Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mesa Glen Care Center during CMS and state inspections, most recent first.
Failure to Provide Requested Medical Records: A resident with DM and Parkinson’s disease, who could make needs known but could not make medical decisions, had a valid request for medical records submitted by the law firm representing the resident’s legal representative. The facility did not provide the records within the required timeframe, and the MRD confirmed the request had been received but the records had not been sent by the time of survey.
Call lights were not kept within reach for two residents. One resident with dementia, Alzheimer’s disease, and anxiety disorder was observed in bed and later eating lunch with the call light hanging behind the bed and out of reach, and the resident said they would have to scream for help if needed. Another resident with severely impaired cognition, dysphagia, and GT status was observed in bed with the call light hanging on the bed rail and touching the floor, and an LVN confirmed it was not reachable. The DON and facility policy stated call devices should be within the resident’s reach.
Inaccurate MDS Coding for Diagnosis and Discharge Status: Two residents had inaccurate MDS assessments. One resident’s anxiety disorder was not coded even though the chart showed the diagnosis and buspirone HCL use, and another resident’s discharge status was coded as home/community instead of discharge home with home health. The MDS nurse and MDS coordinator acknowledged the coding errors, and the DON stated MDSs should accurately reflect diagnoses and discharge destination.
Care plans were not individualized or followed for three residents. One resident had an active Namenda order for dementia, but no specific CP was developed for the medication. Two residents had low air loss mattresses set to weights that did not match their current weights, and one of those residents also had pressure ulcer treatment orders that were not followed because the wounds were not covered with dressings before treatment. The DON and TN stated the CPs and orders were not being carried out as written.
LAL mattress settings were not kept consistent with residents’ actual weights for several residents with PU/PI risk or active wounds, and one resident’s ordered wound dressings were not in place before treatment. A resident with stroke and DM2 had an LAL set far above the recorded weight, another resident with dementia, malnutrition, hemiplegia, and existing PUs had an LAL set above weight and two wound orders not followed, a resident with stage 4 PUs had the mattress on static instead of alternating pressure, and two other residents with paraplegia or DM2/obesity also had LAL settings above their recorded weights.
Improper Catheter Securement and Bag Positioning: Two residents with indwelling urinary devices were observed with care not provided as described in the facility’s policy. One resident’s suprapubic catheter tubing was not secured to the thigh with a strap or securement device, and another resident’s bilateral nephrostomy bags were placed higher than the bladder while full. The TN and DON stated tubing should be secured to prevent pulling and bags should be kept lower than the bladder to prevent backflow of urine and UTI.
Improper PICC Line Dressing and Lumen Coverage: Two residents receiving IV therapy had PICC line care issues identified during observation. One resident with a right upper arm PICC had a loose, unlabeled dressing, and staff could not confirm when it was last changed. Another resident with a left upper arm PICC had one lumen left uncovered. Staff stated PICC dressings should be kept clean and changed per policy, and lumens should be capped and covered when not in use.
Respiratory care was not provided as ordered for two residents. One resident with COPD was observed with NC tubing touching the floor, not connected to the POC, and the prongs resting on the cheek instead of in the nostrils. Another resident with pneumonia, COPD, and morbid obesity had a BIPAP mask left on top of the machine, and the OSR did not show a physician order for nighttime BIPAP use. The DON stated NCs should be properly placed and connected, and BIPAP use requires a doctor’s order.
Daily nurse staffing information was not posted in a prominent, readily accessible location for residents, visitors, and staff. An IPN, ADSD, DON, and ADM all confirmed the information was not posted in the lobby, hallways, or nurse stations and was kept inside a binder in the North station. A resident with musculoskeletal symptoms, dysphagia, and moderately impaired cognition said the North station was too far to walk to and preferred the South station.
Unsafe Food Storage and Labeling Practices: The kitchen had chopped fresh fruit left in Refrigerator 1 beyond the facility’s 3-day limit, an open loaf of white bread past its use-by date, and two bags of frozen pie shells in Freezer 1 that were not dated. The DS stated the fruit, bread, and unlabeled frozen items should have been discarded or labeled per facility food safety practices, and the DON stated food beyond the used-by date should not be stored in the kitchen.
Improper Trash Storage and Pest Presence: The facility failed to keep dumpster lids closed and the dumpster area free of litter, with four large trash dumpsters overfilled and trash observed on the ground near the kitchen and parking lot. Staff stated the conditions were unacceptable and could attract rodents or bugs. A resident room also had a dead cockroach on the bathroom door, and staff acknowledged bugs in resident rooms were an infection control issue.
Failure to maintain a resident's privacy during GT site care. A resident with dysphagia, GT status, and severely impaired cognition was observed while an LVN assessed the GT site without closing the privacy curtain or room door, exposing the resident's abdominal area to the roommate and passersby. The LVN and DON both stated the curtain and door needed to be closed to provide privacy, dignity, and comfort, consistent with the facility's Dignity and Respect policy.
Bathroom Sink Hot Water Not Functioning: A resident with cervical disc disorder, MDD, and anxiety reported that the bathroom sink in the room never worked properly, with cold water flowing freely but hot water only trickling out and never getting warm. Staff observations confirmed the hot-water faucet produced only a slow trickle of cold water, and the MS and DON acknowledged the sink was not functioning as it should and that residents should have access to working bathroom sinks with running hot water.
A resident with impaired cognition, dementia, schizophrenia, and a stroke history was observed wearing a Wanderguard for elopement risk even though the chart lacked an active physician order for the device. The record showed consent from the RP and orders only for placement checks and skin monitoring, while the DON, IPN, LVN, and TN all stated the Wanderguard required a physician order and was considered a restraint.
Conflicting Diet Orders in Care Plan: A resident with DM2, CVA, and hypertensive CKD had a nutrition assessment and active MD order for a fortified diet with regular texture, but one care plan directed staff to serve a fortified diet while another still listed a CCHO NAS diet. The MDSC stated the care plans were confusing because they contained two different diet orders, and the DON stated updated care plans guide nursing staff on resident care.
A resident who did not speak or understand English and whose preferred language was Korean did not have a communication board in the room. The resident had dementia, severely impaired cognition, and needed assistance with multiple ADLs. LVN and DON interviews confirmed that non-English speaking residents should have a communication board with pictures and descriptions in their spoken language, but none was present for this resident.
Failure to provide ordered quarter side rails for mobility and repositioning. A resident with DM2, prior CVA, and CKD was observed in bed without the side rails that were ordered to help her turn and reposition. The resident stated the rails had been removed and she had not been able to turn herself for weeks, while an LVN confirmed the order was not being followed and the DON stated equipment is important to prevent decreased ROM or mobility.
Failure to Address Significant Weight Loss: A resident with impaired cognition and dependence for several ADLs had a 6.5% weight loss over a short period, dropping from 98.2 lbs. to 91.8 lbs. Record review found no NPP documentation, no MD or RP notification, no COC assessment, no IDT conference record, no care plan for weight loss, and no MDS assessment reflecting the significant weight loss. RN and DON both stated the loss was significant and should have been addressed.
Missing Hemodialysis Emergency Kit at Bedside: A resident with ESRD and dependence on renal dialysis did not have an E-kit at the bedside despite orders to monitor the dialysis access site for bleeding and apply a pressure dressing if needed. During observation, the resident was awake in bed with a left chest hemodialysis access site, and the LVN stated the E-kit should have been visible and accessible for staff in case of bleeding; the DON confirmed bedside E-kits were needed for residents on hemodialysis.
Failure to obtain order and informed consent for bed rails: A resident with DM, depression, PVD, intact cognition, and bilateral AKA was observed in bed with half side rails on both sides. The LVN and DON stated there was no physician order or informed consent from the resident or representative before the rails were installed, despite the facility P&P requiring staff to explain benefits and hazards and obtain informed consent before using bed rails.
Failure to Complete CNA Skills Competency Upon Hire: The facility failed to complete and validate the orientation skills competency for one CNA who had been employed full-time since January 2026. The ADSD and DON both confirmed the competency was not completed upon hire, despite the facility policy requiring orientation competency assessment and DSD validation for nursing staff.
A resident with GERD, CKD, and malnutrition remained on Protonix 40 mg daily after a pharmacist noted the PPI had been used for more than 12 weeks and should be reassessed. The prescriber signed the recommendation, but the form was left incomplete because it was undated and the response section was not checked off; the DON, WCN2, and IPN stated the recommendation was therefore not properly acted upon.
Medication Errors Involving Crushing of ER Seizure Medication: The facility had a 7.14% medication error rate after an LPN crushed and administered two lamotrigine ER tablets to a resident with epilepsy, despite no order permitting crushing. The resident’s orders were for lamotrigine ER 25 mg and 250 mg every 12 hours, and staff, the pharmacist consultant, and the PCP all stated the ER tablets should not be crushed.
A resident with epilepsy, COPD, and parkinsonism was given lamotrigine ER 25 mg and 250 mg after an LPN crushed both tablets and mixed them with applesauce. The resident’s orders did not allow crushing, the facility’s do-not-crush list included lamotrigine ER, and the pharmacist consultant, PCP, and DON stated the ER medication should not have been crushed.
Incomplete Fall Risk Evaluation and Documentation: A resident admitted with dysphagia and GT status had an admission FRE that identified low fall risk based on intermittent confusion and being bedbound, but multiple required assessment elements were left incomplete, including fall history, ambulation/elimination status, SBP, vision, predisposing diseases, recent condition changes, recent hospitalization history, gait, balance, and medications. The MDS showed severely impaired cognition and max assistance needs for several ADLs, and the DON stated the FRE was not filled out completely and the resident was not properly assessed for fall risk.
Unsecured hallway handrail in North Station: The facility failed to keep a hallway handrail firmly secured to the corridor wall. An observation found the handrail was not secured, and the DON, MS, and IPN all stated it was not sturdy and should be secured for resident use. The MS reported that three of the mounts attaching the rail to the wall were broken.
Pest observed in shared resident room: A bug was found crushed in the bathroom door frame of two residents' shared room. One resident said she had crushed it the night before and had seen many bugs in the facility, while the other said bugs were seen in the room all the time. CNA, HSK, MS, DON, and IPN all stated pests should not be in residents' rooms, and the facility's Pest Control policy required a clean, safe, sanitary environment free from insects, rodents, and other pests.
A resident with dementia, swallowing problems, and significant ADL dependence required staff assistance with eating and oral hygiene, including RNA support for all meals and shift-by-shift oral inspections. Review of ADL documentation and the medical record showed no entries for eating and oral hygiene on one evening shift and no oral hygiene documentation on a subsequent night shift, despite care plan and policy requirements for detailed charting of meal assistance and oral care. Staff interviews confirmed that nursing staff were expected to document assistance with eating, oral hygiene, and meal intake percentages each time care was provided, and the DON acknowledged that the ADL documentation for those shifts was incomplete.
Surveyors found that the facility failed to maintain infection control when two residents used a shower room with a clogged drain that left standing water during showers, despite one resident requiring substantial assistance for bathing and another reporting having to stand in pooled water. In a separate issue, a resident with multiple psychiatric and medical diagnoses was observed with three full urinals hanging at the foot of the bed, and the assigned CNA admitted not emptying them, explaining they did not enter the room unless the call light was used. The IP reported that staff were expected to round every two hours and empty urinals at least that often, and facility policies required daily cleaning and disinfection of bathrooms and frequent checking, emptying, and cleaning of bedside urinals.
Surveyors found that a resident with cellulitis, lack of coordination, hypertension, and moderate cognitive impairment, who required significant assistance with bathing and toileting, used a shower room where the call light did not activate when the cord was pulled. In another shower room, the call light pull cord did not reach the floor, making it inaccessible if a resident fell. The Maintenance Director confirmed both the nonfunctioning call light and the too-short pull cord, and the DON reported there was no P&P for the call light system.
Two residents who required staff assistance with bathing and toileting hygiene were observed and reported showering in a room where the drain was clogged, causing them and staff to stand in pooled water that did not drain and was described as disgusting and making them feel dirty. The Maintenance Director confirmed the shower drain in the room next to the dining area was clogged and standing water was present. In a separate issue, staff failed to empty three full urinals hanging at the foot of a resident’s bed. These conditions conflicted with facility policy requiring a safe, clean, sanitary, and homelike environment.
A resident with eczema and multiple psychiatric diagnoses had a physician order for daily application of Clotrimazole 1% solution to the face, but nursing staff failed to administer the medication on multiple documented days. The resident reported not receiving the topical treatment for several consecutive days. Review of the TAR and progress notes showed missed doses due to the medication not being on hand. The treatment nurse acknowledged not giving the medication, not contacting the pharmacy about its unavailability, and not notifying the prescribing physician. The DON reported that nurses are expected to follow up with the pharmacy and inform the prescriber when medications are unavailable and also stated there was no formal P&P for medication administration.
Staff failed to consistently wear required identification badges while on duty, contrary to facility policy and state regulations. Surveyors observed an LVN wearing an ID badge clipped below the waist, a care coordinator assisting a resident with documents without a badge, a hairdresser moving between rooms without a badge, a newly hired treatment nurse without a badge, and another LVN at the nurses’ station who had forgotten to put a badge back on after lunch. One resident with anorexia nervosa, schizophrenia, and anxiety disorder, who was cognitively intact and dependent on staff for several ADLs, reported that multiple staff did not wear badges and stated a need for staff to wear them to know who was providing care. Another resident with a right arm fracture, T2DM, and lack of coordination, with moderately impaired cognition and ADL dependence, was also involved in these observations.
Surveyors found that hot foods served during meal service were not maintained at or above the required 140°F, with test tray measurements showing pasta and turkey at 105°F and green beans between 110°F and 120°F. The Dietary Supervisor acknowledged ongoing problems with a malfunctioning plate warmer that may have contributed to inadequate food temperatures, especially during morning meals, and explained that staff reheat food for about 15 seconds to reach approximately 160°F upon resident request. Facility policy requires that hot TCS foods be maintained above 140°F during trayline service, and the deficient practice was noted as having the potential to cause rapid bacterial growth leading to foodborne illness and insufficient intake with weight loss.
Two residents with physician orders and care plans for continuous 1:1 supervision were not provided the required level of monitoring. One resident had hemiplegia, contractures, high fall risk, and needed maximal assistance with ADLs, while the other had dementia, Alzheimer’s disease, anxiety, impaired cognition, and a history of aggression, exit-seeking, and unprovoked agitation. Despite orders specifying that each resident receive their own 1:1 sitter and not be left unattended, the facility scheduled a single sitter to cover both residents, requiring the sitter to move back and forth between rooms and leaving each resident alone at times. Staff interviews, including from an LVN, CNAs, an RN supervisor, the DON, and the administrator, confirmed that 1:1 meant continuous, dedicated supervision and that residents should not be left alone, yet observations showed the sitter leaving each resident unattended while checking on the other.
A resident with hemiplegia, hemiparesis, contractures, and high fall risk was found with the bed placed against a wall on one side and a Geri chair wedged tightly against the other side, creating a barrier that restricted the resident from getting out of bed. The care plan called for 1:1 supervision due to confusion and prior unassisted bed-exit attempts, but there was no physician order for Geri chair use. A sitter reported the DON had permitted the Geri chair placement, and an LVN stated it was intentionally used as a restraint to prevent the resident from rising, with the Administrator and DON aware. Facility staff, including an RN supervisor, later acknowledged this setup constituted a restraint and conflicted with facility policies that limit restraint use to treatment of medical symptoms and prohibit use for staff convenience or fall prevention.
A resident with paranoid schizophrenia, severely impaired cognition, and a documented history of aggressive behavior, including prior attempts to hit others and a hospital transfer for aggression, was care planned with vague, non–behavior-specific interventions after psychiatric hospitalization. Another resident with pneumonia, anxiety disorder, and moderately impaired cognition, who required substantial/maximal assistance with ADLs and mobility, was seated in a lobby area when the aggressive resident approached in a wheelchair and struck the resident on the back of the head, causing significant head pain and emotional distress. An RN at the nearby nursing station heard a cry of pain, separated the residents, and observed the aggressive resident making a fist-like motion. Both the RN and the DON acknowledged that residents with known aggressive histories require individualized, specific, and measurable behavioral interventions, and that the lack of such detailed guidance left staff without clear direction to prevent escalation, resulting in this incident of physical abuse in violation of the facility’s abuse prevention and resident rights policies.
A resident with paranoid schizophrenia and severely impaired cognition had repeated episodes of aggression, including attempting to hit others and requiring hospital transfer and a 5150 hold. After readmission, the facility opened a behavior care plan but did not individualize it, omitting monitoring parameters, behavioral triggers, and clear staff guidance on approach and redirection. Although the care plan problem was initiated, specific interventions were not implemented for several weeks, contrary to facility policy requiring comprehensive, person-centered care plans with measurable objectives and timeframes.
The facility failed to post current daily nurse staffing information in a prominent area accessible to residents, staff, and visitors. Surveyors observed outdated "Census and Direct Service Hours Per Patient Day" postings near a nursing station on multiple days, with dates that did not reflect the current day. The DON acknowledged the postings were not current and stated they should be updated daily. A CNA reported being responsible for entering RN, LPN, LVN, and CNA hours into a computer program to generate the daily staffing printout but was unable to report on time due to personal circumstances. The CNA also stated that projected staffing hours had been prepared and left for weekend nurses to post near two nursing stations. Review of facility policy confirmed that licensed nurse and CNA staffing numbers must be posted within two hours of each shift’s start, which did not occur as required.
A resident with multiple chronic conditions and intact cognition exhibited ongoing hoarding behavior, resulting in significant clutter and safety hazards in their room. Despite initial interventions and education, the resident refused assistance, and the care plan was not updated or revised to address the continued issues, leading to a deficiency in maintaining a safe and clean environment.
A resident's room was found to be excessively cluttered with boxes, clothing, and personal items, creating accident hazards and leaving the call light out of reach. Despite the resident's need for assistance with daily activities and documented refusals of cleaning, staff did not effectively implement care plan interventions or maintain a safe environment as required by facility policy.
Surveyors observed that an expired water filter was connected to the icemaker in the kitchen, and the Dietary Manager was unsure of the replacement schedule. The maintenance log lacked a clear date, and the manufacturer's guidelines for annual replacement were not followed, resulting in unsanitary ice and water handling practices.
A resident with multiple medical conditions, including ESRD and diabetes, experienced a fall and fracture after attempting to rise from a rollator walker without a care plan in place for its use. The facility did not develop or implement a care plan addressing the resident's specific needs for the assistive device, and there was a lack of communication between therapy and nursing staff regarding recommendations and safety instructions, contrary to facility policy.
A resident with a history of elopement, seizures, and depression exited the facility without staff knowledge or supervision. Despite being assessed as cognitively intact but at risk for wandering, the resident was last seen in bed and later could not be found, leading to a facility-wide search. Staff interviews confirmed the resident was ambulatory and frequently walked the facility, but no prior signs of intent to leave were noted. The facility's policy required targeted interventions and supervision, which were not effectively implemented, resulting in the resident's unsupervised exit.
Staff did not promptly respond to call lights and toileting requests for three residents, including individuals with dementia, incontinence, and mobility deficits. Delays of up to several hours were reported and observed, leading to residents feeling ignored and frustrated. Facility policy and the DON both indicated that prompt response is necessary to maintain resident dignity, but this standard was not met.
A resident with severe cognitive impairment was readmitted with orders for multiple psychotropic medications, but the facility failed to verify or obtain informed consent from the resident's representative as required. Medication changes made during a recent hospital stay were continued without proper notification or consent, and documentation inaccurately indicated that consent had been obtained. This resulted in the resident receiving psychotropic medications without the necessary informed consent process.
A resident with severe cognitive and psychiatric impairments was subjected to physical abuse when an RN deliberately threw juice in the resident's face and chest after the resident, during an agitated episode, threw juice at the RN and a CNA. The RN admitted to intentionally mirroring the resident's behavior, contrary to the resident's care plan and facility abuse prevention policies. The incident left the resident visibly distressed and was later reported to facility leadership.
A resident with severe cognitive impairment and behavioral issues was subjected to physical abuse when an RN threw juice at the resident after the resident threw juice at the RN. The incident was witnessed by a CNA, but was not reported to the Abuse Coordinator or Administrator within the required two-hour timeframe, as mandated by facility policy. The delay in reporting was confirmed through staff interviews and review of facility records.
Two residents were not treated with dignity when one was referred to as a "feeder" by an Activity Assistant and another was assisted with eating by a staff member standing over them, contrary to facility policy. Both residents had significant cognitive or physical impairments and required substantial staff assistance.
Three residents with cognitive impairments and fall risks were not adequately supervised, including one who was left unsupervised while the assigned sitter was distracted by a personal phone. Additionally, two residents who experienced multiple falls did not receive timely interdisciplinary team reviews as required by facility policy.
Failure to Provide Requested Medical Records
Penalty
Summary
The facility failed to provide Resident 6’s medical records within the required timeframe after receiving a valid request from the law firm representing the resident’s legal representative. Resident 6 was admitted with diagnoses including type 2 diabetes mellitus and Parkinson’s disease, and the history and physical indicated the resident could make needs known but could not make medical decisions. A request for medical records was faxed to the facility on 5/15/2026, along with an authorization for release of medical information signed by the resident’s legal representative. During interview and record review, the Medical Record Director stated the request was received on 5/15/2026 and that the records were not sent by the time of the survey on 5/28/2026. The Administrator and Medical Record Director referenced the facility’s policy, which stated requested copies of the record should be sent within 48 hours of receipt of a valid written request, while the Administrator stated the facility had 15 days to send medical records to law firms.
Call Lights Not Kept Within Residents’ Reach
Penalty
Summary
The facility failed to ensure that call lights were within reach for two residents. Resident 69 was admitted with dementia, Alzheimer’s disease, and anxiety disorder, and the record showed the resident could make needs known but could not make medical decisions. The resident’s MDS indicated the resident needed supervision or touching assistance for several activities of daily living and was high risk for falls. During observation, Resident 69 was found in bed with the call light hanging on the wall behind the bed and not within reach, and later while sitting up eating lunch the call light was still not within reach. The resident stated they did not know where the call light was and would have to scream for help if needed. CNA 3 and the DON both stated the call light should be within the resident’s reach. Resident 5 was admitted and readmitted with diagnoses including dysphagia and GT status. The resident’s MDS showed severely impaired cognition and need for maximum assistance with oral hygiene, toileting hygiene, showering, dressing, and footwear. The care plan identified the resident as at risk for falls related to confusion and being unaware of safety needs, and directed staff to ensure the call light was within reach and to encourage use for assistance. During observation, Resident 5 was awake in bed with the call light hanging on the right side of the bed rail and touching the floor, and LVN 2 stated the resident could not reach it. The DON stated residents’ call lights needed to be accessible and within reach at all times, and the facility policy stated to place the call device within the resident’s reach before leaving the room.
Inaccurate MDS Coding for Diagnosis and Discharge Status
Penalty
Summary
The facility failed to ensure that two residents had accurate MDS assessments. For one resident, the admission record showed diagnoses including amnesia and anxiety disorder, and a psychiatric progress note and physician order later documented anxiety disorder with buspirone HCL ordered twice daily. The resident’s MDS dated [DATE] documented intact cognition and levels of assistance with activities of daily living, but it did not code the anxiety disorder diagnosis even though the resident was receiving medication for anxiety. For the second resident, the admission record showed diagnoses including sepsis and hypertension, and the physician order directed discharge to home with home health for wound follow-up. The resident’s MDS dated [DATE] documented intact cognition and assistance needs with eating, oral hygiene, toileting hygiene, showering/bathing, personal hygiene, and bed-to-chair transferring, but it coded the discharge destination as home/community instead of discharge home under the care of an organized home health service organization. The physician discharge summary also stated the resident was discharged home with home health because the resident no longer needed facility services. During interview, the MDS nurse stated the first resident’s anxiety disorder should have been coded because the resident was taking buspirone HCL for anxiety and that the MDS should be modified and resubmitted to CMS. The MDS coordinator stated the second resident’s MDS was not an accurate assessment and that the facility transcribed the resident’s assessment to CMS. The DON stated the MDS should accurately indicate residents’ diagnoses and discharge destination, and the facility policy required all MDS assessments to be completed accurately with the MDS coordinator responsible for chart review and correcting errors promptly, and the DON responsible for reviewing MDS accuracy.
Care plans were not individualized or followed for medication, low air loss mattress settings, and pressure ulcer treatment
Penalty
Summary
The facility failed to develop and implement specific, comprehensive, and individualized person-centered care plans for three sampled residents. For one resident admitted with amnesia and anxiety disorder, the record showed an active order for Namenda 5 mg twice daily for dementia, but the DON stated there was no care plan developed to address the medication. The DON stated the licensed nurse who received the order should have developed a specific, resident-centered care plan for Namenda, and the MDS Coordinator policy stated the MDS Coordinator was responsible for ensuring care plans reflect the resident’s current clinical status. For another resident with diagnoses including cerebral infarction, type 2 diabetes mellitus, and cognitive communication deficit, the record showed a physician’s order for a low air loss mattress for wound management and for the mattress to be checked every shift for placement, function, and setting. The resident’s care plan also directed staff to monitor the mattress for placement, function, and setting. During observation, the mattress control panel was set to 210 pounds even though the resident’s most recent weight was 119 pounds. The treatment nurse stated the mattress should not have been set at 210 pounds and that the correct setting should have matched the resident’s weight. The treatment nurse and DON stated the mattress was not at the appropriate setting, and the treatment nurse stated the care plan was not followed because the mattress was not set correctly. For a third resident with malnutrition, dementia, and hemiplegia, the record showed current pressure ulcers on the right hip and left fourth finger, with physician orders for daily wound care and for the wounds to be covered with dressings. The resident’s care plans addressed the pressure ulcers and low air loss mattress use. During observation, the mattress control panel was set to 200 pounds while the resident’s most recent weight was 102 pounds. During wound treatment, both pressure ulcers were found without dressings in place before treatment began. The treatment nurse stated the wound orders to keep the wounds covered with dressings were not carried out, and also stated the low air loss mattress was not at the correct setting and the related care plans were not followed.
LAL Mattress Settings and Wound Dressing Orders Not Followed
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and skin maintenance for five sampled residents by not keeping low air loss (LAL) mattresses set to the residents’ current weights and, for one resident, not following ordered wound dressing instructions. Resident 1 had diagnoses including stroke, type 2 diabetes mellitus, and cognitive communication deficit, and the record showed moderate impairment of thinking and memory and risk for pressure ulcers. On observation, Resident 1’s LAL mattress was turned on but set to 210 pounds even though the most recent recorded weight was 119 pounds. The treatment nurse stated the mattress should have been set to the resident’s most recent weight and that the order to check placement, function, and setting every shift was not followed. Resident 85 had diagnoses including malnutrition, dementia, and hemiplegia, with severe problems in thinking or memory and existing pressure ulcers. The resident’s most recent recorded weight was 102 pounds, but the LAL mattress was observed set to 200 pounds. In addition, two ordered wound treatments were not carried out as written: the right hip stage 3 pressure ulcer and the left fourth-finger stage 4 pressure ulcer were observed without dressings in place before treatment began, despite physician orders to cleanse the wounds and cover them with dressings every day and as needed. The treatment nurse stated the wounds should always have been covered with dressings and that the orders were not followed. Resident 3 had stage 4 pressure ulcers of the sacral region and right buttock and was ordered to have an LAL mattress for wound management with checks every shift. During observation, the mattress was being used, but the CNA stated it was set at 120 and on static, and the yellow sticker on the control unit showed a resident weight of 159 pounds. Resident 50, who had paraplegia and was dependent for multiple activities of daily living, was also observed on an LAL mattress set at 200 pounds even though the yellow sticker showed a weight of 168 pounds. Resident 58, who had type 2 diabetes mellitus with foot ulcer and morbid obesity, was observed on a bariatric LAL mattress set at 400 pounds even though the recorded weight was 283.4 pounds. The treatment nurse and DON stated the mattress settings needed to be based on the residents’ actual weights, and the treatment nurse stated the mattress should be on alternating pressure rather than static except during care.
Improper Catheter Securement and Bag Positioning
Penalty
Summary
Provide appropriate care for residents with indwelling catheters was not maintained for two sampled residents. Resident 50 had diagnoses including paraplegia, neuromuscular dysfunction of the bladder, and presence of urogenital implants, and the care plan identified a suprapubic catheter with a goal of not showing signs and symptoms of infection. During observation, Resident 50 was in bed with the suprapubic catheter bag hanging on the right side of the bed, and the tubing was not attached to the resident’s thigh with a securement device or strap. CNA 1 stated the tubing was not secured to the thigh. Resident 104 was admitted with diagnoses including malignant neoplasm of the colon, artificial openings of the urinary tract, and colostomy. During observation, Resident 104 was in bed with left and right nephrostomy bags placed on top of the foot part of the bed, while the foot/leg section was elevated, leaving both bags higher than the level of the bladder. CNA 1 stated both bags were full. The TN stated catheter tubing should be connected to the thigh to prevent pulling and dislodgement, and catheter bags should be placed lower than the bladder to prevent backflow of urine and UTI. The DON also stated catheter tubing should be attached to a securement device or strap on the thigh and bags should be kept lower than the bladder and emptied when half-full, every shift, and as needed.
Improper PICC Line Dressing and Lumen Coverage
Penalty
Summary
The facility failed to maintain the integrity and proper labeling of PICC lines for two residents receiving IV therapy. Resident 75 was admitted with diagnoses including liver abscess, bacteremia, and DM, and had a care plan identifying infection risk related to a PICC line in the right upper arm. During observation, Resident 75 was sitting in a wheelchair with the PICC line dressing loose and coming out, and the dressing was not labeled with a date. The LVN stated the last dressing change was unknown and that the PICC site should be maintained clean to prevent infection. Resident 106 was admitted with diagnoses including UTI, ESBL-resistant infection, and DM, and was receiving IV antibiotics through a left upper arm PICC line. During observation, Resident 106 was in bed with a PICC line that had two lumens, and one lumen was not covered. The RN stated all PICC lumens should be capped and covered when not in use for infection control. The DON later stated the PICC site should be kept clean and the dressing changed every 7 days or as needed when loose or not clean.
Respiratory Therapy and Oxygen Equipment Not Properly Managed
Penalty
Summary
The facility failed to provide necessary respiratory care for Resident 9, who had diagnoses including epilepsy and COPD and was on oxygen therapy for COPD. The care plan indicated the resident was to receive oxygen therapy, and the order summary showed oxygen at 2 liters per minute via nasal cannula every shift. During an observation in the resident’s room, the resident was in bed with the nasal cannula in place, but the tubing was touching the floor, the tubing was not connected to the portable oxygen concentrator, and the prongs were resting on the resident’s left cheek instead of being placed in the nostrils. The LVN stated the tubing should not touch the floor, should be connected to the portable oxygen concentrator, and the prongs needed to be inside the nostrils so the resident would receive enough oxygen. The facility also failed to ensure Resident 11’s BIPAP use had a physician’s order and that the BIPAP mask was stored appropriately when not in use. Resident 11 was admitted with diagnoses including pneumonia, COPD, and morbid obesity, and the MDS indicated intact cognition and that the resident was on oxygen therapy. During observation in the resident’s room, the BIPAP mask was found on top of the BIPAP machine while the resident was in bed. The CNA stated the resident used the BIPAP machine during the night. During record review, the OSR reviewed with the LVN did not show an order for BIPAP use at night. The LVN stated the resident should have a physician’s order for BIPAP use to ensure the correct setting and setup for the resident’s health concerns. The DON stated staff should ensure nasal cannulas were placed properly and connected to the portable oxygen concentrator, that tubing should not touch the floor, that BIPAP required a doctor’s order and prescription, and that respiratory items such as BIPAP masks, nebulizer masks, and nasal cannulas should be stored in the transparent bag intended for respiratory supplies when not in use.
Daily nurse staffing information not posted in a prominent accessible location
Penalty
Summary
The facility failed to post the actual nurse staffing information at the beginning of the shift in a prominent location that was readily accessible to residents, visitors, and staff on one of four recertification survey days. During an observation in the lobby, hallways, reception area, and North Nursing Station, no daily nurse staffing information was posted. In a concurrent interview, the Infection Prevention Nurse stated the staffing information was not posted in the North Nursing Station, lobby, or hallway, and the Assistant Director of Staff and Development stated she was responsible for posting the staffing information but had not done so. During interviews and record review, the DON stated the facility was required to post daily staffing data each shift in a prominent location and that the information should be easily seen and read by residents, staff, and visitors. The DON stated the staffing information was inside a binder in the North Station and was not readily accessible if kept there. The DON also stated there was no staffing information posted in the South Nurse Station. Resident 23, who had been admitted with diagnoses including musculoskeletal symptoms and dysphagia and had moderately impaired cognition on the MDS, stated it was too far to walk to the North Nurse Station to look for the staffing information and would prefer it be posted in the South Nurse Station.
Unsafe Food Storage and Labeling Practices
Penalty
Summary
The facility failed to ensure safe food storage practices in the kitchen by leaving a plate of chopped fresh fruit dated 4/28/2026 in Refrigerator 1 and another plate of chopped fresh fruit dated 5/1/2026 in the same refrigerator. During observation with the Dietary Supervisor on 5/5/2026 at 8:24 AM, both fruit plates were present in Refrigerator 1. The Dietary Supervisor stated the facility stored chopped fresh fruit in the refrigerator for up to three days and that kitchen staff should discard any chopped fresh fruit three days after the labeled date. The Dietary Supervisor also stated the fruit plate could have bacterial growth and placed the resident at risk of infection, and that it was infection control to discard the fruit plate after three days of refrigeration to prevent the spread of bacteria and germs and avoid food-borne illness. The facility also had an open loaf of white bread beyond its use-by-date of 5/2/2026 in the bread storage area, and two bags of frozen pie shells in Freezer 1 that were undated. During the concurrent observation and interview on 5/5/2026 at 8:39 AM, the Dietary Supervisor stated the bread should have been discarded because it was beyond the use-by-date and should not be kept in the kitchen, and that food beyond the use-by-date had the potential to cause infection/food-borne illness. During the observation in Freezer 1 at 8:47 AM, the Dietary Supervisor stated the two bags of frozen pie shells did not have dates labeled and that kitchen staff should label them with received and opened dates. The Director of Nursing later stated that food beyond the used-by date should not be stored in the facility kitchen because it should not be consumed to prevent infection and food-borne illness. The facility policy titled Food Labeling stated all refrigerated and stored food items should be labeled with the received date and expiration or discard date, and that expired, unlabeled, or improperly labeled food items should be discarded.
Improper Trash Storage and Pest Presence
Penalty
Summary
The facility failed to keep the dumpster area free from litter and failed to securely cover four of four large trash bins, contrary to its policy on garbage and rubbish disposal. During a facility tour, one of four large trash bins had an open lid and there was trash on the floor around the dumpster area. During a later tour of the parking lot and driveway area, four large trash dumpsters outside the kitchen were overfilled with bags of trash, preventing the lids from closing, and trash was observed on the ground in the surrounding area. Facility staff, including the Maintenance Supervisor and Infection Control Nurse, stated the lids should be closed and the bins should not be overfilled because trash on the ground or unsecured lids could attract rodents or bugs. The report also documented a dead cockroach on top of Resident 23’s bathroom door during an observation in the resident’s room. Resident 23, who had been admitted with anxiety disorder and major depressive disorder and was documented as having capacity to understand and make decisions, stated, “I don't like them. I don't like bugs.” A CNA confirmed the cockroach was present on the door, and the Housekeeper stated bugs could get in through the bottom of the door because there was no weather strip. The Maintenance Supervisor stated the facility had been made aware of a bug in a resident room and acknowledged it was not acceptable to have bugs or cockroaches inside resident rooms because it was an infection control issue.
Failure to Maintain Resident Privacy During GT Site Care
Penalty
Summary
The facility failed to promote and treat one of one sampled resident with respect, privacy, and dignity in accordance with its Dignity and Respect policy. Resident 5 was admitted on 3/21/2026 and readmitted on [DATE] with diagnoses including dysphagia and GT status. The MDS dated 3/26/2026 indicated the resident had severely impaired cognition and required maximum assistance from staff for oral hygiene, toileting hygiene, showering, upper and lower body dressing, and putting on/taking off footwear. During a concurrent observation and interview on 5/5/2026 at 8:52 am, LVN 2 was observed in Resident 5's room pulling up the resident's gown and assessing the GT site without closing the privacy curtain or the room door. This exposed the resident's abdominal area to the roommate and passersby. LVN 2 stated the privacy curtain and room door needed to be closed prior to providing care and treatment to provide privacy. The DON later stated the resident's privacy curtain and room door needed to be closed prior to providing care and treatment to provide privacy, dignity, and comfort. The facility's Dignity and Respect policy stated residents shall be treated in a manner that maintains the privacy of their bodies and that a closed door or drawn curtain shields the resident from passers-by.
Bathroom Sink Hot Water Not Functioning
Penalty
Summary
The facility failed to ensure the bathroom sink in one resident’s room was repaired when the hot water did not flow freely. The resident was admitted with diagnoses including cervical disc disorder, major depressive disorder, and anxiety disorder, and the H&P indicated the resident had the capacity to understand and make decisions. The MDS showed no impairment to the resident’s upper or lower extremities and that the resident required partial assistance with toileting hygiene and personal hygiene. During interview, the resident stated the bathroom sink never worked properly, that cold water flowed easily but the hot water did not run, and that when the hot-water handle was turned on the water barely trickled out and never got hot. The resident said staff had been told before, but it had never been fixed, and that working hot water would be more comfortable for washing hands. Observations confirmed that cold water flowed freely while hot water only trickled out and remained cold after running for five minutes. The Maintenance Supervisor stated the sink was not working as it should and that hot water should flow freely and begin warming up immediately. The DON stated residents should have working bathroom sinks and access to running hot water in their bathrooms.
Wanderguard Used Without Physician Order
Penalty
Summary
The facility failed to ensure that one sampled resident was free from restraints when Resident 46 was wearing a Wanderguard without a physician's order. Resident 46 was admitted with diagnoses including cerebral infarction, schizophrenia, and dementia. The MDS showed moderately impaired cognition and the resident required varying levels of assistance with hygiene, dressing, toileting, and showering. An elopement assessment identified Resident 46 as at risk for elopement, and the care plan noted the Wanderguard was in place because of that risk. The resident's record included informed consent from the responsible party for Wanderguard use and orders for staff to check placement and monitor skin integrity, but the order summary did not include an order and reason for the Wanderguard itself. During observation, Resident 46 was seen wearing the Wanderguard on the right wrist while ambulating in the hallway and later while resting in bed. CNA3 stated the resident had the Wanderguard on the right wrist and that skin was checked daily for cuts, rashes, or bruises. During interviews and record review, LVN 3 stated there was no active physician's order for the Wanderguard and that the device should not be worn without one. TN2 stated the Wanderguard was considered a restraint because it restricted the resident from going out and prevented leaving the facility, and that it was not acceptable to place it without a physician's order. The IPN and DON also stated that a physician's order was needed for Wanderguard use, along with elopement assessment and consent. The facility policy stated restraints shall only be used upon the written order of a physician and after obtaining consent, while the devices policy stated monitoring devices such as wander guards may be used for residents assessed at risk to promote safety.
Conflicting Diet Orders in Care Plan
Penalty
Summary
The facility failed to revise Resident 64’s care plan so it clearly reflected the correct diet order. Resident 64 was admitted with diagnoses including type 2 diabetes mellitus, cerebral infarction, and hypertensive chronic kidney disease. Her H&P stated she had the capacity to make her needs known, and her MDS indicated she was capable of normal cognition and memory. A nutrition assessment identified her diet order as a fortified diet, and the DON stated that Resident 64’s prescribed diet was a fortified diet. A physician’s order also indicated a fortified diet with regular texture, and the MDSC stated that was the only active diet order for Resident 64. During review of the care plans, one care plan titled, The Resident has Potential Nutritional Problem Related to Fortified Diet, directed staff to serve the fortified diet as ordered. A separate care plan titled, Resident is at Risk of Altered Nutrition/Hydration, last revised earlier, indicated Resident 64 was on a CCHO NAS diet and to serve that diet as ordered. The MDSC stated the care plans were confusing because they contained two different diet orders and that the care plan should be revised to identify the correct diet. The facility policy stated care plans must be reviewed and revised with significant changes in condition and as needed based on resident progress or decline.
Missing Communication Board for Non-English Speaking Resident
Penalty
Summary
The facility failed to ensure that a non-English speaking resident was provided with a communication device in a language the resident understood. Resident 105 was admitted with diagnoses including major depressive disorder, dementia, and anxiety. During observation in the resident’s room, the resident was in bed, smiled when greeted, and did not answer when asked. LVN 1 stated the resident did not speak or understand English and did not have a communication board in the room. LVN 1 also stated that residents whose primary language is not English should have a communication board with pictures and descriptions in their spoken language to help them communicate basic needs and help staff understand their needs. Record review showed Resident 105’s preferred language was Korean and that the resident had severely impaired cognition. The MDS also indicated the resident required assistance with eating, oral hygiene, toileting, showering, upper and lower body dressing, and personal hygiene. The DON stated that non-verbal, alert and oriented residents and non-English speaking residents should have a communication board in the room to express their needs and allow staff to address those needs appropriately. The facility’s Communication Board policy stated it would make reasonable effort to communicate effectively with residents who do not speak or understand English and may use communication boards, translation services, picture boards, and interpreter assistance.
Failure to Provide Ordered Bed Side Rails for Mobility and Repositioning
Penalty
Summary
The facility failed to ensure that Resident 64 was provided bilateral quarter side rails on her bed for mobility and repositioning as ordered. Resident 64’s record showed diagnoses including type 2 diabetes mellitus, cerebral infarction, and hypertensive chronic kidney disease. Her H&P indicated she had the capacity to make her needs known, and her MDS indicated normal cognition and memory, no upper extremity impairment, one-sided lower extremity impairment, and moderate assistance needed for rolling from side to side in bed. Her care plan stated she should remain free of complications, including contractures, and included monitoring for decreases in self-performance of ADLs. During observation, Resident 64 was lying in bed without side rails attached. She stated she was upset that the facility removed the side rails and said she previously used her right arm to grab them to turn her body from side to side, but had not been able to turn herself since they were gone. The physician’s order allowed bilateral quarter side rails to assist with mobility and repositioning, but LVN 3 stated the side rails were not currently attached and the order was not being followed. The DON stated it is important to provide residents with the equipment they need to prevent a decrease in ROM or mobility.
Failure to Address Significant Weight Loss
Penalty
Summary
The facility failed to address a significant weight loss for one resident who lost 6.52% of body weight from 3/20/2026 to 3/29/2026. Resident 65 was admitted on 1/12/2026 and later readmitted with diagnoses including acute respiratory failure with hypoxia and major depressive disorder. The resident’s history and physical dated 3/26/2026 indicated the resident did not have the capacity to understand and make decisions. The MDS dated 4/23/2026 indicated moderately impaired cognition, setup assistance needed for eating, moderate assistance needed for oral hygiene, maximal assistance needed for toileting hygiene, showering/bathing, and personal hygiene, and dependence for bed-to-chair transferring. The weight record showed Resident 65 weighed 98.2 lbs. on 3/20/2026 and 91.8 lbs. on 3/29/2026, with a documented 6.5% weight loss; the resident weighed 91 lbs. as of 5/7/2026. During interviews, RN 1 stated the weight loss should have been documented in the NPP, the physician and responsible party notified, the RD recommendation followed up, the DON and wound care team notified, a care plan developed, and a change of condition assessment completed. Review of the record showed no documentation that the facility addressed the weight loss, no notification to the physician or responsible party, no COC assessment, no IDT conference record, no care plan initiated for the weight loss, and no MDS assessment indicating the significant weight loss. The DON stated the weight change was significant and that the licensed nurse should have completed the COC assessment and MDS significant change assessment, notified the physician and RD, and developed a weight loss care plan.
Missing Hemodialysis Emergency Kit at Bedside
Penalty
Summary
The facility failed to provide a resident on hemodialysis with an emergency kit at the bedside. Resident 2 was admitted with end stage renal disease and dependence on renal dialysis, and the Minimum Data Set indicated moderately impaired cognition and dependence on staff for several activities of daily living. The resident’s order summary directed staff to check the dialysis site for bleeding and signs and symptoms of infection, and to apply a pressure dressing if bleeding occurred. During a concurrent observation and interview, Resident 2 was awake and lying in bed with a hemodialysis access site on the left chest, and the LVN stated the resident did not have an E-kit at bedside. The LVN stated the E-kit needed to be at bedside, accessible and visible for staff to use in case of bleeding from the dialysis access site. The DON also stated residents on hemodialysis needed to have an E-kit at bedside, visible, close, and easily accessible to staff to use to stop and control bleeding from the hemodialysis access site. The facility policy on Hemodialysis Access Care stated that if there is bleeding from the site, gauze and a pressure dressing should be applied and the physician notified.
Failure to Obtain Order and Informed Consent for Bed Rails
Penalty
Summary
The facility failed to implement its Policy and Procedure on the use of bed rails for one sampled resident. Resident 106 was admitted with diagnoses including DM, depression, and PVD. The MDS dated 5/8/2026 indicated the resident had intact cognition and required varying levels of assistance with activities of daily living, including partial/moderate assistance with oral hygiene and upper body dressing, substantial/maximal assistance with toileting, showering, and lower body dressing, and dependence with personal hygiene. During an observation on 5/5/2026, Resident 106 was in bed with one-half bedrails up on both sides of the bed. Resident 106 stated that help was needed with bed mobility and had bilateral above-the-knee amputations. During a concurrent interview and record review, LVN 2 stated there was no physician order and no informed consent from the resident or representative before the bilateral half side rails were installed. The DON also stated that a physician order and informed consent should have been obtained before installation of siderails. The facility's undated Bed Safety and Bed Rails P&P stated that before using bed rails, staff shall inform the resident or representative about the benefits and potential hazards and obtain informed consent, including the assessed medical needs addressed and the resident's risks from bed rail use.
Failure to Complete CNA Skills Competency Upon Hire
Penalty
Summary
The facility failed to conduct skills competencies upon hire for one of five sampled staff, Certified Nurse Assistant 2 (CNA 2). During a concurrent record review and interview on 5/7/2026 at 10:20 am, the Assistant Director of Staff Development reviewed CNA 2's employee file and stated that CNA 2 had been a full-time employee since 1/13/2026 but did not complete a skills competence upon hire. The ADSD stated that skills competency should be completed upon hire and yearly by the Director of Staff Development. During a concurrent record review and interview on 5/7/2026 at 10:25 am, the Director of Nursing reviewed CNA 2's employee file and stated that CNA 2's skills competency upon hire was not completed and validated by the DSD. The DON stated that orientation skill competency should have been completed and validated by the DSD upon hire to ensure employees were competent in providing safe patient care. The facility's undated policy titled Nursing Staff Competency stated that nursing staff members shall complete orientation competency assessment for the appropriate job category, and the DSD or designee must validate all skills for competent performance.
Pharmacist Recommendation for Protonix Not Properly Acted Upon
Penalty
Summary
The facility failed to ensure that the pharmacist’s recommendation regarding Protonix (pantoprazole) 40 mg delayed-release oral tablet was acted upon for one sampled resident. Resident 69 was admitted with diagnoses including protein/caloric malnutrition, chronic kidney disease, and GERD without esophagitis. The resident’s record showed an active order for Protonix 40 mg by mouth daily before breakfast, and the medication regimen review identified that the resident had been receiving the proton pump inhibitor for more than 12 weeks and should be reassessed to determine whether the therapy was still indicated. The pharmacist’s Note to Attending Physician/Prescriber was signed by the provider, but it was undated and the Physician/Prescriber Response section was not checked off. The DON, WCN2, and IPN each stated that the form was not completed because it lacked a date and response, and that nursing staff should have clarified the incomplete recommendation. The facility’s Medication Regimen Review policy stated that irregularities are to be documented and sent to the attending physician, Medical Director, and DON, and that these reports will be acted upon; the Physician Services policy stated that health record progress notes and other appropriate entries are part of physician services.
Medication Errors Involving Crushing of ER Seizure Medication
Penalty
Summary
The facility failed to prevent medication errors when two errors were identified out of 28 observed opportunities, resulting in a medication error rate of 7.14 percent. The errors involved Resident 9, who had diagnoses including epilepsy, chronic obstructive pulmonary disease, and parkinsonism, and whose MDS indicated normal thinking and memory and no difficulty swallowing medications. Resident 9 had physician orders for lamotrigine ER 25 mg and lamotrigine ER 250 mg every 12 hours for epilepsy, to be given together for a total dose of 275 mg. During a concurrent observation, an LVN crushed both lamotrigine ER tablets, mixed each with applesauce, and administered them to Resident 9. The LVN stated she crushed the medications because it was the resident's preference, but later acknowledged there was no order allowing the medications to be crushed and that medications should not be crushed without an order. RN staff, the facility's medication list, the pharmacist consultant, and the PCP all stated lamotrigine ER should not be crushed. The DON also stated that incorrectly crushing lamotrigine ER could cause an increase in seizures.
Crushed ER seizure medication administered without an order
Penalty
Summary
The facility failed to prevent a significant medication error for one of eight sampled residents when lamotrigine ER 25 mg and lamotrigine ER 250 mg were crushed before administration. Resident 9 had diagnoses including epilepsy, COPD, and parkinsonism. The resident’s MDS indicated normal thinking and memory abilities and no difficulty swallowing medications. Physician orders dated 5/5/2026 directed administration of one tablet of lamotrigine ER 25 mg every 12 hours and one tablet of lamotrigine ER 250 mg every 12 hours, with each order noting the tablets were to be given together for a total dose of 275 mg. During a concurrent observation and interview, an LVN crushed both lamotrigine ER tablets into separate medication cups, mixed applesauce into each cup, and administered them to the resident. The LVN stated she crushed the medications because it was the resident’s preference, but later acknowledged there was no order to crush them and that medications should not be crushed without an order. The facility’s medication list identified lamotrigine ER as a medication that should not be crushed, and the facility’s pharmacist consultant, the PCP, and the DON all stated that crushing lamotrigine ER was inappropriate because it defeated the extended-release mechanism.
Incomplete Fall Risk Evaluation and Clinical Record Documentation
Penalty
Summary
The facility failed to maintain clinical records in accordance with accepted professional standards for one sampled resident by not accurately completing the Fall Risk Evaluation upon admission. Resident 5 was admitted and later readmitted with diagnoses including dysphagia and GT status. The admission FRE dated 3/21/2026 identified the resident as low risk for falls due to intermittent confusion and being bedbound, but the assessment was not completed for history of fall, ambulation/elimination status, systolic blood pressure, vision status, predisposing diseases, change in condition in the last 14 days, recent hospitalization history in the last 30 days, six-month hospitalization notes, gait, balance, and medications. The resident’s MDS dated 3/26/2026 indicated severely impaired cognition and that the resident required maximum assistance from staff for oral hygiene, toileting hygiene, showering, upper and lower body dressing, and putting on/taking off footwear. During interview, the DON stated the FRE was not filled out completely and therefore the resident was not properly assessed for fall risk, and that the FRE needed to be completed accurately for staff to implement specific interventions to minimize and prevent falls. The facility’s undated policy on charting and documentation stated the resident’s clinical record is a concise account of treatment, care, response to care, signs, symptoms, and progress, and that the licensed nurse will document a complete physical and mental nursing assessment within the first 24 hours.
Unsecured hallway handrail in North Station
Penalty
Summary
The facility failed to maintain a safe and secure handrail in one hallway at the North Station of the building. During observation on 5/6/26 at 8:14 AM, the handrail in the hallway was not firmly secured to the corridor wall. In an interview later that day, the DON stated the handrail was not secured to the wall and said that if a resident used it, the resident could lose balance and fall. The DON also stated the handrail should be secured to keep residents safe and prevent harm, and identified the MS as responsible for maintaining the facility in good condition and safe for residents. On 5/7/26, the MS observed the same hallway handrail and stated it was not sturdy for patients to use, was not fixed securely to the wall, and that three of the mounts attaching the rail to the wall were broken and should have been replaced. The MS stated he was responsible for ensuring all facility handrails were safe and sturdy for residents to use. During an interview on 5/8/26, the IPN stated handrails should be sturdy and secured to the wall and described the unsecured handrail as a safety issue for residents. The facility's undated Maintenance Department, Physical Environment, and Homelike Environment policies were reviewed and included maintaining a clean and safe facility, providing a safe and functional environment, and equipping corridors with firmly secured handrails on each side.
Pest observed in shared resident room
Penalty
Summary
The facility failed to ensure a residents' shared room was free from pests when a bug was found in the bathroom door frame of Resident 23 and Resident 64's room. Resident 23's record showed diagnoses including cervical disc disorder, major depressive disorder, and anxiety disorder, and her H&P stated she had the capacity to understand and make decisions. Resident 64's record showed diagnoses including type 2 diabetes mellitus, cerebral infarction, and hypertensive chronic kidney disease, and her H&P stated she had the capacity to make her needs known; her MDS indicated she was capable of normal cognition and memory. During a concurrent observation and interview, a brown bug about three inches long was seen crushed in the bathroom door frame. Resident 23 stated she had crushed the bug the night before after using the bathroom and said it was one of many bugs she had seen in the facility, adding that seeing bugs in her room made her feel grossed out and scared. Resident 64 stated she saw bugs in their room all the time and described them as dirty. CNA 2 stated the bug should not be in the room and identified it as a safety and infection risk. HSK 1 stated it looked like a cockroach and said bugs sometimes came into rooms from outside the facility. The MS stated water bugs sometimes came out after rain and that pests should not be in residents' bathrooms because they are dirty and can bring in germs. The DON and IPN both stated bugs should not be in the facility or residents' rooms, and the facility's Pest Control policy stated the environment must be kept free from insects, rodents, and other pests.
Incomplete ADL and Meal Assistance Documentation for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete medical record for one resident when documentation of assistance with eating and oral hygiene was missing for specified shifts. The resident, who had diagnoses including primary arthritis, dementia, and gastro-esophageal reflux disease, was severely cognitively impaired and dependent or requiring substantial/maximal assistance for multiple ADLs, including eating and oral hygiene, per the 2/28/2026 MDS. The resident’s orders included a regular diet, minced and moist, with RNA assistance for feeding at all meals. The care plan documented swallowing problems and required staff to check the resident’s mouth after meals for pocketed food and debris, report findings to the nurse, and provide oral care to remove debris. Another care plan for ADL self-care deficits indicated the resident required staff assistance to eat, had their own teeth, and required oral inspection every shift for oral care. Record review of the Documentation Survey Report for ADLs in February 2026 showed no entries for eating and oral hygiene on the evening shift of 2/2/2026 and the night shift of 2/3/2026. Further review of the medical record found no RNA or CNA documentation that the resident was assisted with dinner and provided oral hygiene on the 2/2/2026 evening shift, or that oral hygiene was provided on the 2/3/2026 night shift. During interviews, a CNA and an LVN stated that staff who assisted the resident with eating were required to document assistance with eating and oral hygiene on the ADL charting every shift or every time care was provided, including meal consumption percentages and related details. In a concurrent interview and record review, the DON confirmed that the ADL documentation for eating and oral hygiene was incomplete for the identified shifts and stated that accurate completion of documentation was important to verify the resident’s health condition and reflect the care provided. The facility’s policy on assisting residents with in-room meals required detailed documentation of meal assistance, including date and time, staff identity, amount consumed, resident participation, special requests, difficulties with feeding, chewing or swallowing, refusals, and interventions, which was not present for the resident on the cited shifts.
Failure to Maintain Infection Control in Shower Area and Bedside Urinal Management
Penalty
Summary
The deficiency involves the facility’s failure to follow infection prevention and control practices related to a clogged shower drain and the handling of bedside urinals. Two residents, one with anorexia nervosa, schizophrenia, and anxiety disorder and another with cellulitis of both legs, lack of coordination, and hypertension, required staff assistance with bathing and toileting. One resident reported taking a shower in the shower room next to the dining room while seated in a shower chair, during which the water did not drain and formed a puddle that the assisting CNA stood in. Another resident, observed in the same shower room on a different day, stated they had to stand in pooled water over a clogged drain during showers and expressed feeling disgusted and concerned about infection. On observation with the Maintenance Director, there was a pool of water over the shower drain, and the Maintenance Director confirmed the drain was clogged. The facility also failed to properly manage and empty bedside urinals for one resident. During observation in the resident’s room, three urinals full of urine were hanging on the foot of the bed, and the resident stated staff had not emptied the urinals all day and that this occurred frequently. The CNA assigned to the resident that shift acknowledged not having emptied the urinals and stated their practice was not to enter the resident’s room when the resident was present unless the call light was activated. The Infection Preventionist stated staff were expected to round on residents every two hours and that the resident’s urinals should be emptied at least every two hours, noting that failure to empty them could result in urine being spilled on the resident or floor. Facility policies indicated that bathrooms, including showers, were to be cleaned and disinfected daily and that if a resident preferred to keep a urinal at bedside, it should be checked frequently and emptied and cleaned as necessary.
Nonfunctional and Inaccessible Call Systems in Shower Areas
Penalty
Summary
The deficiency involves the facility’s failure to ensure that resident-accessible call systems were functional and appropriately configured in shower and bathing areas. During observation of a resident in the shower room next to the dining room, the call light did not activate when the pull cord was used. The resident reported taking showers independently in that shower room and stated that if he fell to the ground, he would be unable to call for help because the call light did not work. Review of this resident’s assessment records showed admission and readmission with diagnoses including cellulitis of both legs, lack of coordination, and hypertension, and a Minimum Data Set (MDS) indicating moderate cognitive impairment. The MDS further documented that the resident required substantial/maximal assistance for bathing, lower body dressing, and toileting hygiene, and partial/moderate assistance for oral hygiene and upper body dressing. On a separate observation in the shower room across from the South Nurses’ Station, the call light pull cord did not extend to the floor. The Maintenance Director confirmed in both shower rooms that the call light in one did not activate when pulled and that the pull cord in the other was too short to reach the ground, acknowledging that the call light needed to function and be reachable in case a resident fell and needed assistance. In an interview, the DON stated that the facility did not have a policy and procedure regarding the call light system. These observations, interviews, and record reviews demonstrated that the facility was not adequately equipped to allow residents in general to call for staff assistance in bathroom and bathing areas.
Clogged Shower Drain and Unemptied Urinals Compromise Infection Control
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, and sanitary environment and to follow infection control practices for two residents using a shower room and for one resident’s bedside urinals. One resident, admitted with anorexia nervosa, schizophrenia, and anxiety disorder and assessed as needing substantial/maximal assistance with bathing and toileting hygiene, reported taking a shower in the shower room next to the dining room while seated in a shower chair when the water was not draining, resulting in a puddle of water that the resident described as disgusting. The resident stated that the CNA assisting with the shower was also standing in the puddle of water. Another resident, admitted with cellulitis of both legs, lack of coordination, and hypertension and assessed as moderately cognitively impaired and needing substantial/maximal assistance with bathing and toileting hygiene, was observed in the same shower room standing in a pool of water over the shower drain and stated having to stand in the pooled water during showers, feeling disgusted and dirty because the drain was clogged. During a concurrent observation and interview with the Maintenance Director in the shower room next to the dining room, there was a visible pool of water over the shower drain, and the Maintenance Director confirmed the shower drain was clogged. In addition, staff failed to empty three full urinals that were hanging on the foot of the first resident’s bed. The facility’s policy titled “Quality of Life - Homelike Environment” indicated residents are to be provided with a safe, clean, comfortable, and homelike environment, including a clean, sanitary, and orderly environment. The observed clogged shower drain with standing water and the unemptied, full urinals at the bedside were inconsistent with this policy and represented failures in maintaining infection control and environmental cleanliness.
Failure to Administer Ordered Topical Medication and Notify Provider
Penalty
Summary
The facility failed to administer a physician-ordered topical medication as prescribed for one resident. The resident was admitted with diagnoses including anorexia nervosa, schizophrenia, and anxiety disorder, and had no cognitive impairment per the MDS dated 2/6/2026. The MDS also documented that the resident required varying levels of staff assistance with ADLs such as footwear, bathing, toileting hygiene, oral hygiene, and lower body dressing. The Order Summary Report dated 3/27/2026 showed a physician order, dated 3/3/2026, for Clotrimazole 1% external solution to be applied to the resident’s face every day shift for eczema. In an interview, the resident reported having an order for a topical solution for itching and eczema and stated that staff did not provide the medication for 5 days beginning on 3/11/2026. Review of the March 2026 Treatment Administration Record revealed that staff did not apply the ordered Clotrimazole solution on 3/13/2026 and 3/15/2026. Progress notes indicated the medication was not given on 3/13/2026 because it was not on hand. The treatment nurse confirmed not administering the Clotrimazole on 3/13/2026 due to the medication being unavailable, and further stated that they did not contact the pharmacy to determine why the medication was not available and did not notify the resident’s physician that the ordered medication was not given. In an interview, the DON stated that when a resident’s medication is not available, the nurse is expected to follow up with the pharmacy and notify the prescriber, and also stated that the facility did not have a policy and procedure for medication administration.
Staff Failure to Wear Required Identification Badges
Penalty
Summary
The facility failed to ensure staff complied with state regulations and its own policy requiring employees to wear identification name badges at all times while on duty. Surveyors observed multiple staff members either not wearing ID badges or wearing them improperly. One LVN had an ID badge clipped to a pants pocket below the waist and stated this was their usual practice. A care coordinator working with a resident in the lobby to sign documents was not wearing an ID badge and stated they did not have it with them. The hairdresser was observed going from room to room without an ID badge and stated they did not have one. A treatment nurse, identified as a newly hired staff member, was not wearing an ID badge and stated they had not yet been given one. Another LVN at the nurses’ station was not wearing an ID badge and stated they had forgotten to put it on after returning from lunch. Resident records showed that one resident admitted with anorexia nervosa, schizophrenia, and anxiety disorder had no cognitive impairment and required varying levels of assistance with ADLs such as bathing, toileting hygiene, oral hygiene, and dressing. Another resident, admitted with a right arm fracture, type 2 diabetes mellitus, and lack of coordination, had moderately impaired cognitive skills and required substantial to partial assistance with ADLs including bathing, dressing, toileting hygiene, and oral hygiene. During an interview, the cognitively intact resident stated that multiple staff did not wear ID badges while working and expressed a need for staff to wear badges so the resident would know who was providing their care. Review of the facility’s “Identification Name Badges” policy indicated that each employee must wear an identification name badge at all times while on duty, and state regulation (California Code of Regulations, Title 22, Section 72501(h)) requires all employees serving patients or the public to wear name and title badges unless contraindicated.
Failure to Maintain Required Hot Food Temperatures During Meal Service
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to maintain hot foods at or above 140°F during meal service, as required by facility policy for time/temperature control for safety (TCS) foods. During a test tray observation conducted with the Dietary Supervisor (DS) at 12:25 PM, food temperatures were recorded as pasta at 105°F, turkey and sauce at 105°F, and green beans at 120°F. A repeat test tray observation at 12:35 PM, again in the presence of the DS, showed that the temperatures remained below required levels, with pasta at 105°F, turkey at 105°F, and green beans at 110°F. In a concurrent interview, the DS reported that the facility had been experiencing issues with a malfunctioning plate warmer, which the DS believed may have contributed to food being served at inadequate temperatures, particularly during the morning meal service. The DS also stated that if residents request reheating, staff reheat food for approximately 15 seconds to reach about 160°F, not exceeding that temperature. Review of the facility’s policy and procedure on cooling and reheating of potentially hazardous or TCS food during meal service confirmed that hot foods are to be maintained at temperatures greater than 140°F during meal service. This deficient practice was documented as having the potential to result in rapid growth of bacteria that can cause foodborne illness and can lead to insufficient meal intake and weight loss due to cold or improperly heated food.
Failure to Provide Ordered 1:1 Supervision and Continuous Observation for Two High-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders and care plan interventions for 1:1 supervision and continuous observation for two residents, resulting in both residents being left unattended at various times. Resident 1 was admitted with hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, and contractures of the right upper arm and right knee. Assessment documents showed Resident 1 required substantial/maximal assistance with most ADLs and had a high fall risk score of 19 on the facility’s fall risk evaluation, with a care plan identifying risk for falls related to confusion and a history of attempting to get out of bed unassisted. The care plan and physician orders required 1:1 supervision, maintenance of 1:1 observation at all times, and that Resident 1 not be left unattended. Resident 2 was admitted with dementia, Alzheimer’s disease, and an anxiety disorder, and had moderately impaired cognition. The MDS indicated Resident 2 required supervision or touching assistance for toileting, bathing, dressing, footwear, and personal hygiene. Physician orders and care plans dated 1/30/26 documented 1:1 supervision for Resident 2 due to episodes of aggression toward staff, exit-seeking behavior, unprovoked agitation, crying, and aggression, with interventions specifying that a 1:1 sitter be placed with the resident for safety, that the resident not be left unattended, that a reliever be requested before the sitter went on break, and that 1:1 observation be maintained at all times. Despite these orders and care plan directives, the facility’s sitter schedule for the night shift on 2/1/26 showed a single sitter (S1) assigned simultaneously to both residents. Observations and staff interviews confirmed that the 1:1 supervision orders were not implemented as written. During an early morning observation in Resident 1’s room, S1 was present with Resident 1, whose bed was positioned against a wall with a Geri chair wedged tightly against the bed frame on the other side, creating a physical barrier. S1 reported having permission from the DON to place the Geri chair next to the bed. LVN 1 stated that S1 was assigned as a 1:1 sitter for both residents and had to go back and forth between their rooms every 15–20 minutes, even though a 1:1 order meant one sitter should be dedicated to one resident for the entire shift. LVN 1, CNA 1, CNA 2, the RN supervisor, the DON, and the Administrator all acknowledged that each resident with a 1:1 order should have continuous supervision, should not be left alone, and that another staff member should cover when the sitter left the room. Direct observation showed S1 leaving Resident 1 alone to walk down the hallway and around a corner to briefly check on Resident 2, then leaving Resident 2 alone to return to Resident 1, while S1 also described Resident 2 as unpredictable, with a history of hitting other residents and staff and throwing objects. These observations and interviews demonstrated that both residents, each with a physician’s order and care plan for continuous 1:1 supervision and not to be left unattended, were in fact left alone at times, and that one sitter was inappropriately assigned to cover both residents.
Improper Use of Geri Chair as Bedside Restraint Without Physician Order
Penalty
Summary
Surveyors identified that a resident was not kept free from physical restraints when the resident’s bed was positioned against a wall on one side and a Geri chair was wedged tightly against the bed frame on the other side, creating a physical barrier that restricted the resident’s ability to get out of bed. The resident had been admitted with hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, as well as contractures of the right upper arm and right knee. The resident’s history and physical documented that the resident had the capacity to understand and make decisions. The Minimum Data Set showed the resident required substantial/maximal assistance for multiple ADLs, and a fall risk evaluation identified the resident as high risk for falls. The care plan documented the resident was at risk for falls related to confusion and a history of attempting to get out of bed unassisted, with interventions including 1:1 supervision and maintaining constant observation without leaving the resident unattended. During an early-morning observation in the resident’s room, the bed was seen placed against the wall on the left side and the Geri chair was placed directly against the right side of the bed, wedged against the bed frame. The resident was lying in the center of the bed in a fetal position, wrapped in a blanket from head to toe. Interview with the sitter assigned to the resident revealed that the DON had given permission to place the Geri chair next to the bed. An LVN confirmed awareness that the Geri chair was placed against the bed and stated it was being used as a restraint to prevent the resident from rising from the bed because the resident tended to “wiggle out” of bed. The LVN reported that the Geri chair had been in that position since the day shift two days earlier and that both the Administrator and the DON were aware of its use in this manner. Record review showed there was no physician’s order for the use of a Geri chair for this resident, despite its use as a device that restricted the resident’s movement and access to getting out of bed. The facility’s policies on restraint use stated that restraints were to be used only to treat medical symptoms and never for discipline, staff convenience, or fall prevention, and policies on safety and supervision emphasized maintaining an environment free from accident hazards and promoting resident dignity and well-being. In interviews, the RN supervisor, DON, and Administrator each acknowledged that placing the Geri chair against the bed in this way constituted a restraint, could result in entrapment, and was not acceptable, and that other alternatives should have been used instead of using the Geri chair as a restraint for this resident.
Failure to Prevent Resident-to-Resident Physical Abuse Despite Known Aggressive History
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident in accordance with its Abuse Prevention/Prohibition and Resident Rights policies. One resident (Resident 3) had a history of aggressive behavior, including an SBAR on 8/8/2025 documenting attempts to hit others in the hallway and a transfer to a general acute care hospital on 8/11/2025 for aggressive behavior, shouting, screaming, and attempting to hit others. Resident 3’s MDS dated 11/3/2025 showed severely impaired cognition and a need for partial/moderate assistance with ADLs and mobility. After a psychiatric hospitalization and readmission on 9/23/2025, the facility initiated a care plan for aggressive behavior, but the DON later acknowledged that the interventions in this care plan were vague, not individualized, and not behavior-specific, despite Resident 3’s known history of aggression. Resident 4 was admitted on 12/5/2025 with diagnoses including pneumonia and anxiety disorder, with an MDS indicating moderately impaired cognition and a need for substantial/maximal assistance with ADLs and mobility. On 1/19/2026, an SBAR documented that Resident 4 was sitting by the time clock on the North Station when Resident 3 hit Resident 4 on the back of the head. Resident 4 reported head pain rated 7/10 and was transferred to a general acute care hospital for further evaluation and treatment. In an interview, Resident 4 stated they were seated in the lobby watching the clock when Resident 3 approached in a wheelchair; Resident 4 attempted to move out of the way but was struck in the back of the head before they could reposition, describing the contact as sudden and unexpected and reporting emotional distress and feeling shaken by the incident. In interviews, Resident 3 demonstrated a fist motion as if punching Resident 4 and stated being angry because Resident 4 was blocking the way, though did not verbally admit to striking the other resident. RN 2 reported being at the North Nursing Station, hearing someone yell, “Ow, he hit me,” and immediately separating the two residents; RN 2 did not witness the actual strike but saw Resident 3 making a fist-like motion. RN 2 stated that when a resident has a known history of aggressive behavior, the care plan must be individualized and include specific, measurable interventions such as defined supervision levels, identification of triggers, early intervention strategies, de-escalation techniques, environmental modifications, redirection methods, staff approach guidelines, and escalation criteria, and that vague, generalized interventions without behavior-specific guidance leave staff without clear direction to prevent escalation. The DON similarly stated that without detailed individualized interventions for a resident with a known history of aggressive behavior, staff lack clear direction to proactively prevent escalation, increasing the risk for resident-to-resident altercations, even when aggressive behaviors have been dormant for months. The facility’s policies defined abuse as the willful infliction of injury resulting in physical harm, pain, or mental anguish and guaranteed residents the right to be free from abuse and neglect.
Failure to Timely Implement Individualized Care Plan for Aggressive Behaviors
Penalty
Summary
The deficiency involves the facility’s failure to timely develop and implement a comprehensive, individualized, person-centered care plan to address a resident’s known aggressive behaviors. The resident was admitted with diagnoses including paranoid schizophrenia and diabetes mellitus, and had documented episodes of aggression. On one occasion, an SBAR Communication Form recorded that the resident was in the hallway attempting to hit others. A subsequent Skilled Nursing Facility to Hospital Transfer Form documented that the resident was transferred to a general acute care hospital for aggressive behavior, shouting, screaming, and attempting to hit others. Following a 5150 psychiatric hold for being physically aggressive to staff, the resident was readmitted, and a care plan addressing aggressive behavior was initiated on 9/26/2025. However, this care plan was not individualized or resident-specific. It lacked documented monitoring parameters, did not identify behavioral triggers, and did not provide staff guidance on how to approach, redirect, and manage the resident’s aggressive behaviors. Although the care plan problem was opened on 9/26/2025, the specific interventions were not added or implemented until 11/5/2025, resulting in a significant delay in putting any concrete strategies into practice. The resident’s MDS dated 11/3/2025 indicated severely impaired cognition and a need for partial/moderate assistance with ADLs and mobility, underscoring the need for clear, structured behavioral interventions. During interviews, an RN and the DON both acknowledged that the care plan did not reflect a comprehensive, individualized, person-centered approach and was missing resident-specific guidance related to monitoring, triggers, and staff direction for managing aggressive behaviors. The facility’s own policy on comprehensive, person-centered care plans requires measurable objectives, timeframes, and services derived from thorough assessment and ongoing review, including after hospital readmission, which was not followed in this case.
Failure to Post Current Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that current nurse staffing information was posted daily in a prominent location accessible to residents, staff, and visitors, as required by its policy. On 1/2/26 at 12:08 PM, surveyors observed a posting titled "Census and Direct Service Hours Per Patient Day" in front of Nursing Station 1 near the entrance lobby with a date of 12/31/25, indicating the information was not current. During an interview at 12:10 PM, the DON acknowledged the posting was not current and explained that the Director of Staff Development had resigned and the staff member responsible for posting the staffing information did not come to work due to personal circumstances. At 1:00 PM the same day, CNA 1 stated that CNA 1 had been responsible for creating the posting by entering licensed nurse and CNA hours into a computer program that generated the daily nursing hours for posting, and that a personal circumstance had prevented CNA 1 from reporting on time to print and post the information. On 1/5/26 at 8:50 AM, surveyors again observed the same type of staffing posting in front of Nursing Station 1 near the entrance lobby, now dated 1/2/26, showing that the information still had not been updated daily. In a concurrent observation and interview at 9:10 AM, the DON stated that the posting needed to be updated every day. At 10:00 AM, CNA 1 reported that projected nursing hours for posting had been prepared and placed in a bin in front of the staffing office, and that nurses working the weekend were expected to retrieve these projected hours and post the staffing information near the two nursing stations. CNA 1 stated that the nursing hours needed to be posted so staff, residents, and families would have staffing information. Review of the facility’s July 2016 policy "Posting Direct Care Daily Staffing Numbers" confirmed that within two hours of the beginning of each shift, the numbers of licensed nurses and unlicensed nursing personnel directly responsible for resident care must be posted in a prominent, accessible, clear, and readable format, which was not done as observed on multiple days.
Failure to Update Care Plan for Resident with Hoarding Behavior
Penalty
Summary
The facility failed to reevaluate and update the care plan interventions for a resident exhibiting hoarding behavior, despite ongoing issues with clutter and refusal of assistance. The resident, who had diagnoses including bilateral primary osteoarthritis of the knee, COPD, anxiety disorder, and personality disorder, was observed to have intact cognition and the capacity to make medical decisions. The resident required setup or clean-up assistance with several activities of daily living. Observations revealed significant clutter in the resident's room, including boxes, clothing, personal items, and food scattered around the bed, with the call light cord not within reach. Interviews and record reviews indicated that the Social Services Director had discussed the hazards of the clutter with the resident in early September, but there were no further documented interventions or encouragement to address the issue in the following months. Nursing notes showed that the resident refused deep cleaning and continued to decline assistance, despite being educated on proper cleaning and hygiene. The care plan for hoarding, initiated in late July and last revised in early August, included interventions such as encouraging the resident to organize belongings, offering to clean and organize, explaining risks, and assisting with expired food, but these interventions were not updated or revised after the resident's continued refusal and persistent clutter. The facility's policy required ongoing assessment and revision of care plans when desired outcomes were not met or when there was a significant change in the resident's condition. However, the care plan for this resident was not reevaluated or updated in response to the lack of progress and continued safety hazards, resulting in a deficiency related to the failure to maintain a safe and clean environment for the resident.
Failure to Maintain Resident Room Free of Accident Hazards Due to Excessive Clutter
Penalty
Summary
A deficiency was identified when a resident's room was observed to be excessively cluttered, with multiple boxes, clothing, bags, food, drinks, and personal grooming items scattered around the bed and on the floor. The call light cord was found on the floor and not within the resident's reach. These conditions were noted during an observation and interview, where the resident stated that the facility would not assist with moving boxes to storage or provide additional boxes for organizing belongings. The resident had a history of bilateral primary osteoarthritis of the knees, COPD, anxiety disorder, and personality disorder, but was assessed as having intact cognition and the capacity to make medical decisions. The Minimum Data Set indicated the resident required setup or clean-up assistance with several activities of daily living. Despite this, the room remained cluttered, and the resident had refused deep cleaning services, as documented in housekeeping and nursing progress notes. Social services had previously discussed the hazards of the clutter with the resident, but there were no further documented interventions or encouragement to address the issue in the following months. The resident's care plan included goals to maintain a safe and clean living area and interventions such as encouraging the resident to organize belongings and offering staff assistance with cleaning. However, the care plan interventions were not effectively implemented, as the clutter persisted and the environment remained hazardous. Facility policies required a safe, clean, and homelike environment, but these standards were not met in this instance.
Expired Water Filter on Icemaker and Inadequate Maintenance Documentation
Penalty
Summary
The facility failed to maintain safe and sanitary practices for ice and water handling by not replacing an expired water filter connected to the icemaker in the kitchen. During an observation, the expired filter was noted, and the Dietary Manager (DM), who was new to the position, was unsure of the replacement schedule for the filter. A log sheet attached to the icemaker was reviewed, but it only indicated the month of December without specifying the year, making it unclear when the last replacement occurred. The manufacturer's specifications for the water filter recommend replacing the cartridge at least once per year or when the flow rate becomes inconveniently slow. A review of the facility's policy and procedure for maintenance service indicated that the Maintenance Department is responsible for ensuring all equipment, including the icemaker, is maintained in a safe and operable manner according to manufacturer recommendations. The policy also assigns the Maintenance Director the responsibility of developing and maintaining a maintenance schedule. However, the observation and interviews revealed that these procedures were not followed, resulting in the use of an expired water filter and a lack of clear documentation regarding maintenance activities.
Failure to Develop and Implement Care Plan for Assistive Device Use
Penalty
Summary
The facility failed to develop and implement a care plan addressing the use of a rollator walker for a resident with end-stage renal disease on hemodialysis and diabetes mellitus type 2. Despite the resident being at risk for falls due to gait and balance problems, psychoactive drug use, and weakness, there was no individualized care plan in place for the safe use of the rollator walker. The resident's care plan only generally addressed fall risk but did not include specific interventions or measurable objectives related to the assistive device, as required by facility policy. On the day of the incident, the resident attempted to get up from the rollator walker on the outside patio, lost balance, and fell, resulting in an acute humeral neck fracture that required hospitalization. Documentation revealed that the physical therapy department had discharged the resident from services without completing an assessment or evaluation for rollator walker use, and there was no communication of recommendations to the nursing staff. The lack of a care plan and communication between therapy and nursing staff contributed to the resident's fall and injury. Interviews with the DON and occupational therapist confirmed that there was no care plan for the use of the rollator walker and that nurses were not made aware of the resident's needs regarding the device. Facility policies required comprehensive, person-centered care plans and documentation of assistive device use based on assessment, but these were not followed. The deficiency was further compounded by the absence of interdisciplinary communication and failure to adhere to established policies and procedures.
Failure to Provide Adequate Supervision Resulting in Resident Elopement
Penalty
Summary
A deficiency occurred when a resident exited the facility without staff knowledge or supervision. The resident had a history of elopement at home, wandering behavior, and an elopement risk score of 6.0 upon admission. The resident was admitted with diagnoses including seizures and depression, and had fluctuating capacity to make medical decisions. The Minimum Data Set assessment indicated the resident was cognitively intact and required limited assistance for activities of daily living. Despite these risk factors, the resident was last observed in bed early in the morning, and staff were unable to locate the resident during subsequent checks, prompting a facility-wide search. Interviews with staff revealed that the resident was ambulatory and frequently walked around the facility. The Director of Nursing stated that the elopement was unexpected, as the resident had not previously shown signs of wanting to leave. The facility's policy on safety and supervision emphasized the importance of targeting interventions to reduce individual risks and providing adequate supervision. However, the lack of effective supervision allowed the resident to leave the premises unnoticed, constituting a failure to prevent accidents as required by facility policy.
Failure to Promptly Respond to Call Lights and Toileting Requests
Penalty
Summary
Facility staff failed to promptly respond to call lights and requests for toileting assistance for three of five sampled residents, as required by the facility's policy on dignity. One resident with severe cognitive impairment and significant assistance needs for toileting and hygiene was reported by a family member to experience long delays in staff response, often requiring the family member to seek help directly from the nurses' station. Another resident, who was incontinent and at risk for skin breakdown, reported waiting up to 30 minutes or more for assistance after activating the call light, including a specific incident where the resident waited a total of three hours to be changed after an incontinent episode. This resident described feeling ignored and demeaned by the delays. Observations confirmed that call lights remained on for extended periods before staff responded. In one instance, a resident waited 30 minutes for help with a soiled brief, and in another, a resident waited for assistance after an episode of incontinence, with staff not returning as promised. Interviews with residents revealed that these delays were not isolated incidents, with reports of waiting hours for assistance, particularly during nighttime hours. Residents expressed feelings of frustration and a lack of dignity due to these prolonged waits. Staff interviews corroborated that residents should not have to wait long for assistance, especially when in need of changing soiled briefs. The Director of Nursing stated that residents should not wait longer than five minutes for such assistance to maintain their dignity, as outlined in the facility's policy. The policy specifically prohibits practices that compromise dignity and requires prompt response to toileting requests, which was not consistently followed in these cases.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that informed consent was properly obtained for psychotropic medications prescribed to a resident with severe cognitive impairment. The resident, who had diagnoses including dementia, anxiety disorder, and hypertension, was readmitted to the facility with orders for multiple psychotropic medications. Documentation indicated that the resident was severely impaired in cognitive skills and required substantial assistance with daily activities. Upon review, it was found that the facility continued the psychotropic medication regimen initiated during a recent hospital stay without verifying or obtaining new informed consent from the resident's representative. Interviews with the resident's daughter revealed that medication changes, specifically an increase in depression medication dosage, were made without her notification. The Social Service Director and MDS Nurse confirmed that the medication changes occurred during the resident's hospital stay and were continued upon readmission to the facility. However, there was uncertainty about whether proper notification or consent had been obtained for these changes. The facility's records included informed consent forms for the psychotropic medications, but the psychiatric nurse practitioner stated that they did not actually obtain consent from the resident's representative as indicated on the forms. The facility's policy required verification of prior informed consent for psychoactive medications upon admission or readmission, and if such documentation was not present, the admitting physician was responsible for obtaining consent. In this case, there was no verified documentation from the discharging hospital, and the admitting provider did not obtain informed consent from the resident's representative. This resulted in the resident receiving psychotropic medications without the required informed consent process being completed.
Physical Abuse of Resident by Registered Nurse
Penalty
Summary
A deficiency occurred when a registered nurse (RN) engaged in physical abuse against a resident with severe cognitive impairment and multiple psychiatric diagnoses, including intellectual disability, schizoaffective disorder, and anxiety disorder. The resident, who required substantial assistance with daily activities and had a history of verbal aggression but not physical aggression, was subjected to an incident where the RN threw a cup of juice in the resident's face and chest. This action was in response to the resident having thrown juice at the RN and a certified nursing assistant (CNA) during a period of agitation. The RN later admitted to 'mirroring' the resident's behavior by intentionally throwing juice back at the resident, believing it might discourage future incidents, despite recognizing afterward that this was not permitted. Observations and interviews confirmed that the resident was left visibly distressed, crying intermittently and unable to articulate their feelings following the incident. The care plan for the resident included interventions for staff to use calm approaches, provide cues, and allow the resident time to adjust when agitated, but these were not followed during the event. Staff interviews indicated that the resident's aggressive behaviors were typically managed through verbal de-escalation, medication, or giving the resident time alone, and that the resident was not considered a physical threat. The facility's policies on abuse prevention and resident rights explicitly prohibit willful infliction of injury or punishment and require staff to treat residents with kindness, respect, and dignity. Despite these policies and staff education on abuse, the RN's actions constituted physical abuse, as confirmed by both facility leadership and the abuse coordinator. The incident was reported internally after another RN received a text message confession from the involved RN, which was then escalated to the administrator.
Failure to Timely Report Physical Abuse Incident
Penalty
Summary
The facility failed to report an incident of physical abuse involving a resident with severe cognitive impairment and multiple psychiatric diagnoses within the required two-hour timeframe to the California Department of Public Health. The resident, who had a history of behavioral issues and required significant assistance with daily activities, was involved in an altercation where a registered nurse (RN) threw juice at the resident after the resident had thrown juice at the nurse. This incident was witnessed by a certified nursing assistant (CNA), who did not report the event as required due to being occupied with other duties. The facility's policies and procedures, as well as staff interviews, confirmed that all staff are mandated reporters and are required to report any suspected abuse, neglect, or mistreatment immediately, and no later than two hours after the incident. Despite this, the CNA failed to report the incident to the Abuse Coordinator or Administrator. The RN involved in the incident later sent a text message to another RN describing the event, but this message was not seen until the following day, further delaying the reporting process. Record reviews and staff interviews indicated that the facility's abuse prevention and reporting policies were not followed in this case. The delay in reporting the incident resulted in a violation of the resident's rights and had the potential to delay the investigation of abuse and expose the resident to further harm. The deficiency was identified through interviews, record reviews, and examination of facility policies.
Failure to Maintain Resident Dignity During Care and Meals
Penalty
Summary
The facility failed to treat two residents with dignity during daily care activities. For one resident with severe cognitive impairment and multiple diagnoses, an Activity Assistant referred to the individual as a "feeder" while the resident was seated in the dining room. This terminology was used in the presence of the resident and was confirmed during an interview with the staff member. The resident's records indicated a high level of dependence on staff for daily activities, including eating and personal hygiene. In a separate incident, another resident with Huntington's disease, dysphagia, and moderate cognitive impairment was assisted with eating by a staff member who stood over the resident at the bedside. The resident later stated that being assisted at eye level would have maintained their dignity. The staff member involved acknowledged standing while assisting and confirmed awareness that sitting at the same level is the appropriate practice. Facility policies reviewed indicated that residents should be treated with dignity and respect, specifically noting that staff should not stand over residents while assisting with meals and should avoid using labels such as "feeder."
Failure to Provide Adequate Supervision and Post-Fall Review
Penalty
Summary
The facility failed to maintain an environment free from accident hazards and did not provide adequate supervision for three residents. One resident, who was severely cognitively impaired and required a 1:1 sitter due to aggressive behaviors and a history of losing balance, was left unsupervised on the patio while the assigned sitter was inside the facility using a personal phone for four minutes. The sitter acknowledged being distracted by personal emails and not observing the resident as required by facility policy, which prohibits personal phone use during supervision duties. Additionally, two other residents with significant cognitive impairments and histories of falls experienced multiple unwitnessed and witnessed falls. Despite these incidents, the facility did not conduct required interdisciplinary team (IDT) meetings after each fall, as outlined in their policies. Record reviews confirmed that no post-fall IDT meetings were held for these residents following their falls in July and August, even though the facility's procedures mandate such reviews within 24 hours to analyze causes and update care plans. The lack of supervision and failure to follow post-fall protocols were confirmed through staff interviews, record reviews, and direct observation. The Director of Nursing and other staff acknowledged that the facility's policies require constant supervision for high-risk residents and timely IDT meetings after falls, but these procedures were not followed for the residents in question.
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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 Glendora
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Glendora Canyon Transitional Care Unit | 0.7 mi | ★★★★★ | 28 | 0 |
| Gladstone Sub-acute And Rehab Center | 0.9 mi | ★★★★★ | 5 | 0 |
| Arbor Glen Care Center | 1.5 mi | ★★★★★ | 27 | 0 |
| Glendora Grand, Inc | 1.9 mi | ★★★★★ | 3 | 0 |
| Emanate Health Inter-community Hospital- D/p Snf | 3.1 mi | ★★★★★ | 0 | 0 |
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