Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Monrovia Gardens Healthcare Center during CMS and state inspections, most recent first.
A resident with a history of stroke-related hemiplegia, hemiparesis, and DM experienced substantial unplanned weight loss over several months, dropping from 225 lbs to 178 lbs. Although an initial care plan for a 24-lb weight loss in one month was created with interventions to monitor weight loss and contact the physician and RD if decline persisted, the plan was not updated when the resident continued to lose an additional 19 lbs over a later period, and no care plan documented an intentional 47-lb loss. The resident, cognitively intact but dependent for ADLs, frequently ordered outside food, reported disliking facility meals, and was described by the RD as non-compliant with the diet while pursuing a personal weight-loss goal, yet the care plan was not revised in a timely manner to reflect these ongoing changes and continued weight loss.
A resident with DM, hemiplegia, and hemiparesis, dependent on staff for ADLs but cognitively intact, had a physician order for a podiatry consult and treatment that was placed on hold during a hospital stay and not reactivated on return. Nursing staff were aware of the resident’s long, thickened toenails but did not complete a change of condition report or notify the physician, citing that staff generally would not trim toenails for a diabetic resident at high risk for infection. The resident reported only concern about the pending podiatry appointment, and observation confirmed long, thickened toenails on both feet, while facility policies required physician notification for significant changes and resident participation in care planning.
A resident with ESRD and severely impaired cognition returned from hemodialysis with a right upper arm fistula and a pressure dressing in place, under a physician order directing removal of the dressing four hours after return. Nursing documentation showed the resident arrived back from dialysis in the afternoon with the fistula intact and no signs of infection, but the pressure dressing was not removed until the evening, several hours after the ordered timeframe, when an LVN noted scant bleeding and applied a new dressing. The LVN acknowledged awareness of the order and stated that prolonged use of the pressure dressing increased the risk of clotting, while facility policy required staff caring for ESRD residents to be trained in the care of grafts and fistulas.
The facility failed to keep AD documentation in the medical records for three residents. One resident had an incomplete AHDAF on file, while two other residents had no AHDAF at all. Records showed one resident with acute respiratory failure, depression, and HTN had mixed documentation about AD status, another resident with DM II, HTN, and dementia lacked decision-making capacity, and a third resident with DM II, alcohol abuse, and HTN stated a family member held the AD. The SSD confirmed the missing or incomplete AHDAFs during record review.
A resident with disorientation and impaired coordination had a cardiology visit that indicated a neurology follow-up was needed to rule out acute CVA, but the facility did not enter the neurology consult order until later. Another resident with DM II, HTN, and alcohol abuse had Pepto Bismol Ultra brought from home left at the bedside without a physician order; the resident later reported taking a dose for heartburn even though the MAR/OSR did not show an order for the medication or for self-administration.
Improper Storage of Discontinued Controlled Medications: The facility failed to properly secure discontinued controlled medications for two residents. One resident had hydrocodone-acetaminophen discontinued after transfer, and another resident had hydrocodone-acetaminophen and alprazolam discontinued after transfer. During review, the DON found discontinued DCMs in medication carts with active meds, while the facility’s policy required controlled substances remaining after discontinuation or discharge to be securely locked until destroyed.
Kitchen 1 had sanitation and food storage deficiencies identified during survey observation and interview. A bag of frozen meat was found unlabeled and undated in the walk-in freezer, and the DS stated it lacked information showing what it was or when it expired. The dishwasher water collection area had brown and tan buildup, the stove top had sticky grease and food particles, and the area behind the stove was dusty with layered buildup. The DS and DON both acknowledged the kitchen and equipment should be kept clean and sanitary.
Failure to Knock Before Entering Resident Room: An LVN entered a resident’s room without knocking or announcing self after leaving to get morphine. The resident, who had paraplegia, MDD, and colostomy status and was cognitively intact, said the lack of knocking bothered him a little. The facility’s Dignity and Resident Rights policies required staff to treat residents with dignity and respect and to knock and request permission before entering rooms.
Missing Background Check for CNA. The facility failed to complete and document a background check for one of three sampled CNAs. Although the employee file indicated a background check was completed, the DSD stated there was no background check on the CNA and could not locate paperwork for the criminal conviction investigation or sex offender checks. The facility policy requires background screening, reference checks, and criminal conviction investigations for applicants with direct access to residents.
Failure to develop a comprehensive care plan for a resident with DM and anticoagulant use. The resident had diagnoses including type 2 DM with hyperglycemia and was ordered heparin sodium, but RN review confirmed care plans addressing DM and anticoagulant therapy were not developed. The facility policy required a comprehensive, person-centered care plan with measurable objectives and timetables within 21 days of admission.
Failure to revise a resident’s fall risk care plan after a fall during a Hoyer lift transfer. The resident had ESRD, DM, blindness in one eye, impaired cognition, and dependence on staff for most ADLs, bed mobility, and transfers. The existing fall care plan included bed safety and call light interventions, but it was not updated after the resident slipped through the lift sling and slid down the shower chair. RN and DON stated the care plan should have been revised after the change in condition.
Failure to Provide Resident's Preferred Television Activity: A resident with dx including major depressive disorder, generalized anxiety disorder, and impaired mobility was independent with activity involvement and enjoyed watching TV, but her TV was missing channels and did not display many basic stations. She repeatedly reported the issue to staff, and the MRL showed multiple repair requests marked corrected the same day, while the MS acknowledged the TV still needed repair and that he had received multiple complaints.
Pressure ulcer care not provided as ordered. A resident with a stage 3 pressure ulcer on the right plantar foot, severe cognitive impairment, immobility, and contractures was ordered a low air loss mattress for skin management and foot boots every shift. During observation, the mattress was found set to static mode and the foot boots were off. The LVN, treatment nurse, and DON confirmed the resident should have been on the active mattress setting and wearing foot boots for pressure relief and wound healing.
Failure to complete a post-fall review after a resident fell during a Hoyer lift transfer. The resident had ESRD, DM, left-eye blindness, impaired cognition, and dependence on staff for most ADLs and transfers. The chart showed a CIC for the fall, but no post-fall review was documented, and the DON stated post-fall documentation should include a CIC, pain assessment, fall risk assessment, and post-fall review.
Unlabeled Enteral Feeding Bag: A resident with DM, dysphagia, and a G-tube was receiving ordered enteral nutrition when the feeding bag was observed without the time hung or the nurse’s initials. The resident had severely impaired cognition and was dependent on staff for all ADLs. An LVN and the DON stated the bag should have been labeled with the date and time because the formula is only good for 48 hours once opened, and facility policy required the label to include the initials, date, and time hung.
Failure to Provide Ordered Oxygen Therapy: A resident with COPD, acute respiratory failure with hypoxia, and ESRD did not receive oxygen at the ordered 4 L/min via NC and was observed on lower flow rates after returning from dialysis and again during a later change in condition. Staff confirmed the resident was receiving less oxygen than ordered, and the resident later had low O2 saturation with desaturation and transfer to the ER.
A resident with ESBL resistance and impaired cognitive skills was observed with a restroom that was not kept clean and orderly. The restroom contained two wheelchairs, a portable fan, a bucket with a commode chair on the toilet, two urinals, and paper towel trash in the sink. The IPN, RN, and RNA stated resident care equipment should not be stored in resident restrooms and that the sink should be kept clean for infection control purposes.
Failure to Notify MD of Non-Triggered ABX Criteria: A resident receiving IV daptomycin for bacterial arthritis and osteomyelitis had an Infection Screening Evaluation showing Loeb’s criteria and McGreer’s criteria were not triggered for ABX use, and the manual trigger was not checked. The IPN completed an ATO and documented an ABX review with the MD, but later stated the MD was not informed that the resident did not meet criteria for ABX use, despite the facility policy requiring provider notification of review findings.
A resident with intact cognition and a history of mental health conditions returned from the hospital with a right eye hematoma, which was identified as a potential sign of physical abuse. Despite facility policy requiring immediate reporting of such injuries, staff did not notify CDPH within the mandated timeframe after becoming aware of the injury.
A CNA failed to check and change a dependent resident after an episode of stool incontinence, leaving the resident in a soiled diaper for over five hours despite repeated requests for assistance. The resident, who communicated via an iPad, expressed frustration and helplessness, and the situation was confirmed by the resident's roommate and another CNA who later provided care.
Two residents did not receive appropriate ADL care according to facility policy, resulting in one being left with matted hair that was not brushed for several days and another being left soiled in a brief with urine and feces. Staff interviews and documentation confirmed that required hygiene tasks, such as hair brushing and regular incontinence care, were not consistently performed.
A resident with impaired mobility and incontinence was unable to access their call light, which was not connected to the wall or within reach, resulting in the resident being left soiled and unable to request assistance. Staff and nursing interviews confirmed the call light was not functioning or accessible, despite care plan and facility policy requirements for call light accessibility and prompt response.
A resident with severe dysphagia and a physician-ordered minced and moist diet was served toasted bread, contrary to their prescribed dietary requirements. Despite documentation and repeated notifications from the responsible party, bread continued to be provided. Staff interviews revealed that required checks of meal trays for correct diet and texture were not properly conducted, resulting in the resident being served inappropriate food items.
Two residents used swamp coolers in their rooms that had not been cleaned or had filters and water tanks changed since placement, with staff confirming there was no scheduled maintenance or cleaning for these devices, contrary to facility policy.
A resident who was unable to perform activities of daily living did not receive the necessary care and assistance from staff, resulting in unmet personal care needs.
The facility did not set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action, resulting in a lack of systematic review and response to quality issues.
A resident with a communication impairment did not have access to a communication board as outlined in their care plan. Staff were unable to locate the adaptive device during observation, despite facility policy requiring accommodation of such needs.
A resident with severe cognitive impairment and multiple medical conditions was found physically restrained in a wheelchair using a hospital gown tied around the waist, preventing free movement. The restraint was applied by a CNA to prevent falls, without a physician's order, care plan, or consent, and contrary to facility policy, which prohibits such use for staff convenience or fall prevention.
A resident with speech and neurological conditions did not have a physician-ordered MRI scheduled as required. The MRI order, documented after a neurology appointment, was not carried out, resulting in a delay in diagnostic testing. The DON confirmed the oversight during record review.
A resident with limited mobility and dependence on staff for toileting was found to have a non-functional call light, as the device was unplugged and out of reach. Staff did not check the call light during their rounds, and the issue was only discovered during an observation. Facility policy requires call lights to be plugged in and working at all times.
The facility did not ensure that its abuse prevention policy required or documented reference checks for new employees. Review of employee files showed that three CNAs lacked evidence of completed reference checks, and the policy did not specify the need to screen for abuse history with previous employers. Interviews confirmed that reference checks were expected but not documented for these staff members.
CNAs did not provide timely incontinent care to a resident with impaired mobility and inability to alert staff, despite care plan requirements for checks every two hours. The resident was repeatedly observed in a wet gown and adult brief, and communicated that care was not being provided. Staff interviews confirmed that care was delayed or not performed due to other priorities, in violation of facility policy.
Staff failed to perform proper hand hygiene and use required PPE when handling food trays and entering a room under respiratory precautions for two residents exposed to COVID-19 and another resident with significant care needs. CNAs handled dirty and clean food trays without sanitizing hands and did not wear gloves or use hand sanitizer as required by facility policy.
A resident with severe cognitive impairment and dependence on staff for daily activities was repeatedly observed not wearing a face mask or wearing it improperly during a COVID-19 outbreak. Despite known non-compliance and the need for frequent reminders, staff did not create or update a care plan with individualized, measurable interventions to address the resident's behavior, contrary to facility policy.
During a night shift, only two CNAs were available to care for 89 residents, far below the facility's usual staffing levels and policy requirements. As a result, a resident with diabetes, mobility issues, and frequent incontinence was not checked or changed throughout the night, despite their care plan requiring checks every two hours. Staff interviews confirmed the short staffing, with licensed staff having to assist with ADL care, leading to delays in care for residents.
A Social Services Director mistakenly emailed a resident's confidential medical and personal information, including insurance details and care needs, to another resident's family member instead of the intended medical provider. The resident involved had severe cognitive impairment and required significant assistance with daily activities. The incident was not reported to facility leadership as required by policy.
A resident dependent on staff for ADLs did not receive timely incontinence care, resulting in prolonged exposure to wet bedding and clothing. The delay was caused by confusion and late completion of CNA staffing assignments at the start of the shift, preventing prompt care as required by the resident's care plan and facility policy.
A resident with a history of fracture and cognitive impairment did not receive proper pain management when LNs failed to assess and document pain levels before and after administering oxycodone, as required by the care plan and facility policy. Additionally, when the resident reported new abdominal pain, staff did not document pain characteristics or provide pain medication as ordered. Interviews confirmed that staff did not follow expected pain assessment and documentation procedures.
A resident with significant communication and cognitive impairments did not receive their requested dinner meal due to a miscommunication between dietary staff and kitchen personnel. Although the resident had a documented menu of preferred foods and a weekly review process with the Dietary Services Supervisor, only a smoothie was provided for dinner because the kitchen was not informed of the full meal request.
A resident with significant cognitive and physical impairments was found with empty water containers and was not provided water according to their needs and preferences. Staff interviews confirmed that water pitchers should be filled and within reach, but the resident's hydration needs were not met as required by facility policy.
A resident with neurological and mobility impairments did not consistently receive ordered restorative nursing services, including active-assisted range of motion exercises, due to staff failing to provide the care as prescribed and falsifying documentation to indicate completion. Staff admitted to not performing or only partially performing the required exercises on several occasions, and documentation was completed on days when staff were not present.
A resident's medical record contained inaccurate documentation of restorative nursing services, as staff initialed flow sheets to indicate that range of motion exercises were provided even when they were not present or did not perform the ordered interventions. Review of staffing records and interviews confirmed that the required care was not always delivered or properly documented, resulting in incomplete and inaccurate medical records.
A resident's right hand resting splint, prescribed for contracture management, was not inventoried or tracked by staff after it was received. The device was subsequently lost, and staff did not document its disappearance or investigate as required by facility policy, leaving the resident without the necessary equipment.
A resident admitted with a generalized body rash did not have a care plan developed to address this condition, despite facility policy requiring such a plan within a specific timeframe. The resident had multiple diagnoses, including toxic encephalopathy and chronic kidney disease, and the rash was noted upon admission. The Infection Preventionist Nurse confirmed the absence of a care plan, which could lead to unmet needs and a break in continuity of care.
A resident at high risk for falls was left unsupervised in a conference room, leading to a fall and a fracture of the cervical spine. Despite a care plan requiring frequent visual checks and monitoring at the nursing station, staff failed to adhere to these measures. The resident had a history of falls and severely impaired cognition, necessitating close supervision, which was not provided.
The facility failed to provide timely assistance with ADLs for four residents, leading to deficiencies in care. A resident with spina bifida and diabetes experienced delays in changing incontinence briefs, while another with a spinal fracture faced long wait times for care after a bowel movement. A third resident with multiple health issues also encountered delays in receiving necessary care. Additionally, a resident with conversion disorder did not receive scheduled hair care due to communication lapses among staff. These failures highlight the facility's inability to adhere to its policy on supporting ADLs.
The facility failed to provide sufficient CNA staffing, resulting in delayed care for residents. Residents experienced long waits for call lights to be answered and incontinence care, with some CNAs responsible for up to 29 residents per shift. This staffing shortage led to inadequate care and delayed responses to residents' needs.
A non-verbal resident with conditions such as anarthria and aphonia attended a medical appointment without their communication device, contrary to their care plan. The resident, who relies on a tablet for communication, had to use a CNA's mobile phone to communicate during the appointment. Facility staff confirmed the expectation that the resident should have had their communication device, as per the facility's policy on resident rights.
The facility failed to implement care plans for two residents, leading to deficiencies in their care. One resident, at high risk for falls, was not adequately monitored and suffered a serious injury from an unwitnessed fall. Another resident did not receive medication administration as per their care plan, with a staff member failing to follow the requirement for dual staff presence during care.
A resident with conversion disorder, anarthria, and aphonia returned from a neurology appointment without an after visit summary (AVS), leading to a failure in obtaining a recommended MRI. The facility lacked a specific policy for obtaining records after outside appointments, resulting in the LVN not notifying the Medical Records Supervisor to acquire the necessary documentation.
Failure to Revise Care Plan for Ongoing Significant Weight Loss
Penalty
Summary
The facility failed to timely revise and update the care plan for a resident who experienced significant unplanned weight loss. The resident was admitted with hemiplegia and hemiparesis following a stroke affecting the left non-dominant side, as well as diabetes mellitus, and was cognitively intact but dependent on staff for ADLs. Weight records showed a decline from 225 lbs at admission to 178 lbs over approximately five months, including a 24-lb loss in one month and a subsequent 19-lb loss over a later two‑month period. A care plan for unplanned/unexpected weight loss of 24 lbs in one month was initiated and revised in October, with interventions to contact the physician and dietician if weight decline persisted and to monitor and evaluate any weight loss and determine percentage lost per facility protocol. Despite continued weight loss documented in the Weights and Vitals Summary, the care plan was not updated when the resident lost an additional 19 lbs between early November and early January, and there was no care plan indicating that the resident was intended to lose a total of 47 lbs in five months. The unplanned/unexpected weight loss care plan was not updated again until late January. Interviews revealed that the resident was very alert, initially on a puree diet with low intake, later on a regular diet, and frequently ordered food from outside the facility because the resident did not like facility food. The registered dietician reported that the resident had a personal goal weight of 170 lbs, had lost 19 lbs in three months before the dietician began working at the facility, then 1 lb in a month afterward, and was non‑compliant with the prescribed diet and ordering a lot of outside food. These findings showed that the care plan interventions were not revised in a timely manner in response to ongoing weight loss.
Failure to Resume and Act on Podiatry Order for Diabetic Resident
Penalty
Summary
The facility failed to provide podiatry care for a resident with diabetes, hemiplegia, and hemiparesis, who was dependent on staff for ADLs but had intact cognition for daily decision making. The resident had a physician’s order for a podiatry consult and treatment as needed, originally dated 11/2/25. After the resident was hospitalized, all physician orders were placed on hold. When the resident returned from the hospital, staff resumed all orders except the podiatry consult, which remained on hold and was not active. The resident reported that a staff member had recently indicated they would make a podiatry appointment, but the resident had not received any update on the status of that appointment. Nursing staff were aware of the resident’s foot condition but did not act on it. An LVN stated they observed the resident’s long and thickened toenails on 11/20/25 when completing a Change of Condition report for heel redness, but they did not complete a change of condition report related to the toenails and did not notify the physician about this issue. The LVN also stated that, because the resident was diabetic and at high risk for infection, facility staff generally would not trim the resident’s toenails. On observation, the resident’s toenails on both feet were noted to be long and thickened. Facility policies on resident rights and change in condition required that residents be informed of and participate in their care and that physicians be notified of significant changes in condition, but these processes were not followed for the resident’s podiatry needs.
Failure to Follow Physician Order for Timely Removal of Dialysis Pressure Dressing
Penalty
Summary
The deficiency involves the facility’s failure to follow a physician’s order for timely removal of a hemodialysis pressure dressing for a resident with end-stage renal disease who was dependent on renal dialysis and had severely impaired cognition and dependence for ADLs. The resident’s admission record documented ESRD and dialysis dependence, and the MDS showed severely impaired cognition and total dependence on staff. A physician order dated 2/22/26 directed that the resident’s dialysis pressure dressing on the right upper arm be removed four hours after return from dialysis. Nursing documentation showed the resident returned from dialysis on 2/24/26 at approximately 2:15 pm with the right upper arm fistula intact, without swelling or signs of infection. The nursing progress note later that night, dated 2/24/26 at 10:50 pm, documented that the pressure dressing was removed and a new dressing applied. In interview, one LVN confirmed the resident returned from dialysis around 2:15 pm and that the fistula site was intact. Another LVN stated that on 2/24/26 they assessed the pressure dressing at about 4 pm after being informed the resident had returned from dialysis, found no leaking or signs of infection, and knew from the physician order that the pressure dressing should be removed four hours after return. This LVN stated they did not remove the pressure dressing until approximately 8 pm and then applied a new dressing due to scant bleeding at the fistula site, and documented the dressing change at 10:50 pm. The LVN also stated that leaving the pressure dressing on longer increased the risk of clotting. The facility’s ESRD policy stated that residents with ESRD would be cared for according to recognized standards of care and that staff would be trained in the care of grafts and fistulas.
Missing Advance Directive Documentation
Penalty
Summary
The facility failed to ensure that Advance Directive (AD) information was filed in the medical records for three sampled residents: Resident 10, Resident 1, and Resident 51. The report states that the facility’s policy required the social services director or designee to ask about the existence of written advance directives prior to or upon admission and to keep that information prominently available in the medical record. The deficiency involved the absence or incompleteness of the Advance Healthcare Directive Acknowledgement Form (AHDAF) for these residents. Resident 10 was admitted and later readmitted to the facility with diagnoses including acute respiratory failure, depression, and essential hypertension. The MDS dated 10/12/2025 indicated moderately impaired cognitive skills for daily decision making, while the H&P dated 11/9/2025 stated Resident 10 had the capacity to understand and make decisions. The record review showed two AHDAFs on file for Resident 10: one dated 10/7/2025 signed by Resident 10 and RN 2 stating Resident 10 did not have an AD, and another dated 11/5/2025 signed by Resident 10 and RN 1 that was incomplete and did not indicate whether Resident 10 had or did not have an AD. Resident 1’s record showed diagnoses including type 2 diabetes mellitus with hyperglycemia, essential hypertension, and unspecified dementia. The H&P dated 11/10/2025 stated Resident 1 did not have the capacity to understand and make decisions, and the MDS indicated moderately impaired cognitive skills for daily decision making. Resident 51’s record showed diagnoses including type 2 diabetes mellitus with hyperglycemia, alcohol abuse, and essential hypertension. The H&P stated Resident 51 had the capacity to understand and make decisions, and the MDS indicated intact cognitive skills for daily decision making. During interview, Resident 51 stated that Resident 51 had an AD and that Resident 51’s brother had it. The Social Services Director confirmed that Resident 1 and Resident 51 did not have AHDAFs on file, and stated that an AHDAF should have been completed for each resident.
Delayed neurology consult and unauthorized bedside self-administration of home medication
Penalty
Summary
The facility failed to ensure Resident 48’s neurology consult was ordered in a timely manner. Resident 48 was admitted with diagnoses including unspecified disorientation and lack of coordination, and the record showed the resident had been readmitted and later assessed as having severely impaired cognitive skills for daily decision making. An office visit note from a cardiology encounter indicated the resident was to follow up with neurology to rule out an acute CVA, and the physician order from that visit also indicated a neurology follow-up was ordered. A progress note later documented a new neurology consult order regarding rule out acute CVA per cardiology. During interview, the RN stated Resident 48 returned from the cardiology appointment with an order indicating a neurology appointment was needed, but the neurology consultation was not ordered by the facility until later. The DON stated the neurology consult should have been ordered when the cardiology visit occurred, and the facility policy indicated diagnostic service orders were to be promptly carried out as indicated by the physician’s order. The facility also failed to ensure Resident 51 did not self-administer Pepto Bismol Ultra brought from home and kept at the bedside without a physician’s order. Resident 51 had diagnoses including DM II, alcohol abuse, and HTN, and the record showed the resident had capacity to understand and make decisions with intact cognitive skills. After nausea and vomiting, NP ordered Zofran as needed. However, the active order summary did not show an order for Pepto Bismol Ultra or for the resident to take own medication from home. During observation, a bottle of Pepto Bismol Ultra Liquid with most of the contents remaining was found on the bedside table, and the resident later stated the medication had been brought in by the son and that the resident had taken a dose for heartburn. Staff stated the medication should not have been left at the bedside and that an order and consent were needed for self-administration.
Improper Storage of Discontinued Controlled Medications
Penalty
Summary
The facility failed to properly store discontinued controlled medications for two sampled residents, Resident 87 and Resident 89, as required by its policies for controlled substance storage. Resident 87 was admitted with diagnoses including insomnia and hypertension, and had a hydrocodone-acetaminophen order that was discontinued when the resident was transferred to the GACH. Resident 89 was admitted with diagnoses including Type 2 DM and AF, had hydrocodone-acetaminophen ordered for pain and later discontinued when transferred to the GACH, and also had alprazolam ordered for anxiety that was later completed/discontinued. During observation and interview, the DON stated discontinued controlled medications were supposed to be delivered by the LN to the DON, checked for accuracy, and stored in a double-locked cabinet in the DON’s office, but the cabinet was empty and the DON stated there were no DCMs in the facility since 11/26/2025. On a later review of discharged residents, the DON stated Resident 84 and Resident 89’s DCMs were found inside medication carts with active medications. The DON and LVN 1 stated discontinued DCMs should be turned over to the DON within 72 hours or sooner, and the facility’s policies and inservice minutes stated controlled substances remaining after discontinuation or discharge were to be securely locked until destroyed, with accountability records kept with the unused supply.
Kitchen 1 Food Storage and Sanitation Deficiencies
Penalty
Summary
Safe and sanitary conditions were not maintained in Kitchen 1 during survey observations and interviews. A large bag of round brown frozen meat was observed in the walk-in freezer without a label or date. During interview, the Dietary Supervisor stated the meat balls did not have a label or date to show what type of food was in the bag or when it expired, and stated labeling was important to know when food was opened and when it had to be used by to prevent residents from getting sick. On a later tour of Kitchen 1, the dishwasher water collection area had brown and tan gunk buildup with the gunk rimmed around the waterline. The stove top had layered sticky grease spots and food particles, and the area behind the stove was dusty, sticky to the touch, and had a colored layer of buildup. The Dietary Supervisor stated kitchen staff cleaned daily but said, "I don't know," and that staff would clean everything now. The DON stated Kitchen 1 had to remain clean, that equipment should be cleaned after each use and where there was buildup, and that there should be no grease buildup on or behind the stove.
Failure to Knock Before Entering Resident Room
Penalty
Summary
The facility failed to ensure Resident 31 was treated with dignity when LVN 3 entered the resident’s room on 12/16/2025 without knocking or announcing self. Resident 31 had been admitted with paraplegia, major depressive disorder, and colostomy status, and the history and physical dated 12/14/2025 indicated the resident had the capacity to understand and make decisions. The MDS dated 12/14/2025 indicated the resident’s cognitive skills for daily decision making were intact and that the resident was dependent and/or required supervision or touching assistance with activities of daily living. During a concurrent observation and interview, LVN 3 was observed entering Resident 31’s room without knocking. LVN 3 stated that knocking earlier had occurred, but the nurse left the room to get the resident’s morphine and then re-entered without knocking. Resident 31 later stated that some staff knock before entering and some do not, and that staff not knocking bothered the resident a little bit and it would be nice if they knocked first. RN 1 stated that knocking and announcing oneself before entering a resident’s room was important for courtesy and politeness. The facility’s Dignity policy stated residents were to be treated with dignity and respect at all times, private space and property were to be respected, and staff were expected to knock and request permission before entering residents’ rooms.
Missing Background Check for CNA
Penalty
Summary
The facility failed to complete a background check for one of three sampled CNAs, identified in the record as CNA 2. CNA 2 was hired on 2/18/2025, and the employee file indicated that a background check had been completed; however, during interviews on 12/19/2025, the DSD stated there was no background check done on CNA 2 and was unable to locate paperwork for the criminal conviction investigation and sex offender checks. The DSD also stated CNA 2 was hired when there was no DSD in the facility. The facility policy titled Background Screening Investigations states that background screening checks, reference checks, and criminal conviction investigations are to be conducted on all applicants who will have direct access to residents.
Failure to Develop Comprehensive Care Plan for Diabetes and Anticoagulant Therapy
Penalty
Summary
The facility failed to develop a comprehensive care plan for one sampled resident with diabetes mellitus and anticoagulant use. Resident 4 was admitted on 9/3/2025 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side and type 2 diabetes mellitus with hyperglycemia. The resident’s H&P dated 11/2/2025 indicated the resident did not have the capacity to understand and make decisions, while the MDS dated 12/8/2025 indicated the resident’s cognitive skills for daily decision making were intact. The resident’s OSR, active as of 12/18/2025, showed heparin sodium 5000 units ordered starting 11/3/2025. During a concurrent interview and record review on 12/18/2025, RN 1 reviewed the resident’s care plans and stated that care plans addressing diabetes mellitus and anticoagulant therapy were not developed for Resident 4. The facility’s Care Plans, Comprehensive Person-Centered policy stated that a comprehensive, person-centered care plan with measurable objectives and timetables should be developed and implemented for each resident, and that it should be developed no more than 21 days after admission.
Failure to Revise Fall Risk Care Plan After Resident Fall
Penalty
Summary
The facility failed to revise Resident 8’s fall risk care plan after the resident fell during a transfer on 11/26/2025. Resident 8 was admitted with diagnoses including ESRD, DM, and blindness in the left eye, and the H&P dated 7/27/2025 stated the resident did not have the capacity to understand and make decisions. The MDS dated 10/2/2025 indicated moderately impaired cognition and dependence on staff for most ADLs, bed mobility, and transfers. Resident 8’s fall risk care plan, initiated on 4/2/2022, identified the resident as at risk for falling out of bed and included interventions such as frequent checks and repositioning, encouraging use of the call light, keeping the call light within reach, and applying bilateral grab bars in bed. The care plan also documented that Resident 8 slipped through the lift sling and slid down the shower chair on 11/26/2025, but no new interventions were added and no revisions were made after the fall. During interview, RN 1 stated the care plan had no revision and should have been updated after the fall, and the DON stated care plans must be updated after a fall by the nurse who documented the change in condition.
Failure to Provide Resident's Preferred Television Activity
Penalty
Summary
The facility failed to provide one of one sampled resident, Resident 60, with her chosen individual activity when her television was not working. Resident 60 was admitted with diagnoses including fracture of the right femur, major depressive disorder, generalized anxiety disorder, and abnormalities of gait and mobility. Her MDS dated 11/16/2025 indicated normal thinking and memory, and her H&P dated 11/18/2025 stated she had the capacity to understand and make decisions. Her Activity Participation Review dated 11/20/2025 indicated she was independent with activity involvement and enjoyed watching television. The Maintenance Request Log showed Resident 60 requested repair of her television on 11/18/2025, 11/20/2025, and 11/21/2025, with each request signed off as corrected the same date. However, during observation and interview on 12/16/2025, Resident 60 showed that many basic television channels did not have a picture and stated the channels that worked did not interest her. She said she had been asking staff to repair the television and that the Maintenance Supervisor had told her he would replace it but had not. CNA 1 later stated residents often complained about televisions not working and that Resident 60 complained that morning about needing her television changed. The Maintenance Supervisor stated Resident 60's television was missing channels and needed repair, and that he had received multiple complaints but could not provide a work order for the cable company.
Pressure ulcer care not provided as ordered
Penalty
Summary
The facility failed to ensure pressure ulcer measures were provided as ordered for one resident with a stage 3 pressure ulcer on the right plantar foot. The resident was admitted with diagnoses that included a gastrostomy, pressure ulcer/injury stage 3, dementia, and a right-hand contracture, and was documented as having contracted legs, severely impaired cognition, and dependence on staff for bed mobility. The resident was also identified as being at risk for pressure ulcers and had an active physician order for a low air loss mattress for skin management and foot boots every shift. The resident’s care plan identified risk for pressure ulcer development related to a history of wounds and included interventions to float the heels and use a low air loss mattress. The wound management update documented an open wound to the right plantar foot classified as a stage 3 pressure ulcer, with strict pressure offloading, strict offloading of the right foot, and a Prevalon boot placed to the right foot while the resident was in bed. A surgical consult later documented that the right plantar foot pressure ulcer was not healed and measured 1.2 cm by 0.6 cm by 0.3 cm, and recommended continuing offloading, turning, and the pressure reducing mattress. During observation, the resident was found in bed with the low air loss mattress set to static mode and the foot boots not applied. Staff confirmed the mattress was on static and the foot boots were off. The LVN stated the resident needed the low air loss mattress setting because of the foot wound and should have been wearing a foot boot. The treatment nurse also confirmed the mattress was set to static and the foot boots were not applied, and stated the resident should always be wearing a foot boot for pressure relief and that the mattress should not remain on static because it made the mattress harder and could lead to further skin breakdown. The DON stated the low air loss mattress was typically used for residents with stage 3 or 4 pressure ulcers to aid healing and prevention, and that the foot boots should be worn when the resident was in bed.
Failure to Complete Post-Fall Review After Resident Fall
Penalty
Summary
The facility failed to complete a post-fall review for one sampled resident after the resident fell during a transfer in a Hoyer lift. The resident was admitted with ESRD, DM, and blindness in the left eye, and the H&P indicated the resident did not have the capacity to understand and make decisions. The MDS showed moderately impaired cognition and dependence on staff for most ADLs, including bed mobility and transfers. The resident’s fall risk care plan, initiated in 2022, identified the resident as at risk for falling out of bed and included interventions such as frequent checks, repositioning, encouraging call light use, keeping the call light within reach, and applying bilateral grab bars in bed. The resident’s change in condition evaluation documented that the resident fell while being transferred by a nursing assistant in a Hoyer lift. During record review, the medical record did not show a post-fall review was completed. The RN stated a post-fall review should have been completed within 24 hours to document a more thorough assessment of the incident, the surroundings, and details that could have prevented the fall. The DON stated the necessary post-fall documentation after a witnessed or unwitnessed fall consisted of a CIC, pain assessment, fall risk assessment, and post-fall review. The resident’s care plan also noted that the resident slipped through the lift sling and slid down the shower chair, but no new interventions were added or revisions made to the care plan.
Unlabeled Enteral Feeding Bag
Penalty
Summary
The facility failed to ensure that one sampled resident receiving enteral feeding through a gastrostomy tube had a properly labeled enteral feeding bag. Resident 7 was admitted with diagnoses including DM, dysphagia, and gastrostomy, and the H&P indicated the resident did not have the capacity to understand and make decisions. The MDS indicated the resident’s cognition was severely impaired and that the resident was dependent on staff for all ADLs. Resident 7 had an active physician order for DiabeticSource AC 1.2 via G-tube at 50 ml/hour for 20 hours or until the dose was met. The care plan identified the need for tube feeding related to dysphagia and included a goal for the resident to remain free of side effects or complications related to tube feeding. During observation, the resident was receiving the enteral feeding, and the feeding bag was not labeled with the time it was hung or the initials of the nurse who administered it. LVN 1 stated the bag was missing the time hung and should have been labeled because the formula was only good for 48 hours once opened. The DON stated the bag should be labeled with the date and time of administration by the licensed nurse hanging it, and the facility policy required the formula label to document initials, date and time the formula was hung, and initials that the label was checked against the order.
Failure to Provide Ordered Oxygen Therapy
Penalty
Summary
The facility failed to provide proper respiratory care for Resident 23 when the resident did not receive oxygen at the physician-ordered rate of 4 L/min via nasal cannula continuously. Resident 23 had been admitted and readmitted with diagnoses including COPD, acute respiratory failure with hypoxia, and end stage renal disease. The resident’s care plan identified a risk for ineffective airway clearance and included oxygen administration as ordered, but the active order summary showed an order dated 11/30/2025 for oxygen at 4 L/min via nasal cannula continuously every shift for COPD. On 12/16/2025, Resident 23 returned from dialysis on 2 1/2 L/min oxygen via nasal cannula instead of the ordered 4 L/min. During observation later that day, the resident was still receiving 2 1/2 to 2 1/4 L/min oxygen via nasal cannula. RN 2 reviewed the order and stated the facility was not following the physician’s order and that the oxygen flow rate should have been set at 4 L/min. RN 2 also stated staff were supposed to check residents when they returned to the facility to ensure they were stable. On 12/18/2025, Resident 23 had generalized pain and desaturation. The change in condition evaluation documented an oxygen saturation of 87% while the resident was on 2 L/min oxygen via nasal cannula, and the resident was transferred to the emergency room. During observation, the resident was seen with a face mask and paramedics at the bedside. LVN 4 stated the resident’s oxygen saturation was 88% while receiving 2 L/min via nasal cannula. RN 1 reviewed the order and stated staff were not following the physician’s oxygen order and that the correct amount of oxygen was important to prevent desaturation. The facility policy required verification of a physician’s oxygen order and adjustment of the oxygen delivery device so the proper flow was administered.
Infection Control Failure: Resident Restroom Stored With Equipment and Supplies
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when Resident 10's restroom was found in full view of the resident and not kept clean and orderly. Resident 10 was admitted and later readmitted to the facility with diagnoses including acute respiratory failure, ESBL resistance, and depression. The resident's MDS dated 10/12/2025 indicated moderately impaired cognitive skills for daily decision making and dependence for setup or clean-up assistance with ADLs. The H&P dated 11/9/2025 indicated the resident had the capacity to understand and make decisions. During a concurrent observation and interview on 12/16/2025, the Infection Preventionist Nurse observed Resident 10 in bed with EBP signage on the door and noted the restroom contained two wheelchairs, a portable tower fan, a gray bucket on the floor next to the toilet with a commode chair on top of the toilet, two urinals, and paper towel trash in the sink. The IPN stated resident care equipment should not be stored inside resident restrooms, the wheelchairs should be kept at the bedside, the bucket should be kept in the commode chair, and the restroom sink should be clean for infection control purposes. RN 1 later stated resident care equipment should not be stored inside resident restrooms and that there was a parking area for wheelchairs, and the RNA stated wheelchairs should be kept at the bedside, commodes had a storage room, urinals should not be kept in the sink, and equipment supplies should not be stored inside the restroom.
Failure to Notify MD of Non-Triggered Antibiotic Criteria
Penalty
Summary
The facility failed to implement its antibiotic stewardship program for one resident who was receiving daptomycin-sodium chloride IV for arthritis due to other bacteria and osteomyelitis. The resident was admitted with those diagnoses and had capacity to understand and make decisions. An Infection Screening Evaluation dated 12/9/2025 indicated that Loeb’s criteria and McGreer’s criteria were not triggered for antibiotic use, and the manual trigger for antibiotic use was not checked off on the form. An Antibiotic Time Out completed by the IPN on 12/12/2025 documented that an antibiotic review was performed with MD 1 and stated, due to the severity of the resident’s condition, the antibiotic was not appropriate at that time and was ordered to continue. During interview and record review, the IPN stated the resident did not meet Loeb’s criteria or McGreer’s criteria for antibiotic use, but MD 1 was not informed of that finding so the physician could make an informed decision regarding continued antibiotic use. The facility’s policy stated that antibiotic usage and outcome data are to be collected and documented, reviewed by the IPN, and that the provider is to be notified of the review findings.
Failure to Timely Report Suspected Abuse to State Authorities
Penalty
Summary
The facility failed to report an allegation of abuse to the California Department of Public Health (CDPH) within the required two-hour timeframe after becoming aware of a resident's injury. A resident, admitted with conversion disorder and major depressive disorder and assessed as having intact cognition and decision-making capacity, returned from the hospital with right eye discoloration. The injury was identified as a right periorbital hematoma, which is considered a potential sign of physical abuse according to the facility's own policies. The police initially informed an LVN about the resident's eye discoloration, and the Director of Nursing later confirmed that the facility became aware of the injury upon the resident's return from the hospital. Despite the facility's policy requiring immediate reporting of abuse allegations to state authorities, the incident was not reported to CDPH as mandated. Staff interviews and record reviews confirmed that the required notification did not occur. The facility's policies also specify that facial injuries such as black eyes and bruising are to be treated as potential abuse and reported accordingly, but this protocol was not followed in this case.
Failure to Maintain Resident Dignity During Incontinence Care
Penalty
Summary
Certified Nursing Assistant (CNA) 1 failed to maintain the dignity of a resident who was dependent on staff for dressing and toileting hygiene. The resident, who had diagnoses including conversion disorder, aphonia, and general anxiety disorder, was admitted as incontinent of bowel and bladder and required to be checked for incontinence at least every two hours per the care plan. On the day in question, the resident experienced an episode of stool incontinence in the morning and requested to be changed by CNA 1 starting at 8 AM. CNA 1 did not respond to the request or check on the resident for over five hours, leaving the resident in a soiled diaper until 12:30 PM, when another CNA took over care and found the resident soiled. The resident communicated feelings of frustration and helplessness due to being left in a soiled state. The resident's roommate confirmed the presence of a foul stool odor in the room starting around 10 AM. CNA 1 admitted to not checking or changing the resident during the assigned shift and was unaware of the reason for the resident's distress. Facility policy required care to be provided in a manner that promotes resident well-being and dignity, including identifying and addressing individual needs and preferences through assessment.
Failure to Provide Timely ADL Care and Hygiene
Penalty
Summary
The facility failed to provide activities of daily living (ADL) care in accordance with its own policy and procedures for two residents. One resident, who had moderately impaired cognition and required assistance with personal hygiene, was observed with matted hair that had not been brushed for several days. The resident reported that the last time their hair was brushed was the previous week, and only the front was brushed. Staff interviews confirmed that hair brushing should occur daily and as needed, regardless of whether the resident refused showers. Documentation did not reflect consistent refusals of care, and staff acknowledged that personal hygiene tasks such as hair brushing should still be performed even if a shower is refused. Another resident, who was incontinent and dependent on staff for toileting and hygiene, was found soiled with urine and feces in their brief. The resident communicated that they had not been changed since the previous day. Observations confirmed that the resident's brief, bed sheet, and gown were wet and soiled, and staff confirmed the resident's condition. The care plan for this resident required staff to check and change the resident at least every two hours and as needed, but this was not followed, resulting in the resident being left unclean and uncomfortable. The Director of Nursing confirmed that hair brushing is part of ADL care and should be performed after showers, during morning care, and as needed. The DON also stated that residents' briefs should be checked and changed every two hours and as needed to prevent discomfort. The facility's policy indicated that residents unable to perform ADLs independently should receive necessary services to maintain good grooming and hygiene, which was not provided in these cases.
Failure to Ensure Call Light Accessibility and Timely Response to Resident Needs
Penalty
Summary
A deficiency occurred when a resident's call light was not fully connected to the wall and was not within the resident's reach, preventing the resident from requesting assistance as needed. Observations and interviews confirmed that the call light was not accessible, and staff acknowledged the issue, with one CNA stating that the call light was not working and not within reach. The resident, who was dependent on staff for toileting hygiene and had impaired mobility, was unable to alert staff and was left soiled in their briefs with urine and/or feces. The care plan for this resident specified that the call light should be placed within reach, hanging from the trapeze above the resident's head, and that staff should be educated on this preference. The care plan also required CNAs to check the resident for incontinence at least every two hours and to keep the call light accessible and answer it promptly. The resident had a history of conversion disorder, aphonia, generalized anxiety disorder, and neuropathy, and was at risk for infection and skin breakdown due to incontinence and immobility. The facility's policy required that call lights be plugged in, functioning, and accessible to residents at all times. Despite these requirements, the call light was observed to be disconnected and out of reach on multiple occasions, and maintenance had not yet completed securing the call light to the wall. The Director of Nursing confirmed that the issue with the call light's accessibility had been identified but not resolved prior to the incident.
Failure to Provide Prescribed Therapeutic Diet to Resident with Dysphagia
Penalty
Summary
The facility failed to ensure that a resident with severe dysphagia and a physician-ordered minced and moist diet received meals consistent with their prescribed dietary requirements. Despite clear documentation in the resident's records, including a speech therapy plan recommending pureed consistency food and a physician's order for a minced and moist texture diet, the resident was served toasted bread on their lunch tray. The responsible party reported repeated notifications to staff about the resident's inability to safely consume bread, yet bread continued to be provided. The dietary service supervisor acknowledged the error, stating the bread was likely placed on the tray by accident, and recognized the risk of choking associated with this mistake. Further review revealed that the facility's policies required both dietary and nursing staff to check trays for correct diet and texture before serving meals to residents. However, interviews with staff indicated that these checks were not properly conducted, resulting in the resident being served inappropriate food items. The director of nursing confirmed that failure to check trays could lead to residents receiving the wrong diet, which in this case, exposed the resident to potential harm due to their swallowing difficulties.
Failure to Maintain Swamp Coolers in Safe and Operable Condition
Penalty
Summary
The facility failed to maintain swamp coolers in a safe and operable manner for two of three sampled residents. Observations revealed that swamp coolers in use in residents' rooms did not have water in their tanks, and both residents reported that the facility had not cleaned or changed the filters or water tanks since the coolers were placed in their rooms. One resident stated the cooler had not been maintained for at least a month, while the other indicated no maintenance had occurred since admission. Interviews with facility staff, including the administrator, interim Maintenance Director, and Infection Preventionist, confirmed that there was no scheduled maintenance or cleaning time for the swamp coolers. Review of facility policy indicated that the maintenance director was responsible for developing and maintaining a schedule of maintenance service and that maintenance personnel should follow the manufacturer's recommended maintenance schedule. However, no such schedule or records existed for the swamp coolers, resulting in the deficient practice.
Failure to Assist Dependent Residents with Activities of Daily Living
Penalty
Summary
A deficiency was identified when care and assistance were not provided to residents who were unable to perform activities of daily living (ADLs) independently. The report notes that residents requiring help with ADLs did not receive the necessary support from staff, resulting in unmet care needs for those individuals. This failure to provide assistance directly affected residents who were dependent on staff for daily personal care tasks.
Failure to Establish Ongoing Quality Assessment and Assurance Group
Penalty
Summary
The facility failed to establish an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. This inaction resulted in the absence of a systematic process to identify, review, and address quality issues within the facility. As a result, there was no documented evidence that quality deficiencies were being regularly reviewed or that corrective plans were being developed and implemented to address identified issues.
Failure to Provide Communication Board for Nonverbal Resident
Penalty
Summary
Facility staff failed to provide a communication board for a resident who was unable to speak, as required by the resident's care plan. The care plan, dated 10/14/2024, identified the resident's communication problem and included interventions such as ensuring the availability and functioning of adaptive communication equipment, including a message board and alternative communication tools. During an observation, the resident was found sitting on the bed, unable to verbally communicate but able to nod and shake her head. When asked, the Certified Nurse Assistant present was unable to locate the communication board for the resident. A review of the facility's policy on accommodation of needs indicated that residents' individual needs and preferences, including access to assistive and adaptive devices, should be accommodated to the extent possible. Despite this policy and the care plan's directives, the communication board was not available for the resident's use, resulting in a failure to ensure continued communication for the resident.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by the deficient practice: Resident 3 was immediately offered an alternative method of communication on July 9, 2025. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On July 9th, 2025, the Director of Nursing (DON) / designee ensured that all non-verbal residents were provided with appropriate means of communication. This measure was implemented to prevent any lapses in communication between the facility and the affected residents. No additional findings were noted.
Resident Restrained with Gown Without Proper Authorization
Penalty
Summary
A deficiency occurred when a resident was found confined to a wheelchair using a hospital gown tied around their waist, which prevented the resident from moving freely. This action was discovered by a clinical team during routine rounds, and it was confirmed through interviews with the LVN/Treatment Nurse, the Director of Nursing (DON), and the Administrator. The staff involved acknowledged that using a gown in this manner constituted a physical restraint, and there was no physician's order or care plan authorizing the use of restraints for this resident. The resident involved had a history of dementia, cognitive impairment, hypertension, left lower leg contracture, lack of coordination, and a history of transient ischemic attack and cerebral infarction. The Minimum Data Set (MDS) indicated the resident had severely impaired cognitive skills and required substantial to total assistance with most activities of daily living. Despite these needs, the MDS and facility records showed that restraints were not ordered or care planned for this resident at the time of the incident. Facility policy explicitly prohibits the use of restraints for staff convenience or fall prevention and requires that all less restrictive alternatives be attempted before considering restraint use. The Certified Nurse Assistant (CNA) who tied the resident to the wheelchair admitted to using the gown to prevent the resident from falling, without following proper protocol or obtaining the necessary orders and consents. The facility's investigation confirmed that the CNA did not comply with policy, resident rights, or standard care protocols, resulting in the resident being physically restrained without appropriate justification or documentation.
Plan Of Correction
What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur? From July 10, 2025 to July 11, 2025, the Director of Staff Development (DSD) or designee conducted an in-service training for licensed nursing staff and Certified Nursing Assistants (CNAs). The training focused on the importance of ensuring that non-verbal residents are provided with an effective and reliable means of communication, in order to support continuous and timely interaction within the facility. Incoming admissions will be reviewed during the daily Interdisciplinary Team (IDT) Clinical Meeting to promptly identify non-verbal residents and ensure appropriate communication tools are made available. Any findings requiring additional follow-up will be reported to the Administrator for further review and action. How the facility plans to monitor its performance to make sure that solutions are sustained: The Administrator/designee will provide any negative findings to the QAPI committee monthly for three months for further monitoring and action planning as indicated or until the QAA committee determines compliance. Date of Compliance: July 11th, 2025 How corrective actions will be accomplished for those residents found to have been affected by the deficient practice: Resident 1 was immediately released from the wheelchair and appropriately assessed for injury on June 26, 2025. CNA 1 was terminated following the substantiated allegation of abuse. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On June 27, 2025, department supervisors conducted room rounds with residents and/or their responsible parties (RPs) to ensure there were no similar concerns regarding interactions with facility staff and to assess residents' perceptions of their safety within the facility. No additional concerns were identified during the review. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur: From June 26, 2025 to June 27, 2025, the Director of Staff Development (DSD), designee conducted multiple in-service trainings for licensed nursing staff and Certified Nursing Assistants (CNAs). The trainings emphasized the importance of implementing appropriate fall prevention interventions. In-services also covered the recognition and prevention of abuse, reinforcing staff responsibilities in reporting and maintaining resident safety. Training also highlighted the proper use of restraints, stressing that restraints must only be applied when absolutely necessary and always with a valid physician's order obtained prior to utilization along with informed consent. This training aimed to ensure compliance with facility policies and regulatory standards while promoting the health, safety, and dignity of residents. Any negative findings identified throughout daily operations from staff will be reported to the Administrator for further review and action in accordance with our abuse policy. How the facility plans to monitor its performance to make sure that solutions are sustained: The Administrator/designee will provide any negative findings to the QAPI committee monthly for three months for further monitoring and action planning as indicated or until the QAA committee determines compliance. Date of Compliance: June 27th, 2025 All residents have the potential to be affected by this deficient practice. On June 27, 2025, department supervisors conducted room rounds with residents and/or their responsible parties (RPs) to ensure there were no similar concerns regarding interactions with facility staff and to assess residents' perceptions of their safety within the facility. No additional concerns were identified during the review. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur: From June 26, 2025 to June 27, 2025, the Director of Staff Development (DSD), designee conducted multiple in-service trainings for licensed nursing staff and Certified Nursing Assistants (CNAs). The trainings emphasized the importance of implementing appropriate fall prevention interventions. In-services also covered the recognition and prevention of abuse, reinforcing staff responsibilities in reporting and maintaining resident safety. Training also highlighted the proper use of restraints, stressing that restraints must only be applied when absolutely necessary and always with a valid physician's order obtained prior to utilization along with informed consent. This training aimed to ensure compliance with facility policies and regulatory standards while promoting the health, safety, and dignity of residents. Any negative findings identified throughout daily operations from staff will be reported to the Administrator for further review and action in accordance with our abuse policy. How the facility plans to monitor its performance to make sure that solutions are sustained: The Administrator/designee will provide any negative findings to the QAPI committee monthly for three months for further monitoring and action planning as indicated or until the QAA committee determines compliance. Date of Compliance: June 27th, 2025
Failure to Schedule Physician-Ordered MRI
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a physician-ordered MRI was scheduled and completed for a resident. The resident, who was admitted with diagnoses including aphonia, dysarthria, and anarthria, had intact cognitive skills and required supervision to extensive assistance with activities of daily living. The resident's neurology appointment resulted in an order for an MRI of the thoracic and lumbar spine, as documented in the After Visit Summary. Despite the physician's order, the MRI was not scheduled, which was confirmed during an interview and record review with the Director of Nursing. The facility's policy required that diagnostic service orders be promptly carried out as instructed by the physician, but this was not followed, resulting in a delay in the resident's diagnostic testing.
Plan Of Correction
F684 How corrective actions will be accomplished for those residents found to have been affected by the deficient practice: On July 9, 2025, the Facility Case Manager promptly followed-up on MRI appointment for Resident 3 to prevent any further delays in diagnosis and treatment. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On July 10, 2025, the Medical Records Supervisor/designee conducted a review of all appointments within the previous 30 days to ensure appropriate follow-up was documented and completed, preventing any delays in diagnosis or treatment. No further concerns were reported or identified during this review. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur: From July 10, 2025, to July 11, 2025, licensed nursing staff participated in an in-service training conducted by the Director of Nursing (DON)/designee. The training emphasized the importance of appropriate follow-up related to documentation and communication with outside providers after each resident appointment, ensuring continuity of care and timely interventions. A one-on-one in-service was conducted by the DON on July 9th, 2025, with the Facility Case Manager to reinforce the timely scheduling of resident appointments as required and the appropriate communication of follow-up appointments. Any negative findings or barriers will be reported to the Administrator for further review and appropriate action. How the facility plans to monitor its performance to make sure that solutions are sustained: The Administrator/designee will provide any pattern of negative findings to QAPI committee monthly for 3 months for further monitoring and action planning as indicated or until QAA committee determines compliance. Date of Compliance: July 11th, 2025
Call Light Not Plugged In and Non-Functional for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident's call light was found unplugged and non-functional during an observation. The resident, who had diagnoses including conversion disorder and aphonia, was dependent on staff for toileting hygiene and required maximal assistance. The call light button was observed hanging on the trapeze handle, with the plug disconnected from the wall outlet. The wall outlet was located on the head part of the bed and toward the right side, while the resident was unable to move the right side of their body, making it impossible for them to reconnect the call light independently. Staff interviews revealed that the LVN had been in the resident's room earlier in the day but did not check the call light plug at that time. The CNA noted that the resident typically called for assistance frequently and had wondered why there were no calls that day, but did not check the call light's functionality. The DON confirmed that the call light should be within reach and functioning. Review of facility policy indicated that call lights are to be plugged in and operational at all times.
Failure to Document Employee Reference Checks in Abuse Prevention Program
Penalty
Summary
The facility failed to ensure that its Abuse, Neglect, Exploitation, and Misappropriation Prevention Program policy and procedure included requirements for screening potential employees through reference checks with previous or current employers. During a review of six employee files, it was found that three employees did not have documented reference checks. Specifically, one certified nursing assistant (CNA) had a blank Pre-Employment Reference Checklist (PRC), and two others had no PRC or reference check documentation in their files. Additional review of previous employee files did not reveal any evidence of completed reference checks for these individuals. Interviews with the Director of Staff Development (DSD) and the Administrator (ADM) confirmed that reference checks were expected to be conducted, including inquiries about prior allegations of abuse and rehire eligibility. However, there was no documentation to support that these checks were performed for the three employees in question. The facility's policy, dated April 2021, did not specify the requirement to screen potential employees for a history of abuse, neglect, exploitation, or misappropriation by contacting previous or current employers.
Failure to Provide Timely Incontinent Care to Dependent Resident
Penalty
Summary
Certified Nursing Assistants (CNAs) failed to provide timely incontinent care to a resident who was dependent on staff for toileting hygiene and had impaired mobility and inability to alert staff. The resident, admitted with conversion disorder and aphonia, was care planned to be checked for bladder incontinence at least every two hours and as needed. Observations revealed that the resident was left in a wet gown and adult brief, with a noticeable smell of urine, and communicated through gestures and writing that care was not being provided as required. Interviews with CNAs indicated that the assigned staff did not check or change the resident's adult brief during their rounds, prioritizing other tasks and residents instead. CNA 7 admitted to planning to provide care to the resident at the end of rounds and did not check the resident for incontinence care, despite knowing the risks of not doing so. CNA 8 also delayed providing care, stating that other duties, such as showering other residents, took precedence even after being notified by an LVN that the resident needed to be changed. Facility policy required staff to provide appropriate care and services for residents unable to perform activities of daily living independently, including hygiene and toileting, in accordance with the care plan. Despite this, the resident was observed multiple times to be wet and not changed in a timely manner, and staff interviews confirmed that care was not provided as required by policy and the resident's care plan.
Failure to Follow Infection Control Protocols During Food Tray Handling and PPE Use
Penalty
Summary
The facility failed to follow its infection prevention and control measures for three residents by not ensuring proper hand hygiene and use of personal protective equipment (PPE) by staff. Certified Nurse Assistant (CNA) 2 was observed exiting a resident's room after handling a dirty food tray without sanitizing hands and then proceeded to handle clean food trays for other residents without performing hand hygiene. Additionally, CNA 2 did not use alcohol-based hand rub before passing clean food trays to another CNA. CNA 1, who was responsible for setting up food trays in a room with a posted Novel Respiratory Precautions isolation sign, did not wear gloves or perform hand hygiene before accepting and setting up food trays for two residents who had been exposed to COVID-19. CNA 1 also failed to use hand sanitizer between setting up trays for the two residents. Both CNAs acknowledged during interviews that they did not follow proper hand hygiene protocols as required by facility policy. The residents involved had significant cognitive impairments and required assistance with activities of daily living, including eating. Facility policies reviewed indicated that staff were expected to adhere to hand hygiene and PPE protocols, especially when handling food trays and entering rooms with infection control precautions. The Infection Preventionist confirmed the importance of these measures during interviews.
Failure to Develop Comprehensive Care Plan for Mask Non-Compliance During COVID-19
Penalty
Summary
The facility failed to develop a person-centered, comprehensive care plan with measurable objectives for a resident who was non-compliant with wearing a face mask during a COVID-19 outbreak. The resident, who had diagnoses including Alzheimer's disease, generalized muscle weakness, and a cervical vertebra fracture, was assessed as having severely impaired cognitive skills and was dependent on staff for activities of daily living and mobility. Despite being exposed to COVID-19, the care plan only included general interventions such as educating the resident on hand hygiene, mask use, and social distancing, without addressing the resident's specific non-compliance behavior or providing measurable objectives and individualized interventions. Observations showed the resident repeatedly in the hallway without a face mask or with the mask improperly worn, interacting with others. Staff interviews confirmed that the resident required frequent and constant reminders to stay in her room or wear a mask, and that a care plan addressing her non-compliance was not created when the behavior was first noted. Facility policy required ongoing assessment and revision of care plans as resident conditions changed, but this was not followed in the case of this resident's non-compliance with infection control measures.
Insufficient Night Shift Staffing Resulted in Delayed Incontinent Care
Penalty
Summary
The facility failed to provide sufficient nursing staff during one of two reviewed night shifts, specifically the 11 pm to 7 am shift, resulting in inadequate incontinent care for a resident. On the night in question, only two CNAs were on duty for a census of 89 residents, whereas the facility's policy and facility assessment indicated that four to six CNAs were typically required for this census, with an expected ratio of 12 to 16 residents per CNA. As a result, the two CNAs were assigned to care for 33 and 40 residents each, which was significantly above the usual assignment and made it difficult for them to provide timely care to all residents. A resident with a history of Type 2 diabetes mellitus with a foot ulcer, mobility issues, and frequent incontinence was not checked or changed throughout the night, contrary to their care plan, which required checks for bladder incontinence at least every two hours. The resident reported that staff did not check or change them during the night and attributed this to the reduced number of staff on duty. Staff interviews confirmed that the night shift was short-staffed, and licensed staff had to assist with ADL care, which was not typical and caused delays in their other duties. Facility records and staff interviews indicated that management was aware of the staffing shortage and attempted to find replacements but was unsuccessful. The facility's own policy and facility assessment required sufficient numbers of nursing staff to meet residents' needs, but this was not met on the night in question, leading to a delay in the provision of care and services for the affected resident and potentially others.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by the deficient practice: Resident 3's needs were immediately addressed to ensure their care needs were adequately met. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/28/25, department supervisors conducted rounds to ensure that no other individuals were impacted by this deficiency. No additional issues were identified. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur: A in-service training was conducted on 4/1/2025 with the DSD and DON by the Administrator, focusing on the importance of sufficient staffing and meeting staffing per patient day (PPD) requirements. On 10/29/24, QAPI centered on sufficient staffing created by Administrator/DON. The QAPI is ongoing. The facility will reinforce and ensure adherence to the 4-2 staffing ladder for CNAs. The Director of Staff Development (DSD) will be responsible for ensuring adequate CNA coverage for the AM, PM, and NOC shifts. The DSD will report any staffing shortages to the administrator daily (Monday-Friday) during morning stand-up meetings to ensure effective communication regarding CNA and licensed nurse staffing levels. The Administrator/designee will collaborate with the organization's HR Recruiter to ensure CNA hiring efforts remain a hyper-focus. The facility is working closely with a dedicated recruiter to prioritize the recruitment of qualified nursing staff. This partnership focuses on sourcing, screening, and hiring skilled nursing staff. The facility will also collaborate with sister facilities in an effort to meet staffing needs as needed. The facility will continue to implement a bonus incentive on an as-needed basis for licensed nurses/CNAs, effective January 27, 2025, to help maintain adequate staffing levels and effectively address staffing needs. The DSD/designee will continue to maintain a call log when staffing hours for CNAs are insufficient. The log will document all staff members contacted and the outcomes of those communications. The DSD/designee will report any pattern of findings related to staffing to the Administrator for further review and action. How the facility plans to monitor its performance to make sure that solutions are sustained: The Administrator/designee will provide any pattern of findings to the QAPI committee monthly for 3 months for further monitoring and action planning as indicated or until the QM committee determines compliance. Date of Compliance: April 1st, 2025
Unauthorized Disclosure of Resident PHI via Email
Penalty
Summary
A deficiency occurred when the Social Services Director (SSD) sent an email containing a resident's Face Sheet (Admission Record) and information regarding podiatry care needs to an unauthorized recipient, specifically another resident's family member. The email included protected health information (PHI) such as the resident's Medicaid, Medicare, and insurance policy numbers, home address, care providers, emergency contact, and financial representative. The SSD stated that the email was sent by mistake, confusing the intended recipient, a medical provider with the same first name as the family member who received the email. The resident whose information was disclosed had a history of anemia, chronic pain, and gout, and was noted to have severely impaired cognition, requiring substantial to maximal assistance with activities of daily living. The resident was able to make needs known but could not make medical decisions. The SSD recognized the error and attempted to recall the email but did not report the incident to facility leadership or follow the facility's policy for handling breaches of PHI. Interviews with the Administrator and Director of Nursing revealed that the facility's protocol required immediate reporting of any PHI breach to leadership, investigation of the incident, and notification of the resident or responsible party. The facility's policy also specified that access to resident records should be limited to authorized staff and business associates, which was not followed in this instance.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by the deficient practice: Resident 8 was informed of the breach on March 26, 2025, and was assured that the facility would take all appropriate steps to mitigate any potential negative consequences resulting from the incident. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents had the potential to be affected by this deficient practice. Beginning on March 27, 2025, the Social Services Director conducted outreach to residents within the facility to identify any additional potential breaches and to ensure there were no further incidents or concerns related to the confidentiality of Protected Health Information (PHI). No additional findings were identified as a result of this review. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur: From March 27 to March 28, 2025, licensed nurses and department supervisors participated in an in-service training conducted by the Administrator or designee. The training focused on the protection of residents' rights to privacy and the confidentiality of Protected Health Information (PHI), in accordance with HIPAA regulations. On March 27, 2025, the Administrator conducted a one-on-one training with the Social Services Director, emphasizing the importance of secure communication practices and the protection of residents' rights to privacy and the confidentiality of Protected Health Information (PHI), in compliance with HIPAA regulations. The Social Services Director will adhere to safe communication practices and will promptly report any potential breaches of confidentiality to the Administrator for further review and appropriate action. How the facility plans to monitor its performance to make sure that solutions are sustained: The ADMIN/designee will provide any negative findings to QAPI committee monthly x 3 months for further monitoring and action planning as indicated or until the QAA committee determines compliance. Date of Compliance: April 1st, 2025
Failure to Provide Timely Incontinence Care Due to Staffing Assignment Delays
Penalty
Summary
A deficiency occurred when a resident who was dependent on staff for activities of daily living (ADLs), including toileting and personal hygiene, did not receive timely incontinence care. The resident, who had diagnoses including conversion disorder, anarthria, and aphonia, was observed in bed with wet bedding, clothing, and sheets. The resident communicated to the surveyor that they had been wet for a long time and had not been changed. The care plan for this resident required staff to check for incontinence every two hours and as needed, and to provide peri-care after episodes. Staff interviews revealed that the assigned CNA had not changed the resident that morning, citing confusion over assignments at the start of the shift due to delays in finalizing the CNA staffing assignment. The Director of Staff Development confirmed that the assignment was not completed until after the shift began, which delayed care. The Director of Nursing stated that the staffing assignment should be ready before the shift so CNAs can provide immediate care. Facility policy required appropriate support and assistance with hygiene and toileting for residents unable to perform ADLs independently.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by the deficient practice: On March 27, 2025, Resident #1 was promptly provided with Activities of Daily Living (ADL) care by a facility CNA as soon as the deficient practice was identified. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents had the potential to be affected by this deficient practice. On March 28th, 2025, Department supervisors conducted room rounds to follow up with residents to ensure there were no other concerns pertaining to ADL care. No additional findings were identified as a result. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur: From March 27 to March 28, 2025, licensed nurses and CNAs participated in an in-service training conducted by the Administrator/designee. The training focused on the importance of providing timely ADL care, with an emphasis on promptly responding to call lights to ensure residents' needs are consistently and adequately met. The Director of Staff Development (DSD)/Designee will conduct random daily rounds to ensure timely ADL care is being provided and that residents' needs are being consistently met. Any negative findings will be reported to the Director of Nursing (DON) for further review and appropriate follow-up. How the facility plans to monitor its performance to make sure that solutions are sustained: The DON/designee will provide any negative findings to QAPI committee monthly x 3 months for further monitoring and action planning as indicated or until the QAA committee determines compliance. Date of Compliance: April 1st, 2025
Failure to Assess and Document Pain Management
Penalty
Summary
The facility failed to manage pain for one resident by not following its own pain assessment and management policy, as well as the resident's care plan. The care plan required licensed nurses to assess and document the resident's pain level on a 0-10 scale before and after administering pain medication, specifically oxycodone, for pain management. However, review of the medication administration records and progress notes showed that nurses did not document pain assessments before or after giving routine or as-needed pain medication. Additionally, when the resident complained of new abdominal pain, there was no documentation of the pain level, characteristics, or interventions provided to address the pain on the relevant dates. The resident involved had a history of a right femur fracture, was post-surgical for open reduction and internal fixation, and had other mobility issues. The resident was cognitively impaired and dependent on staff for most activities of daily living. Despite having physician orders for both scheduled and as-needed oxycodone for pain, there was no evidence that staff assessed or documented the resident's pain level or characteristics before or after medication administration, nor that pain medication was given in response to new complaints of abdominal pain. Interviews with nursing staff and the Director of Nursing confirmed that the expected practice was to assess and document pain levels before and after administering pain medication, and to address new onset pain as a change in condition. The facility's policy also required detailed pain assessments and documentation, including location, intensity, and characteristics of pain, as well as monitoring and reassessment after interventions. These practices were not followed, resulting in a failure to ensure proper pain management for the resident.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by the deficient practice: Resident #2 was transferred to the hospital on January 14, 2025, and is no longer residing at the facility. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On March 27, 2025, the Medical Records Supervisor/designee reviewed pain level documentation for the 30 days prior, focusing on pre- and post-pain medication administration, to ensure no other residents were affected by this deficient practice. No additional findings were identified. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur: From March 24 to March 28, 2025, licensed nurses received in-service training conducted by the Administrator/designee. The training focused on pain management, including proper procedures and protocols for pain assessment and timely intervention, to prevent physical, mental, and emotional distress. The Medical Records Supervisor will conduct bi-weekly reviews of the Medication Administration Record (MAR) to ensure pain level documentation is completed both prior to and following the administration of pain medication. Any negative findings will be reported to the Director of Nursing (DON) during the daily clinical stand-up meeting to ensure timely identification and resolution of concerns. How the facility plans to monitor its performance to make sure that solutions are sustained: The DON/designee will provide any negative findings to the QAPI committee monthly for 3 months for further monitoring and action planning as indicated or until the QAA committee determines compliance. Date of Compliance: April 1st, 2025
Failure to Honor Resident Food Preferences Due to Dietary Miscommunication
Penalty
Summary
A deficiency occurred when the dietary services department failed to honor a resident's documented food preferences for dinner on a specific date. The resident, who had conversion disorder, anarthria, and aphonia, was dependent on staff for several activities of daily living and communicated her meal preferences through a written list/menu, which was signed by the Dietary Services Supervisor (DSS). The care plan indicated that dietary staff were to review and provide food according to the resident's preferences, and the resident and DSS had agreed to review and update the menu weekly. On the day in question, the resident only received a strawberry smoothie for dinner, despite having a detailed menu of preferred foods for each meal. Interviews with the DSS and kitchen staff revealed a miscommunication: the cook believed only a smoothie was required, as the DSS had not informed the kitchen to prepare the resident's preferred dinner. The DSS acknowledged the need to provide meals according to the resident's written preferences, and the kitchen staff stated they had not received instructions to prepare anything beyond the smoothie and lemons. The facility's policy required staff to determine and honor resident food preferences and to offer a variety of foods at each meal. However, the failure to communicate and provide the resident's requested meal resulted in the resident's food choices not being honored, with the potential for unmet nutritional needs.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by the deficient practice: Resident #1 was seen by the Dietary Supervisor on March 27, 2025, and the dietary preferences were updated to ensure there are no further concerns regarding the residents' meal schedule. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents had the potential to be affected by this deficient practice. On March 28, 2025, the Dietary Supervisor/designee reviewed resident preferences as documented on individual meal slips to ensure all preferences were current and being appropriately followed. No additional findings were identified as a result of the review. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur: From March 26 to March 27, 2025, the Dietary Supervisor or designee conducted in-service training for dietary staff on the importance of following resident preferences and adhering to the established meal slips. Licensed nurses will report any inconsistencies related to meal slips to the Dietary Supervisor for further review. The Dietary Supervisor will report any negative findings to the Administrator for appropriate follow-up and resolution. How the facility plans to monitor its performance to make sure that solutions are sustained: The Administrator/designee will provide any negative findings to the QAPI committee monthly for 3 months for further monitoring and action planning as indicated or until the QAA committee determines compliance. All residents had the potential to be affected by this deficient practice. On March 28, 2025, the Dietary Supervisor/designee reviewed resident preferences as documented on individual meal slips to ensure all preferences were current and being appropriately followed. No additional findings were identified as a result of the review. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur: From March 26 to March 27, 2025, the Dietary Supervisor or designee conducted in-service training for dietary staff on the importance of following resident preferences and adhering to the established meal slips. Licensed nurses will report any inconsistencies related to meal slips to the Dietary Supervisor for further review. The Dietary Supervisor will report any negative findings to the Administrator for appropriate follow-up and resolution. How the facility plans to monitor its performance to make sure that solutions are sustained: The Administrator/designee will provide any negative findings to the QAPI committee monthly for 3 months for further monitoring and action planning as indicated or until the QAA committee determines compliance. Date of Compliance: March 28th, 2025
Failure to Provide Water According to Resident Needs and Preferences
Penalty
Summary
A deficiency occurred when a resident, who was admitted with conversion disorder, anarthria, and aphonia, and who had moderate cognitive impairment and was dependent on staff for several activities of daily living, was not provided with water according to their needs and preferences. On the morning of the incident, the resident was observed lying in bed with empty water tumblers and cups. The resident, unable to speak, pointed to the empty tumblers, prompting a licensed vocational nurse to refill them. Staff interviews revealed that night shift nurses were responsible for distributing fresh water at the start of their shift, and morning CNAs were expected to refill pitchers if needed. Further interviews with staff, including the Director of Staff Development and the Director of Nursing, confirmed that water pitchers should be within reach, filled, and checked at least every two hours. The facility's policy emphasized the importance of providing adequate hydration and preventing dehydration. Despite these protocols, the resident's water pitchers were found empty and not refilled as required, resulting in a failure to meet the resident's hydration needs.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by the deficient practice: Resident 1 was provided with immediate proper hydration on March 27th, 2025, to ensure residents' hydration needs are being met. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents had the potential to be affected by this deficient practice. On March 28, 2025, department supervisors conducted room rounds to follow up with residents and ensure there were no additional concerns related to water hydration. No further issues were identified as a result of these rounds. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur: From March 27 to March 28, 2025, licensed nurses and CNAs participated in an in-service training conducted by the Director of Staff Development (DSD)/designee. The training focused on the importance of proper hydration to support residents' overall health and well-being. To reinforce this practice, department supervisors will conduct daily room rounds (Monday through Friday) to ensure water pitchers are filled and within reach of each resident. Any negative findings will be reported to the Director of Nursing (DON) during the daily clinical stand-up meeting for immediate and appropriate follow-up. How the facility plans to monitor its performance to make sure that solutions are sustained: The DON/designee will provide any negative findings to QAPI committee monthly for 3 months for further monitoring and action planning as indicated or until the QAA committee determines compliance. Date of Compliance: March 28th, 2025
Failure to Provide and Accurately Document Restorative Nursing Services
Penalty
Summary
The facility failed to provide restorative nursing services (RNS) as ordered for a resident with significant mobility and neurological impairments. The resident, admitted with diagnoses including conversion disorder, dysarthria, anarthria, and unspecified neuropathy, had physician orders and a care plan specifying active-assisted range of motion (AAROM) exercises for both lower extremities, to be performed daily, five days per week, with 20 repetitions and three sets per session or as tolerated. Despite these orders, documentation and interviews revealed that the resident did not consistently receive the prescribed RNS, and in some cases, the services were not provided at all. Record reviews and interviews indicated that restorative nurse assistants (RNAs) documented providing RNS on days when they were not present or working, and in some instances, initialed flow sheets to indicate completion of services that were not performed. One RNA admitted to only partially completing the ordered exercises and, on some days, not providing the treatment at all due to time constraints, yet still documented the services as completed. The resident also reported that RNAs either did not provide the RNS or only completed part of the ordered exercises on certain days. The facility's policy required that restorative nursing care be provided as needed to promote optimal safety and independence, but the failure to follow physician orders and accurately document care resulted in the resident not receiving the full extent of prescribed RNS. Staff interviews confirmed that documenting unprovided care was considered willful falsification of medical records, and the director of staffing development was unable to confirm whether the resident received RNS on multiple dates when documentation was falsified.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by the deficient practice: RNA 1 and RNA 2 are no longer employed in the facility. Additionally, on March 5, 2025, the Administrator or designee held a one-on-one in-service session with RNA 5 along with a counseling, focusing on the importance of following RNA orders for Resident 2 and other residents in the program. This training emphasized essential steps for enhancing compliance and ensuring that residents' needs are effectively met. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On March 18th, 2025, the Director of Nursing (DON) or designee reviewed residents participating in the restorative nursing assistant (RNA) program to ensure that treatments were properly authenticated and administered, thereby preventing any further decline in range of motion (ROM). No additional findings were noted. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur: The facility's Director of Staff Development (DSD) resigned on March 7, 2025. A new DSD is scheduled to be onboarded on March 19, 2025, and appropriate policies and procedures will be followed to ensure the timely and accurate completion of Restorative Nursing flow sheets. On March 20th, 2025, facility restorative nursing assistants (RNAs) participated in an in-service training session conducted by the Administrator or designee. The training emphasized the importance of adhering to RNA orders for residents and the necessity of accurate charting related to RNA treatments. The Director of Nursing (DON)/designee will review RNA treatments on a weekly basis to ensure that orders are being properly implemented and accurately documented. The Director of Staff Development (DSD)/designee will conduct random rounds during RNA treatments to verify that orders are being executed as specified. Any negative findings will be reported to the Administrator for further review. How the facility plans to monitor its performance to make sure that solutions are sustained: The DON/designee will provide any negative findings to QAPI committee monthly x 3 months for further monitoring and action planning as indicated or until QAA committee determines compliance. Date of Compliance: March 20th, 2025
Inaccurate Documentation of Restorative Nursing Services
Penalty
Summary
The facility failed to ensure accurate documentation of restorative nursing services (RNS) provided to a resident, as required by federal regulations and the facility's own policy. Specifically, restorative nursing assistants (RNAs) initialed the Restorative Nursing Flow Sheet (RNFS) to indicate that range of motion (ROM) exercises were provided to the resident on multiple dates, even though they were not present or did not perform the ordered interventions. Review of timecards and staffing sign-in sheets confirmed that on several dates, the RNAs who initialed the RNFS were not working, and the Director of Staff Development (DSD) could not verify whether the resident received the required RNS on those days. Further investigation revealed that on some occasions, an RNA documented that the full treatment was completed when, in fact, only a partial treatment or no treatment was provided. The RNA admitted to initialing the RNFS to indicate completion of the ordered exercises even when unable to perform them, citing lack of time as a reason. The resident also reported that RNAs sometimes did not provide the RNS as ordered or only completed part of the treatment. This resulted in the resident's medical record containing inaccurate information regarding the care and services provided. The facility's policy on charting and documentation requires that all services provided, progress toward care plan goals, and any changes in the resident's condition be objectively, completely, and accurately documented in the medical record. Interviews with nursing staff confirmed that documenting care as completed when it was not is considered willful falsification of medical records. The inaccurate documentation and failure to provide ordered RNS could not be verified or corrected due to the lack of accurate records, directly impacting the integrity of the resident's medical record.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by the deficient practice: On February 27, 2025, licensed nursing staff and Rehab assessed Resident 2 for any adverse effects associated with missed restorative nursing assistant (RNA) orders. No ill effects were observed, and there was no decline in range of motion. RNA 1 and RNA 2 are no longer employed in the facility. Additionally, on March 5, 2025, the Administrator or designee held a one-on-one in-service session with RNA 5 along with a counseling, focusing on the importance of following RNA orders for Resident 2 and other residents in the program. This training emphasized essential steps for enhancing compliance and ensuring that residents' needs are effectively met. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On March 18th, 2025, the Director of Nursing (DON) or designee reviewed residents participating in the restorative nursing assistant (RNA) program to confirm that treatments were properly authenticated and administered, thereby preventing any further decline in range of motion (ROM). No additional concerns were identified. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur: The facility's Director of Staff Development (DSD) resigned on March 7, 2025. A new DSD is scheduled to be onboarded on March 19, 2025, and appropriate policies and procedures will be followed to ensure the timely and accurate completion of Restorative Nursing flow sheets. On March 20th, 2025, facility restorative nursing assistants (RNAs) participated in an in-service training conducted by the Administrator or designee. This training emphasized the importance of adhering to RNA orders for residents and the necessity of accurate charting related to RNA treatments. The Director of Nursing (DON)/designee will review RNA treatments on a weekly basis to ensure that orders are being properly implemented and documented. The DSD/designee will conduct random rounds during RNA treatments to verify that orders are being executed as specified. Any negative findings will be reported to the Administrator for further review. How the facility plans to monitor its performance to make sure that solutions are sustained: The Admin/designee will provide any negative findings to the QAPI committee monthly for three months for further monitoring and action planning as indicated or until the QAA committee determines compliance. Date of Compliance: March 20th, 2025.
Failure to Inventory and Protect Resident's Durable Medical Equipment
Penalty
Summary
Facility staff failed to protect a resident's property from loss by not properly inventorying a right hand resting splint (RHRS) on the resident's clothing and possession form when it was received. The RHRS, a piece of durable medical equipment prescribed to assist with the resident's contracture management, was not documented as received on the inventory form, and there was no record of its loss in the resident's progress notes. Despite physician orders for the resident to use the RHRS at night, staff did not update the inventory or document the device's whereabouts after it was last seen. The resident, who had moderately impaired cognition and was dependent on staff for most activities of daily living, reported that staff lost the RHRS shortly after it was received and did not respond to requests for its return or provide information about its location. Interviews with staff confirmed that the RHRS was last seen the day after it was received, and that staff were responsible for tracking and documenting the device in the resident's records. However, there was no evidence that staff reported the device missing or investigated its disappearance as required by facility policy. The facility's policy on personal property required that resident belongings be inventoried upon admission and updated as necessary, and that any complaints of missing property be promptly investigated. In this case, the lack of documentation and follow-up regarding the RHRS resulted in the resident being without the prescribed device, with no indication in the records that staff took steps to locate or account for the missing equipment.
Plan Of Correction
F584 How corrective actions will be accomplished for those residents found to have been affected by the deficient practice: Resident 2 was referred to the facility's rehabilitation department for a reassessment of their need for durable medical equipment (DME). If deemed necessary, an appointment with an external rehabilitation provider will be coordinated per resident preference. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On March 18, 2025, the Director of Nursing (DON) or designee conducted a review of all residents with splints in the facility to ensure that the durable medical equipment (DME) was accurately accounted for and easily locatable. No additional findings were noted. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur: From March 17 to March 21, the Director of Nursing (DON) or designee conducted an in-service training for licensed nursing staff on the importance of accurately inventorying resident durable medical equipment (DME) and ensuring its proper placement. This training aims to meet resident needs effectively and eliminate barriers to care. Additionally, the Medical Records department or designee will audit admissions and readmissions to verify proper inventory logging of applicable DME. Any negative findings will be reported to the DON for further review. How the facility plans to monitor its performance to make sure that solutions are sustained: The DON/designee will provide any negative findings to the QAPI committee monthly for 3 months for further monitoring and action planning as indicated or until the QAA committee determines compliance. Date of Compliance: March 21st, 2025 F 584
Failure to Develop Care Plan for Resident's Rash
Penalty
Summary
The facility failed to develop a care plan for a resident who was admitted with a generalized body rash. Upon admission, the resident had multiple diagnoses, including toxic encephalopathy and chronic kidney disease. The Admission/Readmission Data Tool noted the presence of a rash on the resident's arms, back, chest, and abdomen, described as spotted dark brownish red with itching. Despite this, a care plan addressing the rash was not created, which was confirmed during an interview with the Infection Preventionist Nurse. The facility's policy requires a comprehensive, person-centered care plan to be developed within seven days of the required Minimum Data Set assessment and no more than 21 days after admission. However, the care plan for the resident's rash was not developed, even though the hospital had ordered treatment for the rash to continue. This oversight had the potential to result in unmet individualized needs and a break in continuity of care for the resident's existing condition.
Failure to Supervise High-Risk Resident Leads to Fall and Injury
Penalty
Summary
The facility failed to provide adequate supervision and care to prevent a fall for Resident 12, who was assessed as being at high risk for falls. On December 28, 2024, Resident 12 was left unsupervised in the facility's conference room with the door closed, contrary to the care plan that required frequent visual checks and monitoring at the nursing station. This lack of supervision resulted in Resident 12 falling to the floor, sustaining a fracture of the dens of cervical spine 2 (C2). Resident 12 had a history of multiple falls and was identified as having severely impaired cognition, limited mobility, balance problems, and poor safety awareness. The resident's care plan, which was revised multiple times, included interventions such as frequent visual checks and keeping the resident at the nursing station for monitoring. Despite these measures, staff failed to follow the care plan, leading to the resident being left alone in the conference room, where the fall occurred. Interviews with staff, including CNA 4, LVN 6, and RN 2, revealed that the facility did not adhere to the established care plans and policies for fall prevention and resident supervision. The facility's policies emphasized the importance of resident safety supervision and the implementation of interventions to reduce accident risks. However, the staff did not effectively communicate or implement these interventions, resulting in the resident's fall and subsequent injury.
Deficiencies in ADL Assistance for Residents
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for four residents, leading to deficiencies in care. Resident 3, who has spina bifida and diabetes, was not promptly changed after episodes of incontinence, despite being dependent on staff for toileting and hygiene. Resident 8, with a wedge compression fracture, also experienced delays in receiving care after reporting a bowel movement, resulting in a significant wait time before being cleaned and changed. Both residents expressed concerns about the timeliness of care, which was affected by the number of residents assigned to each CNA. Resident 18, who has myelodysplastic syndrome, type 2 diabetes, and chronic kidney disease, was similarly affected by delays in changing incontinence briefs. A family member reported that it took an hour for staff to respond to a request for a diaper change. The care plan for Resident 18 indicated a need for occupational therapy and assistance with various ADLs, yet the facility did not meet these needs in a timely manner. Resident 17, diagnosed with conversion disorder and anarthria, did not receive scheduled hair care, resulting in matted and hard hair. The care plan required hair washing and combing every Wednesday, but staff were not informed of the change from Saturday to Wednesday, leading to a lapse in care. Interviews with staff and family members highlighted the inconsistency in care and the lack of communication regarding care schedules. The facility's policy on supporting ADLs was not adhered to, as residents did not receive the necessary assistance to maintain their daily living activities.
Inadequate CNA Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to ensure sufficient Certified Nursing Assistants (CNAs) were available to provide care and services to four of the 18 sampled residents, as per the facility's policy and procedure on staffing and the Facility Assessment Tool. This deficiency was observed on multiple dates, including 12/16/2024, 12/22/2024, 12/23/2024, 12/26/2024, 12/28/2024, 1/4/2025, and 1/7/2025. The lack of adequate staffing resulted in residents experiencing delays of up to an hour for call lights to be answered and for incontinence care to be provided, which could potentially lead to a decline in their physical and psychosocial well-being. Resident 3, who was admitted with spina bifida and diabetes mellitus, was dependent on others for toileting hygiene and was always incontinent of bladder and bowel. Despite having an intact cognition, Resident 3 reported waiting up to an hour for a diaper change, which was attributed to the number of residents assigned to each CNA. Similarly, Resident 8, who had a wedge compression fracture and required partial assistance, experienced delays in receiving care after a bowel movement, with a CNA taking nearly an hour to respond and provide care. Resident 8 also noted that some CNAs were rough due to being hurried. Interviews with staff and family members revealed that CNAs were often assigned more residents than they could adequately care for, with some shifts having CNAs responsible for up to 29 residents. This staffing shortage was corroborated by the facility's assignment sheets, which showed that the number of residents per CNA often exceeded the facility's own guidelines. The facility's policy indicated that staffing should be based on residents' needs, but the actual staffing levels fell short, leading to inadequate care and delayed responses to residents' needs.
Failure to Provide Communication Device for Non-Verbal Resident
Penalty
Summary
The facility failed to provide a communication device to a resident, identified as Resident 17, who was unable to speak due to conditions including conversion disorder, anarthria, and aphonia. This deficiency was observed when Resident 17 attended a medical appointment without their communication device, which was necessary for them to express their needs and communicate effectively. The resident's care plan specifically indicated the use of a tablet computer for communication, and staff were instructed to ensure the availability and functionality of this adaptive communication equipment. On the day of the appointment, a Certified Nursing Assistant (CNA) who accompanied Resident 17 confirmed that the resident did not have their communication device and had to use the CNA's mobile phone to communicate. Interviews with facility staff, including a Licensed Vocational Nurse (LVN) and the Social Services Director (SSD), highlighted the expectation that Resident 17 should always have a communication device during outside appointments. The facility's policy on resident rights also emphasized the importance of communication access, both inside and outside the facility.
Failure to Implement Care Plans for Two Residents
Penalty
Summary
The facility failed to implement the care plan for two residents, leading to deficiencies in their care. Resident 12, who was at high risk for falls due to multiple medical conditions and cognitive impairment, was not adequately monitored as per their care plan. Despite being placed near the nursing station for supervision, Resident 12 was found unsupervised in a conference room, resulting in an unwitnessed fall that caused a serious injury. Interviews with staff revealed that the care plan's requirement for frequent visual checks was not followed, and the resident was left alone without supervision, contrary to the facility's policies. Resident 17, who had a conversion disorder and required assistance from two staff members for safety and care, did not receive medication administration as per their care plan. LVN 9 administered medication without the accompaniment of another staff member, as required by the care plan. This oversight was confirmed during interviews with both the resident and LVN 9, who admitted to forgetting the requirement for dual staff presence during care. The facility's policy on comprehensive, person-centered care plans was not adhered to, resulting in a failure to meet the resident's needs. The facility's policies and procedures, including those for safety supervision, fall risk management, and comprehensive care planning, were not effectively implemented for these residents. The lack of adherence to established care plans and protocols led to significant deficiencies in the care provided to Residents 12 and 17, highlighting a failure in communication and responsibility assignment among the staff.
Failure to Obtain After Visit Summary from Neurologist
Penalty
Summary
The facility failed to coordinate with an outside care provider to obtain necessary care records for a resident after a neurology appointment. The resident, who was admitted with diagnoses including conversion disorder, anarthria, and aphonia, attended a neurologist appointment but returned without an after visit summary (AVS). This document is crucial as it details the treatment plan and any new orders from the care provider. The absence of this record meant that the facility staff were unaware of the neurologist's recommendation for the resident to undergo an MRI. Interviews with facility staff revealed a lack of communication and follow-up procedures. The Licensed Vocational Nurse (LVN) who received the resident after the appointment did not notify the Medical Records Supervisor (MRS) to obtain the necessary records, as was the facility's practice. The Registered Nurse (RN) and MRS confirmed that there was no specific policy in place for obtaining records after outside appointments, relying instead on informal practices. This oversight resulted in the resident not receiving the recommended MRI, as there was no physician's order documented in the resident's medical record.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 5,771 citations issued within 25 miles in the last 12 months — including the 24 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Monrovia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Community Care Center | 1.3 mi | — | 1 | 0 |
| Monrovia Post Acute | 1.8 mi | ★★★★★ | 26 | 0 |
| Santa Fe Lodge | 1.8 mi | ★★★★★ | 21 | 0 |
| Mayflower Care Center | 1.8 mi | ★★★★★ | 3 | 0 |
| Monte Vista Healthcare Center | 1.9 mi | ★★★★★ | 34 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Monrovia Gardens Healthcare Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.