe cognitive impairment, was not provided with a low-air-loss mattress (LALM) as ordered by their physician. The resident required supervision or assistance for bed mobility and had an active physician order for a LALM to help prevent skin breakdown, particularly around the tailbone. During an observation, it was noted that the resident did not have a LALM in their current room, while an unoccupied bed in the resident's previous room had the LALM assigned to them. Interviews with a Licensed Vocational Nurse (LVN) confirmed that the LALM was intended for the resident and that the omission occurred when the resident was moved to a new room and the mattress was not transferred as required. The LVN acknowledged that the physician's order for the LALM was still active and that the resident should have had the mattress in place. The facility's job description for LVNs indicated that staff are responsible for following physician orders and providing individualized care, which was not done in this instance.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain a written informed consent from a resident or their conservator prior to initiating treatment with Olanzapine, a psychotropic medication. The resident, who was admitted with diagnoses including schizoaffective disorder, epilepsy, and hypertension, had intact cognition and required moderate assistance with activities of daily living. The resident received Olanzapine as prescribed by the attending physician for schizoaffective disorder, and the medication was administered 113 times over a three-month period. During a review of the resident's clinical records, it was found that there was no written informed consent for the use of Olanzapine. The DON confirmed that the facility's policy required the attending physician to obtain informed consent before starting psychotropic medications, and that staff were responsible for verifying and documenting this consent in the resident's medical record. The DON was unable to explain the absence of the consent form and acknowledged that the resident and/or conservator were not given the opportunity to make an informed decision regarding the medication.
Failure to Develop Comprehensive Care Plan for Mental Health Needs
Penalty
Summary
The facility failed to develop a comprehensive care plan addressing a resident's schizoaffective disorder, despite the resident having an active diagnosis and being prescribed Zyprexa for behavioral symptoms such as outbursts of anger. Review of the resident's admission record showed diagnoses including schizoaffective disorder, epilepsy, and hypertension, with the Minimum Data Set indicating intact cognition and a need for moderate assistance with activities of daily living. The resident's order summary confirmed the ongoing use of Zyprexa for schizoaffective disorder, yet no care plan interventions or goals were documented to address the mental health condition, associated behaviors, or the use of psychotropic medication. During an interview and record review, the DON acknowledged the absence of care plan interventions related to the resident's diagnosis, behavioral symptoms, and medication regimen. The facility's policies required comprehensive, person-centered care plans with measurable objectives and timetables to address each resident's medical, nursing, mental, and psychosocial needs. The lack of a care plan meant that staff did not have documented guidance to provide individualized care for the resident's schizoaffective disorder and related needs.
Failure to Complete SBAR Communication Tool After Resident Elopement
Penalty
Summary
A deficiency occurred when staff failed to complete the SBAR (Situation, Background, Assessment, Recommendation) communication tool for a resident who experienced a change in condition and subsequently eloped from the facility. The resident, who had diagnoses including schizoaffective disorder, epilepsy, and hypertension, was admitted with intact cognition and required moderate assistance with activities of daily living. On the day of the incident, the resident was found missing from the facility, prompting staff to search the premises. The attending physician was notified by phone, but the responsible LVN did not complete the SBAR form, citing being preoccupied with the search for the resident. The Director of Nursing confirmed that the SBAR form should have been completed in response to the resident's change in condition and elopement, as it is a critical tool for ensuring clear communication among staff and with the physician. Facility policies required detailed observations and completion of the SBAR form prior to physician notification, as well as complete and accurate documentation of any changes in a resident's condition. The failure to complete the SBAR resulted in an incomplete clinical record and potential miscommunication regarding the resident's status.
Failure to Provide Immediate Emergency Care for Resident with Acute Change in Condition
Penalty
Summary
The facility failed to provide immediate emergency care to a resident who experienced an acute change in mental status and severely elevated blood pressure. Despite the resident presenting with altered mental status, left-sided gaze deviation, and a blood pressure reading as high as 220/138 mmHg, nursing staff did not promptly assess or intervene according to the facility's emergency protocols. The resident, who had a history of hypertension, diabetes, hemiplegia, and epilepsy, was not immediately sent to the hospital, and there was a delay of over three hours from the initial observation of the change in condition to the arrival of emergency medical services. Documentation and interviews revealed that the resident was found unresponsive and staring blankly, with family and staff noting facial drooping and lack of responsiveness. The LVN on duty suspected a seizure due to the resident's history but did not perform a full assessment for stroke or check the resident's blood sugar, despite orders to do so in cases of altered consciousness. The LVN also failed to document vital signs and interventions in a timely manner and delayed calling 911, only doing so after consulting with other staff and family members. The facility's policies required immediate emergency intervention and notification of medical personnel for such acute changes, but these were not followed. As a result of these failures, the resident remained in a compromised state for several hours, ultimately suffering an intracerebral hemorrhage as confirmed by hospital imaging. The resident was intubated and transferred to a higher level of care, but subsequently died. The facility's lack of immediate assessment, failure to follow emergency protocols, and delayed transfer to acute care directly contributed to the resident not receiving timely and appropriate emergency treatment.
Failure to Verify Insulin Dosage and Document Blood Glucose Levels
Penalty
Summary
The facility failed to implement its policy and procedures regarding insulin administration for a resident with multiple diagnoses, including diabetes mellitus, hypertension, hemiplegia, and epilepsy. The physician's order for Insulin Glargine was incorrectly written as 15 milliliters (ml) instead of the appropriate unit-based dosage, and this error was not identified or clarified by nursing staff prior to administration. The Medication Administration Record (MAR) indicated that the incorrect dosage was documented as being administered on multiple occasions, and the order was not verified with the physician as required by facility policy. Additionally, the facility did not ensure that the resident's blood sugar levels were consistently documented in the electronic medical record. There were several dates where blood sugar results were missing, despite the requirement to check and record these levels to guide insulin administration. The lack of documentation meant that it was unclear whether blood glucose was monitored as ordered, which is necessary to safely administer insulin and prevent adverse outcomes. Interviews with nursing staff and the Director of Nursing confirmed that the insulin order was not written in accordance with standard practice, and that the error could have resulted in a significant overdose if administered as written. The facility's policies required verification of insulin dosage and documentation of blood glucose results, but these procedures were not followed, leading to the identified deficiencies.
Failure to Provide Timely Medication Administration and Monitoring
Penalty
Summary
Licensed nurses failed to administer medications within one hour of the scheduled time for three residents, as required by physician orders and facility policy. For one resident with a history of paranoid schizophrenia and hypertension, there were multiple instances where blood pressure medications were not administered or documented, and a Catapres transdermal patch was not available or given as ordered. The resident reported feeling scared and sad due to not receiving the prescribed medication. Additionally, required monitoring for side effects such as rhabdomyolysis and vital signs was not performed or documented for several shifts. Another resident with heart failure and hypertension did not receive timely administration or documentation of carvedilol on multiple occasions. Monitoring for vital signs and signs of bleeding, as ordered for anticoagulant use, was also not completed or documented for several shifts. The DON confirmed these omissions and stated that LVNs are responsible for obtaining, administering, and documenting medications, as well as monitoring for side effects. A third resident with bipolar disorder, schizoaffective disorder, and hypertension experienced missed or undocumented doses of Seroquel and Norvasc, as well as missed monitoring for behaviors, adverse reactions, rhabdomyolysis, bleeding, and vital signs. The DON acknowledged that these failures resulted in multiple late administrations of time-sensitive medications and lack of required monitoring. Facility policies reviewed indicated that medications must be administered within one hour of the prescribed time and that all administration and monitoring must be documented immediately after completion.
Failure to Timely Respond to Call Lights for Dependent Residents
Penalty
Summary
The facility failed to promote a dignified existence and self-determination for two residents who required assistance with activities of daily living (ADLs) by not responding to their call lights in a timely manner. Both residents had significant physical limitations, with one resident having bilateral above-the-knee amputations and muscle weakness, and the other diagnosed with quadriplegia, failure to thrive, and anemia. Both were dependent on staff for ADLs such as dressing, toileting, personal hygiene, and transfers. Observations showed that their call lights were activated, but a CNA walked past their rooms without responding or checking on their needs. The call lights remained unanswered for at least 12 minutes until an LVN responded. Interviews with staff confirmed that answering call lights promptly was considered everyone's responsibility and that delays were not acceptable. The DON stated that residents should not wait longer than two minutes for call lights to be answered and acknowledged that such delays could make residents feel abandoned and neglected. The facility's policy required call lights to be answered as soon as possible to meet residents' needs.
Failure to Develop Care Plans for Residents at High Risk for Elopement
Penalty
Summary
The facility failed to develop and implement care plans for two residents who were identified as being at high risk for elopement. Both residents had significant cognitive impairments and mental health diagnoses, including dementia and schizoaffective disorder, and required substantial to maximal assistance with activities of daily living. Assessments, including the Minimum Data Set, Wandering Risk Assessment, and Elopement Risk Assessment, indicated that both residents were at moderate risk for wandering and elopement due to disorientation, wandering behavior, and exit-seeking actions. One resident had a documented history of elopement or attempted elopement while at home and was observed expressing intentions to leave the facility. Despite these documented risks, the facility did not develop care plans to address the elopement risk for these residents. The Director of Nursing confirmed that care plans should have been created to monitor and ensure the safety of these residents, but this was not done. The facility's policy required comprehensive, person-centered care plans with measurable objectives and timetables for each resident, but this was not followed for the two residents at risk for elopement.
Failure to Secure Exit Doors and Maintain Alarms
Penalty
Summary
The facility failed to ensure that two of four exit doors were locked and had their alarms activated, as required by facility policy to prevent resident elopement and maintain safety. During early morning observations, a CNA was able to open the front door without a key, and the alarm did not sound. The CNA was unaware of why the alarm was off and confirmed that the alarm should always be on to alert staff if residents attempt to leave unsupervised. Similarly, another CNA was observed exiting through the back door near the laundry room without a key, and again, the alarm did not sound. Interviews with staff revealed that the laundry assistant had unlocked the back door for CNAs and left it unmonitored, acknowledging that the door should have remained locked and alarmed. The Director of Nursing confirmed that staff had been instructed to use keys and ensure alarms were activated on all exit doors, emphasizing the importance of these measures for residents at high risk of elopement. Review of the facility's policy indicated a commitment to maintaining an environment free from accident hazards and prioritizing resident safety and supervision.
Failure to Maintain Resident Nail Hygiene
Penalty
Summary
The facility failed to maintain proper hygiene for three residents by not trimming their long and dirty fingernails, which placed them at risk for infections and bacterial growth. Resident 2, who was admitted with conditions including cerebral infarction and major depressive disorder, required substantial assistance with activities of daily living (ADLs). During an observation, it was noted that Resident 2's fingernails were long and uncleaned, and the resident confirmed that their nails had not been trimmed that month. A Certified Nursing Assistant (CNA) acknowledged the oversight and the importance of nail trimming to prevent skin infections. Similarly, Resident 5, who had diagnoses including heart failure and mild cognitive impairment, was observed with long and uncleaned fingernails. The resident expressed a desire for their nails to be trimmed to prevent dirt accumulation. Resident 6, diagnosed with dementia and muscle weakness, also had long and uncleaned fingernails. A CNA admitted to not having checked the resident's nails since their admission two weeks prior. The Director of Nursing stated that CNAs are responsible for assessing and trimming residents' nails every shower day, as per the facility's policy and procedures, which emphasize the importance of maintaining proper hygiene to prevent infections.
Resident Waits 3 Hours for Assistance in LTC Facility
Penalty
Summary
The facility failed to ensure timely assistance for a resident, leading to a deficiency in honoring the resident's right to a dignified existence and self-determination. The resident, who was admitted with conditions including cerebral cyst, hemiplegia, and weakness, was dependent on staff for activities of daily living (ADLs). On a specific day, the resident requested assistance from a CNA to get out of bed and into a chair after breakfast. Despite the request being made around 11:00 a.m., the resident was left waiting until 2:00 p.m., causing feelings of anxiety and sadness. Interviews with staff revealed that the CNA responsible for assisting the resident delayed the request, stating she would help after her lunch break. Other staff members, including another CNA and an LVN, acknowledged the delay and reported the resident's request to a supervisor. The Director of Nursing confirmed that the delay was unacceptable and could lead to feelings of neglect and depression for the resident. The facility's policy on supporting ADLs emphasized the importance of providing appropriate care and services to residents unable to carry out tasks independently, highlighting the deficiency in this instance.
Incomplete ADL Documentation for Two Residents
Penalty
Summary
The facility failed to maintain complete and accurate documentation of Activities of Daily Living (ADLs) for two residents, which could lead to miscommunication regarding the care provided. Resident 1, who was admitted with conditions including cerebral cyst, hemiplegia, and weakness, was noted to be totally dependent on staff for ADLs. However, the ADL documentation for February 2025 showed multiple instances where personal hygiene care was not documented during both day and evening shifts. Similarly, Resident 2, admitted with cerebral infarction and major depressive disorder, required substantial to maximum assistance with ADLs. The documentation for Resident 2 also showed numerous days in February 2025 where personal hygiene care was not recorded. Interviews with staff, including a Certified Nursing Assistant (CNA) and the Director of Nursing (DON), confirmed the missing documentation. The CNA explained that ADL care is documented at the end of each shift, and if not documented, it implies the care was not provided. The DON verified the missing records and emphasized the importance of documenting care twice a day to account for all services provided. The facility's policy on charting and documentation requires that all services and progress toward care goals be documented accurately and completely in the resident's medical record.
Survey Results Not Accessible to Residents and Public
Penalty
Summary
The facility failed to ensure that the results of their last recertification survey were easily accessible and visible to residents and the public. During an observation and interview with an LVN in the front lobby, it was noted that the survey results were not displayed in a location visible to residents or visitors. The LVN expressed that family members need to be informed about the facility's quality of care, including any infractions or major incidents. The survey results were found behind the nurse's station in a non-transparent file rack labeled '11-7 LVN's,' which was not accessible to the public. The facility's policy and procedure on Resident Rights, dated October 2023, indicated that residents have the right to examine survey results.
Incomplete Orientation Skills Checklists for Staff
Penalty
Summary
The facility failed to ensure that four out of five sampled employees had a completed orientation skills checklist upon hire, which is necessary to confirm their competency in providing care. During an interview and record review with the Director of Staff Development (DSD), it was revealed that the employee files of three Certified Nursing Assistants (CNAs) and one Licensed Vocational Nurse (LVN) were incomplete. CNA 1, hired on January 22, 2024, had an orientation skills checklist that was not signed by a trainer and lacked an annual skills checklist for January 2025. CNA 2, hired on July 1, 2024, had an undated orientation skills checklist without signatures from either the CNA or a trainer. CNA 3, hired on November 14, 2024, had a checklist dated but not signed by a trainer. LVN 1, hired on August 29, 2024, did not have an orientation skills checklist in their file. The DSD emphasized that without a completed and signed skills checklist, the competency of the staff could not be verified, potentially leading to substandard care for residents.
Failure to Post NHPPD Information
Penalty
Summary
The facility failed to ensure that the Nursing Hours Per Patient Day (NHPPD) information was posted in an area easily viewable by residents and the public. During an observation and interview with an LVN at the nurse's station, it was noted that there was no NHPPD information posted. The LVN acknowledged that the NHPPD information is supposed to be posted on the bulletin board and should be visible to everyone to inform them about the census and staffing adequacy. The Director of Staff Development confirmed that the NHPPD provides the ratio of nurses to residents and should be updated daily in a location easily seen by the public. A review of the facility's policy indicated that nurse staffing data must be posted in a prominent place accessible to residents and visitors.
Failure to Conduct Monthly Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed a monthly Medication Regimen Review (MRR) for four out of eight sampled residents. This deficiency was identified during interviews and record reviews, revealing that the MRRs were not completed for Residents 4, 5, 10, and 24 from October 2024 to December 2024. The Director of Nursing (DON) acknowledged the absence of these reviews, which are necessary to identify potential drug interactions and prevent overmedication. Resident 4 was admitted with diagnoses including hypertension, diabetes, and dementia, with severe cognitive impairment and dependency on staff for daily activities. Despite these conditions, there was no evidence of MRRs being conducted for three months. Similarly, Resident 5, who had hypertension, diabetes, and congestive heart failure, also did not have MRRs completed during the same period, despite having moderate cognitive impairment and fluctuating decision-making capacity. Resident 10, with diagnoses of dysphagia, diabetes, and intellectual disabilities, and Resident 24, with cellulitis, osteoarthritis, and schizophrenia, also lacked MRRs for the specified period. Both residents required varying levels of assistance with daily activities. The DON confirmed that the absence of MRRs could lead to drug interactions or overmedication, potentially resulting in negative outcomes for the residents.
Food Storage and Cleanliness Deficiencies
Penalty
Summary
The facility failed to maintain cleanliness and proper food storage practices in the dry food pantry and kitchen, leading to potential cross-contamination and pest attraction. During an observation, a whitish granule substance, possibly corn meal, salt, or sugar, was found on the floor and on a container lid in the dry food pantry. Additionally, an open package of Pure Grade A Dried Milk was improperly stored in an unsealed resealable plastic bag, leaving the product exposed. In the kitchen, an opened can of soda and a cup with clear liquid were left on a desk, which should have been discarded. Further inspection revealed a leaking package of ground turkey in the freezer, with a frozen red substance, likely blood, spilling onto another package below it. The Dietary Supervisor acknowledged these issues, confirming that the food storage area and kitchen need to be kept clean to prevent attracting pests or rodents and to avoid cross-contamination. These observations highlight the facility's failure to adhere to professional standards for food storage and cleanliness.
Failure to Submit PBJ Data to CMS
Penalty
Summary
The facility failed to submit payroll-based journal (PBJ) data to the Centers for Medicare and Medicaid Services (CMS) for the fourth quarter of the fiscal year 2024, covering July to September. This deficiency was identified during a review of the PBJ Staffing Data Report dated January 29, 2025. The Administrator was unaware of the failure to submit the data, which is necessary for CMS to verify adequate staffing levels for safe and quality patient care. The Director of Nursing indicated that the responsibility for submitting the PBJ data lay with the payroll department, but the payroll staff was not informed of this responsibility.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications, as well as routine monitoring of room temperatures in the medication storage area. During an observation, it was found that there was no room temperature monitoring log in place, which is crucial for maintaining the stability and effectiveness of medications. This oversight was acknowledged by a Licensed Vocational Nurse (LVN), who confirmed the importance of such monitoring. Additionally, several vials of medication were found without opened date labels, which is necessary to track their validity and ensure they are safe for use. A vial of Aplisol solution, used for tuberculosis testing, was found without an opened date label, making it impossible to determine its safety for administration. The LVN stated that the Aplisol solution is only good for 30 days once opened, and without a label, it posed a risk of adverse drug reactions. Furthermore, vials of lorazepam and Admelog insulin for specific residents were also found without opened date labels. These medications are critical for managing conditions such as anxiety, diabetes, and heart failure. The absence of labeling could lead to the administration of expired medications, which would be ineffective in treating the residents' conditions. The facility's policy requires all drugs to be labeled according to state and federal law, including dating and initialing opened multidose injectables, which was not adhered to in these instances.
Resident Transferred Without Physician Order
Penalty
Summary
The facility failed to ensure that a resident had a physician order for transfer to a general acute care hospital (GACH). The resident, who was cognitively intact and had diagnoses including seizures and hemiplegia, was transferred to the hospital for abdominal pain without a physician's order. A review of the resident's records, including the Face Sheet and Minimum Data Set, confirmed the absence of such an order. During an interview, a Licensed Vocational Nurse (LVN) acknowledged that there were no orders placed for the transfer, emphasizing that it is the physician's responsibility to decide on the necessity of a transfer. The facility's policy requires obtaining a discharge order from the attending physician, which was not followed in this instance.
Failure to Document Change in Condition for Hospital Transfer
Penalty
Summary
The facility failed to ensure that a Change in Condition Form was completed for a resident who was transferred to a general acute care hospital (GACH) due to abdominal pain. The resident, who was cognitively intact and had a medical history including seizures, hemiplegia, and hemiparalysis, was originally admitted and later readmitted to the facility. On the date of the incident, the resident was transferred to the hospital, but there was no documentation in the progress notes explaining the reason for the transfer, nor was there a Change of Condition form completed to indicate the change in the resident's baseline condition. During an interview and record review, a Licensed Vocational Nurse (LVN) confirmed that the resident was transferred to the GACH but acknowledged the absence of documentation regarding the change in condition that necessitated the transfer. The LVN emphasized the importance of completing a Change of Condition form to ensure appropriate monitoring and communication with the physician. The facility's policy on Change of Condition Notification required licensed nurses to assess and document any changes in a resident's condition, which was not adhered to in this case.
Failure to Timely Transmit MDS Assessments
Penalty
Summary
The facility failed to transmit the Minimum Data Set (MDS) assessments for two residents, Resident 29 and Resident 34, to the Center of Medicare and Medicaid Services (CMS) within the required 14-day period after completion. Resident 29 was initially admitted with diagnoses of hypertension and congestive heart failure, requiring set-up assistance for daily activities. Resident 34 was admitted with anemia and failure to thrive, being totally dependent on staff for eating and hygiene. The MDS assessments for these residents, dated 12/20/2024 and 12/22/2024 respectively, were not transmitted in a timely manner, as confirmed by the Minimum Data Set Nurse (MDSN) during a phone interview and record review. The MDSN acknowledged the delay in transmitting the assessments, which should have been sent within 14 days of the Assessment Reference Date (ARD). The Director of Nursing (DON) also confirmed that the delay in transmission could affect resident care and facility reimbursement. The facility's policy and procedure on the Minimum Data Set, which requires encoding and locking the assessment data within seven days of completion, was not adhered to, leading to this deficiency.
Failure to Complete Required PASRR Level II Assessment
Penalty
Summary
The facility failed to ensure that a resident received a required Pre-Admission Screening and Resident Review (PASRR) Level II assessment. This assessment is a federal requirement to ensure that individuals with mental disorders or intellectual disabilities are placed in facilities that can provide appropriate care. The deficiency involved a resident who was admitted with diagnoses including hypertension, schizophrenia, and diabetes. The resident's Minimum Data Set (MDS) indicated severe cognitive impairment, requiring maximal assistance with toileting and lower body dressing, and dependency on staff for bathing. During a review of the resident's records, it was found that the PASRR Level I screening was positive, indicating the need for a Level II evaluation. However, the Level II evaluation was not completed due to a duplicate PASRR on file. The Medical Records Director acknowledged the oversight, stating that she was supposed to follow up on the PASRR but failed to do so. The facility's policy requires a Level II evaluation if a resident is identified during Level I screening as having a possible mental illness, but this was not adhered to, potentially resulting in the resident not receiving necessary services for their mental health condition.
Failure to Develop Care Plan for PICC Line
Penalty
Summary
The facility failed to develop a care plan for a peripherally inserted central catheter (PICC) line for one of the sampled residents, identified as Resident 18. Resident 18 was admitted with diagnoses including an unspecified respiratory disorder and other disorders of the kidney and ureter. The resident's medical records indicated the presence of a PICC line in the right upper arm, but there was no care plan addressing the PICC line's goals and interventions. This oversight was identified during a review of the resident's medical records and confirmed by the Director of Nursing (DON). The DON acknowledged that registered nurses are responsible for monitoring PICC lines, which includes tasks such as changing the dressing, flushing the line, and checking for swelling or redness. However, none of these tasks were documented as completed for Resident 18. The absence of a care plan for the PICC line was noted as a significant deficiency, as it would have identified necessary monitoring areas and potential interventions for the resident's care.
Failure to Monitor Resident's Vital Signs as Ordered
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 21, had their vital signs taken every shift as ordered by the physician. This deficiency was identified through interviews and record reviews. Resident 21, who was cognitively intact, had been admitted with diagnoses including seizures and shortness of breath. An order was placed on May 8, 2024, to monitor the resident's vital signs every shift. However, a review of the Vitals Summary for January 2025 revealed multiple instances where vital signs were not recorded every shift, with some days showing only one or two recordings instead of the required three per day. During an interview, an LVN confirmed the order for checking vital signs every shift and acknowledged the missing entries in the Vitals Summary. The LVN emphasized the importance of adhering to the order to ensure timely intervention in case of significant changes in the resident's condition. The facility's policy and procedure, dated February 6, 2003, also required the monitoring and documentation of vital signs to assess and monitor changes in a resident's condition. The failure to follow these procedures had the potential to delay necessary interventions for Resident 21.
Failure to Provide Vision Care Services
Penalty
Summary
The facility failed to ensure that a vision care service was provided for a resident, identified as Resident 15, who had a history of optic atrophy, macular degeneration, and hypertension. Despite having the capacity to understand and make decisions, as indicated in his History and Physical and Minimum Data Set assessments, Resident 15 was dependent on staff for various daily activities and had severely impaired vision. His care plan, which aimed to prevent a decline in visual function, included interventions such as arranging consultations with an eye care practitioner and ensuring appropriate visual aids were available. However, the resident expressed that he needed new prescription eyeglasses and had been requesting to see an eye doctor due to his blurry vision. The Social Service Designee (SSD) acknowledged that there was no documentation of a referral to an optometrist for Resident 15, which was her responsibility. The SSD recognized the risk of not referring the resident could lead to worsening vision, depression, and decreased independence. The Director of Nursing also noted that progressive vision loss could result in permanent blindness and affect the resident's self-esteem. The facility's policy and procedure on referrals to outside services indicated that the Director of Social Services was responsible for locating agencies and programs to meet residents' needs, and the policy on resident rights emphasized providing care that ensures residents' abilities do not diminish while in the facility's care.
Failure to Provide Podiatry Care for Resident
Penalty
Summary
The facility failed to provide appropriate foot care for a resident, identified as Resident 24, who had long, thick, elongated toenails. This deficiency was observed during a survey where Resident 24 expressed discomfort and irritation due to the inability to wear socks. The resident had been requesting podiatry services, which were not provided, despite the facility offering such services to all residents. The resident's medical history included cellulitis, osteoarthritis, and schizophrenia, and he required moderate assistance with personal hygiene. The Social Service Designee (SSD) acknowledged the oversight, noting that the previous SSD did not refer the resident to a podiatrist. The last podiatrist visit to the facility was several months prior, and the facility's policy required the Director of Social Services to ensure residents' needs were met through appropriate referrals. The facility's policy on foot care emphasized the importance of preventing skin breakdown and infections, which was not adhered to in this case, leading to the deficiency.
Failure to Monitor and Maintain PICC Line
Penalty
Summary
The facility failed to ensure proper monitoring and maintenance of a PICC line for a resident, identified as Resident 18. The resident returned from the hospital with a PICC line for antibiotic administration. However, the Director of Nursing (DON) was unaware of the presence of the PICC line and its maintenance requirements. During an observation, the DON noted that the dressing on the PICC line was soiled and had not been changed as required. The medical records review revealed that registered nurses (RNs) did not perform necessary tasks such as changing the dressing every 7 days or when soiled, flushing the line, measuring arm circumference, and checking for swelling or redness. Resident 18 was admitted with diagnoses including an unspecified respiratory disorder and other disorders of the kidney and ureter. The resident was unable to complete a brief interview for mental status, indicating potential cognitive impairment. The lack of monitoring and documentation of the PICC line care by the RNs posed a risk of complications such as infection or infiltration, as these tasks are crucial to ensure the line's integrity and the resident's safety.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 6,420 citations issued within 25 miles in the last 12 months — including the 39 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Los Angeles
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avalon Villa Care Center | 2.8 mi | ★★★★★ | 73 | 0 |
| Vernon Healthcare Center | 3 mi | ★★★★★ | 24 | 0 |
| View Heights Conv Hosp | 3.1 mi | ★★★★★ | 4 | 0 |
| Hyde Park Healthcare Center | 3.2 mi | ★★★★★ | 26 | 1 |
| Lotus Care Center | 3.4 mi | ★★★★★ | 14 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Manchester Healthcare Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release June 2026) and official state health department websites.