Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Montebello Care Center during CMS and state inspections, most recent first.
Failure to Maintain Resident Dignity: A resident with an indwelling catheter and another resident with a suprapubic catheter were observed with urine drainage bags only partially covered by dignity bags, leaving urine visible in the hallway. A third resident with severe cognitive impairment was observed seated in a wheelchair with yellow, dry, crusted substance on both eyes. Staff interviews confirmed the catheter bags were not fully covered and that residents should be groomed and presentable at all times.
Inaccurate portioning of shredded Monterey cheese was observed during quesadilla preparation when dietary staff used different scoops that did not match the recipe's 2 oz requirement. An RN confirmed the recipe called for 2 oz of cheese per tortilla and the facility's portion control chart identified the blue scoop as the correct measure, while staff stated the yellow scoop or black scoop was used instead.
Food service equipment, spices, and resident food storage were found improperly maintained. A can opener had rust and residue, spice containers were left unsealed, a blender pitcher and food processor cover were cracked with buildup, a food thickener container was open, and the microwave and oven had rust, chipped surfaces, and grease or food residue. A resident’s refrigerator was dirty, items were unlabeled or undated, and several foods were past best-by dates or not stored per policy; the DS and DDM confirmed the conditions and that staff were estimating oven temperatures.
Two residents receiving hospice services had coordination failures between the facility and hospice. For one resident, the DON confirmed the MAR/order summary did not match the hospice med list, with several hospice meds missing from the physician orders and naloxone listed on the order summary but not the hospice list. For another resident, RNs confirmed there was no care plan reflecting hospice 1 involvement, including hospice visit frequency and other POC details, despite hospice status and facility-hospice coordination requirements.
Call Light Not Kept Within Resident Reach: A resident with dementia, muscle weakness, and impaired decision-making had a care plan directing staff to keep the call light within reach at all times, but surveyors observed the call light string behind the bed and out of reach. The resident stated he could not reach it, and CNA and DSD interviews confirmed the call light must be within reach so the resident can call for assistance.
A resident on EBP for a G-tube and permacath had a room trashcan used for soiled PPE observed overflowing. The IPN verified the condition from a photo, and an RN stated trashcans should be kept closed to prevent contamination or spread of bacteria. The facility policy stated residents are to be provided a safe, clean, comfortable, and homelike environment.
A facility failed to ensure two residents were free from unnecessary psychotropic medication use. One resident with dementia, depression, and impaired decision-making had buspirone ordered for dementia with behavioral disturbance, and nursing staff verified the diagnosis was not the correct indication for the medication. Another resident with anxiety, claustrophobia, and depression had a PRN lorazepam order for 30 days, but staff stated there was no documented psychiatrist rationale to extend the PRN psychotropic order beyond the 14-day limit described in the facility policy.
Inaccurate MDS coding of unsupported psychosis diagnosis. A resident’s quarterly MDS listed psychosis even though the medical record, including admission diagnoses and psychiatric consult notes, did not support that diagnosis. RN and MDSA both verified the diagnosis was not active, the resident was not receiving psych meds for psychosis, and no psychosis care plan existed. The resident also had dementia, depressive disorder, muscle weakness, and required varying levels of assistance with ADLs.
Failure to revise a hospice care plan after a resident was discharged from one hospice and later enrolled with another hospice. The resident had dementia, AFib, AV block, and severe cognitive and ADL impairment, but the active care plan still listed the prior hospice without a discontinue date or updated hospice details. RNs verified the plan was not resolved or updated to reflect the change in hospice status.
Failure to provide grooming and hygiene assistance: A resident with hemiplegia, hemiparesis, dementia, and poor vision was supposed to receive setup help with personal hygiene, but was observed with long, jagged fingernails and dry brownish-yellow substance on the hands, wrist, and under the nails. A CNA identified the substance as dry poop, and the RN stated the ADL policy was not followed. The resident said he wants to be clean all the time and needs somebody to help him.
A resident with dementia and an unstageable sacral pressure ulcer had a LALM ordered for wound management, but the mattress was observed set at 180 lbs even though the resident weighed 152 lbs. The care plan required the LALM settings to be checked every shift based on manufacturer guidelines, and the RN confirmed the mattress should be set to the resident’s weight.
Improper Disposal of Used Insulin Syringe in Sharps Container: A used insulin syringe was observed protruding halfway out of a sharps container near a medication cart. An LPN stated that residents, visitors, and staff passed by the area and could access the needle, and an RN confirmed the syringe was not properly discarded per the facility's sharps disposal policy.
Failure to Elevate HOB During Oxygen Therapy: A resident with dementia, DM, and a history of pneumonia was on oxygen via nasal cannula with orders and a care plan directing staff to keep the HOB elevated, including at 45 degrees if tolerated, to support lung expansion. However, staff observed the resident flat in bed while receiving oxygen on multiple occasions, and an LVN confirmed the HOB was not elevated as ordered; the DON acknowledged the care plan was not followed.
A resident with ESRD, CHF, and bradycardia received hemodialysis, but the Hemodialysis Communication Record was not fully completed when the resident returned from dialysis. The record lacked the post-dialysis weight and the LPN/RN signature, despite the care plan calling for pre- and post-weights and written communication with the dialysis center.
Failure to Administer Potassium as Ordered: An LVN gave a resident's potassium tablet without food or a full glass of water, despite the MD order to administer it with meals/food or a full glass of water. The resident had diagnoses including muscle weakness, HF, and acute kidney failure, and the facility policy required meds to be given as prescribed and in accordance with ordered time frames.
A resident with dementia had memantine incorrectly entered on the order list as being for a supplement instead of for dementia, and both RN and DON interviews confirmed the indication was documented in error. Another resident on dialysis and fluid restriction had a physician-ordered 24-hour I&O tally that was not accurately completed, with several days documented as zero despite recorded intake totals. The facility’s policies required orders and charting to be complete and accurate.
Improper Storage of G-tube Tip: A resident with a G-tube, ESRD, and muscle weakness had the G-tube tip found inside the bedside drawer wrapped in tissue paper. An LVN observed this condition, and the DON and IPN stated the tube should be recapped when disconnected and not wrapped in tissue paper or placed in the cabinet.
A resident with severe cognitive impairment, gait abnormalities, and muscle weakness eloped from the facility after being left unsupervised for an extended period while the assigned CNA was on break. Earlier that day, the resident had gone out with a sister and later expressed a desire to go home, paced in the room, and exited through a shared bathroom into the hallway. The resident was discovered missing around 8 PM when the CNA returned and noted the empty bed, triggering a Code Pink. Nursing staff described the resident as forgetful with an unsteady gait and believed the resident exited through the main door near the nurse’s station. The DON confirmed the main door, though locked from the outside after 6 PM, could be pushed open from the inside and was not supervised after that time, despite a facility policy stating it would provide a safe environment.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, increasing the risk of resident accidents.
A resident with severe cognitive impairment and dependence on staff for ADLs was found with untrimmed, sharp fingernails, a bruise near the eye, and scratches on the forehead. Staff confirmed nail care was their responsibility, but there was no care plan or specific policy addressing nail care or self-scratching behavior, resulting in inadequate hygiene and risk of injury.
A resident with severe cognitive impairment and total dependence on staff did not have a comprehensive care plan developed or implemented for Foley catheter care, despite physician orders and facility policy requiring such planning. Staff interviews and record reviews confirmed the absence of a care plan addressing catheter care and urine output monitoring.
A resident with multiple pressure injuries and significant cognitive and physical impairments was incorrectly documented as having no skin issues on a weekly summary, despite other clinical records and wound assessments confirming the presence of wounds. The LVN responsible acknowledged the documentation error, and the DON confirmed the inconsistency with facility policy and other records.
A resident with an indwelling catheter was not consistently monitored or documented for signs and symptoms of UTI, as required by their care plan and facility policy. Staff failed to observe and record changes in urine appearance, sediment, and discomfort, and did not consistently follow interventions for catheter care, resulting in a deficiency related to appropriate catheter management and infection prevention.
Two residents with indwelling urinary catheters were observed with uncovered urine collection bags, despite facility policy and care plans requiring privacy bags to maintain dignity. Nursing staff and the DON confirmed that the bags should have been covered, and the facility's policy prohibits practices that compromise resident dignity, such as exposing catheter bags.
Two residents were placed at risk when a razor blade was found on the floor in the room of a cognitively impaired resident and medication was left unattended on the bedside table of another resident with moderate cognitive impairment and multiple medical conditions. Staff confirmed that both the presence of the razor blade and the unattended medication violated facility policy and could have resulted in harm.
Surveyors found expired medications, including insulin, suppositories, ointments, enemas, and vitamins, in medication carts and storage rooms, as well as eye drops not discarded within the labeled timeframe and insulin not properly refrigerated. Nursing staff and the DON confirmed these medications were expired or improperly stored and should have been discarded or stored according to policy.
Three residents with complex medical needs did not receive advance meal menus, were not served meals according to prescribed portions or preferences, and were not informed of available meal options. One resident waited over two hours for a required fortified meal and could not take medications, while others reported persistent hunger, lack of menu access, and limited substitution choices. Staff confirmed that menus were only posted in common areas and not distributed to residents, contrary to facility policy.
Surveyors found that food items in the kitchen, including pre-filled orange juice cups and pitchers, were not labeled with expiration dates, and staff confirmed this was not in line with facility policy. The conventional oven lacked temperature settings, requiring staff to guess cooking temperatures, and the gas department had previously adjusted the oven due to improper heating. Eighteen baking trays had grease build-up, two food pans were dented, and a blender used for mechanical soft diets was cracked and dirty. The dishwashing machine showed signs of calcification and corrosion, with staff acknowledging potential hazards and sanitation concerns. Facility policies required proper labeling, equipment maintenance, and safe food handling, which were not followed.
Staff failed to follow infection control protocols during care and equipment handling for multiple residents, including not changing gloves or performing hand hygiene after peri-care and wound care, not wearing required PPE, allowing a Foley catheter bag to rest on the floor, and improperly storing respiratory equipment. These actions did not comply with facility infection prevention policies.
A resident with blindness and muscle weakness was not provided with an accessible call light, as required by their care plan and facility policy. The standard push button call light was left out of reach and was not appropriate for the resident's condition, with staff confirming the resident could not use it due to visual impairment.
A resident with severe cognitive impairment and multiple physical diagnoses was inaccurately assessed on the MDS as needing only partial/moderate assistance with personal hygiene, despite consistent documentation and staff reports indicating a need for substantial/maximal assistance. This discrepancy was confirmed through record review, staff interviews, and direct observation, with facility leadership acknowledging the error and its potential impact on care planning.
Two residents did not have required care plans in place: one resident with severe cognitive impairment and dependence in daily activities lacked a care plan addressing smoking safety and refusal to use a protective apron, while another resident with chronic kidney disease, diabetes, and heart failure did not have a care plan reflecting a physician-ordered fluid restriction. Staff interviews and record reviews confirmed the absence of these care plans, despite facility policy and physician orders requiring them.
A resident with multiple pressure ulcers and severe cognitive impairment had their low air loss mattress (LALM) set at a weight much higher than their actual weight, contrary to physician orders and facility policy. Staff confirmed that this incorrect setting could make the mattress too hard and negatively affect wound healing.
A resident with a history of malnutrition, muscle weakness, and diabetes mellitus was observed receiving enteral feeding through a gastrostomy tube without the required label indicating feeding rate, date, or time hung. Staff and the DON confirmed that the facility's policy mandates labeling of enteral feeding, but this was not followed, resulting in noncompliance with established procedures.
A resident with chronic kidney disease, diabetes, and heart failure was not properly monitored for fluid intake despite a physician-ordered fluid restriction. Staff provided additional fluids without verification and did not document actual intake, failing to follow facility policy and physician orders.
A resident with severe cognitive impairment and a feeding tube did not receive the full prescribed doses of Acetazolamide and Oyster Shell Calcium/Vitamin D when an LVN failed to completely administer the medications, leaving significant residue in the medication cup. This action was not in accordance with facility policy, as confirmed by the DON.
A resident with multiple medical conditions did not receive a required monthly medication regimen review by the consulting pharmacist, as confirmed by record review and staff interviews. The resident's name was missing from the MRR list for the month, and facility policy requiring monthly reviews was not followed.
A resident with severe cognitive impairment and a feeding tube did not receive the full prescribed doses of Acetazolamide and Oyster Shell Calcium/Vitamin D when an LVN failed to fully administer the medications, leaving significant residue in the medication cup. This resulted in a medication error rate of eight percent, exceeding the required threshold.
Surveyors found that two large trash bins in the parking lot were repeatedly left uncovered and overfilled, with trash scattered around them. Multiple staff, including dietary, maintenance, and infection prevention, confirmed that the bins should be kept closed at all times per facility policy to prevent contamination and pest infestation. Review of facility policies showed clear requirements for covered, well-maintained waste containers, but these were not followed, resulting in improper waste containment.
A resident experienced significant weight loss and poor meal intake, but the facility failed to notify the primary physician and RD or develop a care plan. This led to the resident's hospitalization for dehydration, anorexia, and general weakness. Staff interviews revealed lapses in following facility policies for documenting and addressing changes in the resident's condition.
The facility failed to maintain a sanitary environment in the laundry room, where old cockroach traps with dead insects were found behind dryer machines, covered in dust and lint. Staff were unaware of when to dispose of the traps, and the facility's policies lacked clear instructions. The infection preventionist nurse highlighted the potential health risks, as cockroaches could contaminate clean linen carts.
A resident with dementia and a history of wandering accessed a bottle of cleaning solution left unattended in a shower area. The resident, who requires moderate assistance and supervision, was found tilting the bottle towards their mouth, posing a risk of ingestion. Facility staff interviews revealed that cleaning solutions should be stored securely, but a housekeeper left the bottle in the shower, and the door was left open, allowing the resident access.
The facility failed to observe infection control measures and did not fully implement its Legionella Water Management Program. A CNA provided care without proper PPE, and the Maintenance Director admitted to inadequate water testing and monitoring. The facility's policies on infection prevention and water management were not followed, potentially compromising resident safety.
The facility failed to ensure the call light was within reach for two residents, leading to potential delays in necessary care. One resident with hemiplegia and muscle weakness could not reach the call light placed beside her right shoulder, while another resident with a history of falls and muscle weakness had the call light placed on the floor, out of reach. This was a deviation from the facility's policy on call light accessibility.
The facility failed to ensure the MDS accurately reflected the status of two residents, leading to potential negative impacts on their care plans. One resident's history of falls was not documented, and another resident's restorative nursing services were not recorded in the MDS, despite being provided.
The facility failed to provide necessary care and services for two residents at risk for falls. One resident experienced multiple falls due to inadequate supervision and an unmodified care plan, while another resident's fall mat was not properly placed as required. The facility's policies for fall management and care plans were not followed, putting both residents at risk for injury.
The facility failed to provide pharmaceutical services to meet the needs of two residents. An LVN did not administer one resident's medications within the required 60 minutes of the scheduled time and failed to check another resident's blood glucose and administer insulin before a meal. These actions were not in accordance with the facility's medication administration policy.
The facility failed to maintain a medication error rate below 5%, resulting in a 30.3% error rate. An LVN administered medications late to a resident with asthma, dysphagia, and hypertension, and failed to check another resident's blood glucose and administer insulin before a meal, as required. These actions were inconsistent with the facility's policies.
The facility failed to label foods in the kitchen with item names and 'use by' dates, and did not discard expired food as per the facility's policy. Several food items in the kitchen's refrigerators and freezer were not properly labeled or had expired dates. The ACM and RD Consultant acknowledged the importance of labeling and discarding expired food to prevent serving expired food to residents.
The facility failed to maintain a safe environment by not fixing broken tiles around two uncovered sewer drains in the hallway near the rehabilitation room and the kitchen/activity/dining room. The Maintenance Director acknowledged the issue but had not received any repair reports, while the Housekeeping Supervisor confirmed that the problem had been reported to maintenance.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to ensure dignity for three sampled residents by not fully covering urinary drainage bags and by leaving one resident with visible eye crusting while seated in the hallway. Resident 3, who had dementia and an unstageable sacral pressure ulcer and was dependent for multiple ADLs, was observed with an indwelling catheter collection bag only partially covered by a dignity bag, leaving urine exposed at the bottom of the bag. During a concurrent interview, an LVN stated the urine was visible to anyone passing by and that the dignity bag was intended to cover the urine to maintain the resident’s dignity. Resident 71, who had paraplegia, type 2 diabetes mellitus, and a suprapubic catheter for neurogenic bladder, was also observed with a suprapubic catheter bag not fully covered by a dignity bag, exposing clear yellow urine in the hallway. The care plan for this resident included use of a privacy bag, and the facility’s IPN stated that all suprapubic and indwelling catheter bags were supposed to be fully covered with dignity bags. The IPN further stated that residents might feel embarrassed, sad, or angry when their catheter bags were not properly covered. Resident 23, who had type 2 diabetes mellitus, hypertension, adult failure to thrive, and severe cognitive impairment, was observed sitting in a wheelchair in the hallway with yellow, dry, crusted substance on both eyes. The resident’s care plan indicated assistance with ADLs, and the facility’s RN stated residents should be groomed as they wish and checked for hygiene even if they are independent, and that they should be presentable at all times. The RN stated the facility’s dignity policy was not followed.
Inaccurate Portioning of Cheese for Quesadilla Meal
Penalty
Summary
The facility failed to accurately measure the shredded Monterey cheese used to prepare quesadillas served for lunch. During observation in the kitchen, one dietary staff member was seen using a black scoop with a capacity of 1 ounce to measure the cheese, while another dietary staff member was seen using a yellow scoop with a capacity of 1 5/8 ounces to measure the same ingredient. In interviews, one staff member stated the yellow scoop was the correct tool and the black scoop was not, while the other staff member stated the black scoop was used to prepare five quesadillas and that the yellow scoop was the correct tool to provide proper nutrition for residents. Record review with an RN showed that the quesadilla recipe dated 2002 directed staff to place 2 ounces of cheese on each tortilla, and the facility's Portion Control Chart identified the blue scoop as the correct measure for 2 ounces. Review of the facility's Menus policy showed that menus are to be served as written unless a substitution is provided for preference, availability, or a special meal. The report states this deficient practice affected the six residents who received the quesadilla on 5/14/2026.
Food Service Equipment and Resident Food Storage Not Maintained Properly
Penalty
Summary
The kitchen and food storage areas contained multiple sanitation and food-handling deficiencies during survey observations. A can opener was observed with rust, peeling metal, and food residue buildup. Containers of ground white pepper, oregano, ground black pepper, and onion powder were not properly closed or sealed. The Brand 1 blender pitcher had cracks and a whitish to yellowish substance buildup, and the Brand 2 food processor cover was cracked with yellowish to whitish and brownish buildup. A clear container of food thickener in the stock room was not properly closed, and the microwave interior was rusted, chipped, and had dry food-like residue. The conventional oven knobs did not have visible temperature numbers or settings and were dirty with grease and food residue buildup. The resident’s refrigerator was observed dirty, with dry crusted food debris and visible liquid residue. The Dietary Supervisor stated the refrigerator should have been checked and cleaned every day, and the log indicated that it was supposed to be cleaned daily. In the same refrigerator, three Brand 3 yogurts were not labeled with the resident’s name and room number, and the Dietary Supervisor stated they had a best-by date of 5/2/2026. The freezer door had visible brown-colored drippings. Several items in the resident’s refrigerator, including mozzarella cheese, chocolate ice cream, Brand 4 Maple Griddle, Brand 5 Bowls Mexican Casserole, Brand 6 Lasagna with Meat Sauce, and cheese ravioli, were not dated with when they were brought in by the resident’s family or representative and were not labeled with the resident’s name and room number. The Dietary Supervisor stated the [NAME] Style Beef [NAME] had a best-by date of 4/22/2026. During interviews, the Dietary District Manager and Dietary staff stated the conventional oven knobs lacked visible temperature settings and that staff estimated the temperature when cooking. Staff also stated the can opener was rusted with peeled metal and residue, the blender and food processor were cracked with buildup, and food and spice containers should be sealed properly. Review of facility policies showed that food brought by family or visitors should be labeled with the resident’s name, current date, and use-by date, stored properly, and discarded after 48 hours; cold foods should be wrapped or covered, labeled and dated, and arranged to prevent cross-contamination; and equipment should be routinely cleaned and maintained. The Dietary Supervisor stated these policies were not followed.
Hospice Coordination and Care Plan Deficiencies
Penalty
Summary
The facility failed to ensure coordination of care between the facility and hospice staff for two sampled residents. For one resident, the record showed hospice care was in place, with diagnoses including unspecified dementia, convulsions, and a history of pneumonia. The resident’s MDS indicated moderately impaired cognitive skills, dependence with multiple activities of daily living, and hospice status. The physician’s order summary included an order to admit the resident to hospice and to have hospice manage care related to Alzheimer’s disease and provide medications related to comfort, symptom control, and management of terminal illness. A review of the resident’s hospice medication list showed several medications that were not reflected on the physician’s order summary, including lorazepam for restless behavior or combativeness, milk of magnesia for constipation, ondansetron for nausea and vomiting, phenobarbital for seizure activity, and zinc for wound healing. The DON confirmed these medications were missing from the order summary and stated the omission was important because the resident had pressure ulcers and needed zinc for wound healing, and phenobarbital was indicated for seizures. The DON also stated the hospice medication list did not include naloxone, which was present on the order summary. The DON stated hospice medications should match the order summary and that the lists should be reviewed and compared during recap to ensure medications are coordinated and available when needed. For the second resident, the record showed hospice care was active, with diagnoses including dementia, atrial fibrillation, and atrioventricular block. The MDS indicated severely impaired cognitive skills and dependence with multiple activities of daily living, and hospice status. The order summary showed an order to admit the resident to hospice on routine level of care. RN 1 and RN 2 both stated the resident did not have a care plan addressing care under hospice 1. They stated the care plan should include coordination of care between the hospice and the facility, including the frequency of hospice visits and other orders from the hospice plan of care summary. The facility’s hospice-related policy and the contract agreement with hospice both stated that the hospice and facility were to communicate and jointly develop and coordinate the plan of care.
Call Light Not Kept Within Resident Reach
Penalty
Summary
The facility failed to ensure the call light device for one sampled resident was within reach, as required by the resident’s care plan and facility policy. Resident 8 was admitted with diagnoses including hypotension, dementia, and muscle weakness. The MDS dated 3/5/2026 indicated moderately impaired cognitive skills for daily decision making and that the resident required supervision or touching assistance with eating, oral care, toileting, and personal hygiene, as well as partial/moderate assistance with showering, dressing, and footwear. Resident 8’s care plan, initiated on 5/15/2025 and revised on 3/13/2026, identified nutritional risk related to muscle weakness, dementia, dysphagia, and cognitive communication deficit and directed staff to place the call light within reach at all times. During a concurrent observation and interview on 5/12/2026, the resident’s call light string was observed away from the resident, behind the bed, and not within reach. The resident stated he could not reach the call light and said it is usually on the left side of the bed where he can easily reach it when he needs help. CNA 1 and the DSD both stated the call light needs to be within the resident’s reach at all times so the resident can call for assistance.
Overflowing PPE Trashcan in Resident Room
Penalty
Summary
The facility failed to provide a clean and homelike environment for one sampled resident by allowing the trashcan used for disposal of soiled PPE in the resident’s room to become overflowing. Resident 102 was admitted with diagnoses including gastrostomy, end stage renal disease, and muscle weakness, and the resident’s H&P indicated the resident did not have the capacity to make decisions. The resident was also ordered for infection precautions enhanced barrier every shift for a G-tube and a right upper chest permacath. During observation, Room A’s trashcan was seen overflowing with PPE. The IPN reviewed a photo of the trashcan and verified that it was overflowing with soiled PPE and stated that Room A was on EBP. RN 1 stated that trashcans are supposed to be closed all the time to prevent contamination or spread of bacteria, especially trashcans for soiled PPE. The facility’s Homelike Environment policy stated that residents are provided with a safe, clean, comfortable, and homelike environment.
Unnecessary Psychotropic Medication Use and Missing PRN Rationale
Penalty
Summary
The facility failed to ensure that Resident 4 was free from an unnecessary psychotropic medication by using buspirone with an incorrect indication. Resident 4 was admitted and readmitted to the facility with diagnoses including dementia, major depressive disorder, and a history of falling. The resident’s MDS showed severely impaired cognitive skills for daily decision making, symptoms of depression, dependence with multiple activities of daily living, and use of antianxiety and antidepressant medications. The order summary listed buspirone 5 mg every 8 hours for dementia with behavioral disturbance manifested by irritability and striking out to staff during ADL care, ordered on 4/9/2026. During record review and interviews, RN 1 and RN 2 verified that the buspirone order was written for dementia and stated that this was not the correct diagnosis for the medication. RN 1 stated buspirone had previously been given for the resident’s anxiety and that the diagnosis and purpose needed to be accurate to ensure the right medication was given for the right purpose. RN 2 stated psychotropic medication orders should include the resident’s diagnosis and the behavior being manifested so the medication is necessary for the resident. The facility’s Medication Utilization and Prescribing-Clinical Protocol stated that when a medication is prescribed, the physician and staff will identify the indications considering the resident’s age, medical and psychiatric conditions, risks, health status, and existing medication regimen. The facility also failed to ensure Resident 55’s PRN Ativan order had documented rationale for use beyond 14 days. Resident 55 had diagnoses including anxiety disorder, claustrophobia, and major depressive disorder, and the MDS showed modified independence with daily decision making, symptoms of depression, and assistance needs with several ADLs. The MAR showed lorazepam 1 mg every 8 hours as needed for anxiety for 30 days, with the start date of 4/10/2026 and behavior described as crying and screaming. RN 1 and RN 2 stated PRN lorazepam orders should be limited to 14 days unless there is psychiatrist documentation and reevaluation documenting the rationale for extending use, and they verified there was no documented reason in the record supporting the 30-day PRN order. The facility policy stated that the physician and staff will evaluate the rationale for medications used intermittently on a PRN basis and document a rationale when the indication, dose, or frequency is greater than commonly practice.
Inaccurate MDS Coding of Unsupported Psychosis Diagnosis
Penalty
Summary
The facility failed to ensure an accurate MDS for one resident by coding a diagnosis of psychosis that was not supported by the resident’s medical record. Resident 32 was admitted and re-admitted with diagnoses including dementia, depressive disorder, and muscle weakness. In the quarterly MDS, the resident was documented as having moderately impaired cognitive skills for daily decision making, being independent with eating, requiring setup or clean-up assistance with oral and personal hygiene, partial/moderate assistance with toileting hygiene and upper body dressing, and substantial/maximal assistance with showering, lower body dressing, and putting on/taking off footwear. During record review and interviews, RN 1 verified that psychosis was listed on the MDS but was not part of the resident’s admission diagnoses and was not supported by other documentation, including recent psychiatric consult notes. RN 1 stated she did not know why psychosis was coded on the MDS. The MDS Assistant also verified that psychosis should not have been coded because the resident had no active diagnosis of psychosis, was not receiving medication for psychosis, and had no care plan related to psychosis. The facility policy stated that MDS information must reflect the resident’s status during the look-back period and that the person completing the MDS must certify the accuracy of that portion of the assessment.
Failure to Update Hospice Care Plan After Hospice Discharge
Penalty
Summary
The facility failed to revise Resident 40’s care plan after the resident was discharged from Hospice 2 on 6/27/2025. Resident 40’s record showed diagnoses including dementia, atrial fibrillation, and atrioventricular block, and the resident’s care plan for hospice care due to medical condition and diagnosis of Afib, initiated on 3/13/2024, still indicated the resident was under Hospice 2 without a discontinue date or the discharge date from Hospice 2. The record review also showed Resident 40 later had an order to admit to HSP on routine level of care, and the MDS dated 2/16/2026 indicated the resident had severely impaired cognitive skills for daily decision making and required extensive assistance or was dependent for multiple ADLs, including eating, oral hygiene, toileting hygiene, showering, lower body dressing, footwear, and personal hygiene. During interviews, RN 1 and RN 2 both verified that the hospice care plan for Hospice 2 remained active and was not revised to reflect that Resident 40 was no longer under Hospice 2 after discharge. RN 1 stated the care plan was not updated to show the resident was under HSP and did not include the hospice frequency of visits. RN 2 stated the hospice care plan should have been resolved, completed, or discontinued when the resident was discharged from Hospice 2, and noted that updating care plans is important so staff have the necessary information to provide appropriate resident-centered care. The facility’s Care Plan Comprehensive policy stated that care plans are reviewed and revised as resident assessments and conditions change.
Failure to Provide Grooming and Hygiene Assistance
Penalty
Summary
The facility failed to provide grooming services in accordance with the care plan and facility policy for one resident who was unable to perform activities of daily living independently. The resident was admitted with hemiplegia, hemiparesis, muscle weakness, and dementia, and the history and physical noted poor vision. The MDS indicated the resident’s cognitive skills for daily decision making were moderately impaired and that the resident needed setup and clean-up assistance with personal hygiene. The care plan, initiated on admission and later revised, stated the resident required assistance with ADL care, including personal hygiene, and setup assistance from one staff member for personal hygiene care. During observation, the resident was seen sitting in a wheelchair in the hallway with a dry whitish substance on the left arm, which a CNA identified as cream to white colored puree food. On a later observation, the resident had a dry brownish to yellowish substance on the right palm and left wrist, and long, jagged fingernails with a yellowish to brownish-black substance under the nails. A CNA stated the substance on the resident’s right palm, left wrist, and under the fingernails was dry poop. The IPN stated residents can put dirty hands in their mouths and on their eyes, which can cause illness in both residents and staff, and identified the issue as infection control and cross-contamination. RN 2 reviewed the facility policy on ADLs and stated the policy was not followed. The resident stated he wants to be clean all the time and needs somebody to help him.
LALM Set Incorrectly for Resident With Pressure Ulcer
Penalty
Summary
The facility failed to ensure that Resident 3’s low air loss mattress (LALM) was set at the correct weight setting in accordance with the manufacturer’s guidelines, the facility’s policy, and the resident’s care plan. Resident 3 was admitted with dementia and an unstageable sacral pressure ulcer, and the Minimum Data Set indicated the resident had severely impaired cognitive ability, was dependent for multiple activities of daily living, and had two unstageable pressure ulcers. The resident’s orders allowed use of a LALM for wound management, and the care plan directed that the mattress settings be monitored for accuracy based on manufacturer’s guidelines every shift. During observation, Resident 3’s LALM was set to 180 lbs even though the resident’s recorded weight was 152 lbs. The LVN stated the mattress should have been set to 150 to 160 lbs and that the correct weight setting was needed to properly prevent skin breakdown. The RN supervisor reviewed the manufacturer’s manual, which stated to determine the patient’s weight and set the control knob to that weight setting, and confirmed the mattress must be set according to the resident’s weight. The RN also stated that if the LALM is set higher than the resident’s weight, it applies more pressure to a wound and might cause the wound to get worse and might create new pressure ulcers.
Improper Disposal of Used Insulin Syringe in Sharps Container
Penalty
Summary
A used insulin syringe was observed protruding halfway out of one of four sharps containers in the hallway near Station 1 medication cart. During the observation, LVN 5 stated that the syringe had not been fully placed into the sharps container and that visitors, residents, and staff were passing in the hallway and could get the needle and use it for other purposes. RN 2 later stated that the insulin syringe should have been disposed of properly to prevent accidents and ensure the safety of residents, staff, and visitors, and added that confused residents might pick up the syringe and play with it. During record review, the facility's Sharp Disposal policy stated that contaminated sharps must be discarded into designated containers that are closable, puncture-resistant, and leakproof on the sides and bottom, and RN 2 stated the facility did not follow its policy because the needle was not correctly disposed in the sharps container.
Failure to Elevate Head of Bed During Oxygen Therapy
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not met for Resident 6, who was admitted and readmitted with diagnoses including unspecified dementia, type 2 DM, and a history of pneumonia. The MDS dated 4/1/2026 indicated the resident had moderately impaired cognitive skills for daily decision making, was dependent for several activities of daily living, and was on oxygen therapy. The order summary included an order for oxygen at 3 LPM via nasal cannula as needed for shortness of breath and an order to keep the head of bed elevated to facilitate lung expansion every shift. The care plan also directed staff to keep the head of bed elevated and to position the resident with the head of bed at 45 degrees, if tolerated, to promote lung expansion and improve air exchange. During observation on 5/12/2026, Resident 6 was awake in bed receiving 3 LPM of oxygen via nasal cannula, but the head of bed was not elevated and the resident was flat on her back. During a concurrent observation and interview on 5/13/2026, Resident 6 was again observed sleeping in bed on 3 LPM of oxygen with the head of bed flat, and LVN 3 stated the head of bed was flat and not elevated to 45 degrees. In a follow-up interview, LVN 3 stated Resident 6 should have her head of bed elevated at least 45 degrees while on oxygen therapy. The DON stated it was standard practice to elevate the head of bed to promote lung expansion while receiving oxygen and acknowledged that Resident 6's care plan to elevate the head of bed was not followed.
Missing Post-Dialysis Weight and Nurse Signature on Hemodialysis Record
Penalty
Summary
Provide safe, appropriate dialysis care/services for a resident who requires such services was not met for a resident with ESRD, CHF, and bradycardia who was receiving hemodialysis at the facility. The resident’s MDS indicated modified independence for daily decision making and varying levels of assistance with activities of daily living, and the care plan directed staff to request pre- and post-dialysis weights from the dialysis center and to send and review a communication book with dialysis. The resident’s order summary showed hemodialysis scheduled every Tuesday, Thursday, and Saturday. During record review and interviews, the Hemodialysis Communication Record for the resident’s return from dialysis on 4/23/2026 did not reflect a post-dialysis weight and did not contain the facility licensed nurse’s signature. RN 1 stated the weight should have been completed in the dialysis center and that the nurse who received the resident from dialysis should have called the dialysis center to request the post-dialysis weight. RN 2 stated the communication record should have been fully completed by the charge nurse, including the resident’s weight and the licensed nurse’s signature, upon return from dialysis to know the resident’s status. The facility policy titled Dialysis Care stated nursing staff will communicate information in writing to dialysis staff and may use the Hemodialysis Communication Record.
Failure to Administer Potassium as Ordered
Penalty
Summary
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was not met for one sampled resident when the LVN failed to administer potassium as ordered. Resident 38 was admitted with diagnoses including muscle weakness, heart failure, and acute kidney failure. The resident's MDS dated 5/5/2026 indicated modified independence with cognitive skills for daily decision making, setup or clean-up assistance with eating and personal hygiene, supervision or touching assistance with oral hygiene, substantial/maximal assistance with upper body dressing, and dependence for toileting hygiene, showering, lower body dressing, and footwear. The resident had a physician's order for potassium oral tablet 10 mEq by mouth once daily for supplement, with instructions to administer with meals/food or a full glass of water. During medication administration observation, the LVN gave the potassium tablet without food or a full glass of water. In interview, the LVN stated he did not administer the medication with food and did not offer a full glass of water. RN 1 stated medications ordered to be given with food should be followed and that Resident 38's potassium should have been given with breakfast. The facility policy stated medications are to be administered in a safe and timely manner, as prescribed, and in accordance with ordered time frames.
Inaccurate Medication Order and Fluid Intake Documentation
Penalty
Summary
Resident 32’s medical record contained an incorrect physician order for memantine hydrochloride ER 28 mg. The order listing showed the medication was entered as being for “supplement” rather than for dementia, even though the resident’s diagnoses included dementia and the medication is used to treat moderate to severe dementia. During record review and interviews, RN 2 and RN 1 both stated that memantine is not a supplement and that the indication had been documented incorrectly when the order was obtained, resulting in inaccurate documentation in the resident’s record. Resident 72’s record also did not reflect the physician-ordered 24-hour intake and output tally as required. The resident had diagnoses including acute kidney failure with tubular necrosis, heart failure, and dependence on renal dialysis, and the care plan directed staff to monitor and tally total intake and output every night shift. The order summary specified a 1200 ml fluid restriction per 24 hours with intake divided across shifts and meals, and LVN 4 stated that night shift staff added the total fluid intake for the day and documented it in the medical record. During review of the MAR and interview with the DON, the facility identified that Resident 72’s total fluid intake was documented as zero on four dates even though the actual 24-hour totals were 580 ml, 380 ml, 580 ml, and 620 ml. The DON stated the physician order to tally the resident’s total fluid intake was not followed. The facility’s policy required documentation to be objective, complete, and accurate, and the physician orders policy required orders to be complete, accurate, and clarified as necessary.
Improper Storage of G-tube Tip
Penalty
Summary
The facility failed to ensure that Resident 102’s G-tube tip was not placed inside the bedside drawer wrapped in tissue paper. Resident 102 was admitted with diagnoses including gastrostomy, end stage renal disease, and muscle weakness, and the H&P dated 5/13/2026 indicated the resident did not have the capacity to make decisions. During a concurrent observation and interview on 5/12/2026 at 12:23 PM, LVN 5 stated that Resident 102’s G-tube tip was inside the bedside drawer and wrapped with tissue paper. During a concurrent interview and record review on 5/13/2026 at 2:20 PM, the DON reviewed the resident’s order summary and confirmed an order for enteral feeding of Nephro 1.8 at 40 mL via G-tube. In a later interview, the DON stated that when the G-tube is disconnected from the resident, the tip must be recapped and stored properly for infection control, although this was not specified in the facility’s P&P for G-tubes. The IPN stated that when the G-tube is not connected to the resident, it must be recapped and should not be wrapped with tissue paper or placed inside the cabinet. The facility’s G-Tube Protocol lesson plan stated that when feeding equipment is not actively in use, it must be recapped and stored correctly.
Elopement Due to Unsupervised Main Exit and Inadequate Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision, safety measures, and monitoring to prevent an elopement. One resident, admitted with diverticulitis, gait and mobility abnormalities, and muscle weakness, had a 3/5/2026 MDS showing severely impaired cognitive skills for daily decision-making and a need for partial/moderate assistance with toileting, dressing, transfers, and walking 50 feet with two turns. On 3/16/2026, this resident left the facility without staff knowledge around 8 PM and was not returned until approximately 8:45 PM by police. A progress note documented that the resident was discovered missing when a CNA observed that the resident was not in her room or near the nurse’s station, prompting a Code Pink for elopement. Interviews and record review showed that earlier that day the resident had left with her sister for an appointment and, according to another resident with decision-making capacity, had expressed a desire to go home and later paced in the room before exiting through a shared bathroom into the hallway. The CNA assigned to the resident reported last seeing her in the room around 6:10 PM before going on break and discovering her absence around 8 PM when assisting the roommate. Nursing staff stated the resident had an unsteady gait and was forgetful and believed she could only have exited through a door in front of the nurse’s station. The DON reported that the main door was locked at 6 PM and did not open from the outside but could still be pushed open from the inside, that the resident most likely exited through this main door because it was closest to her room, and that the main door was not supervised after 6 PM. The facility’s Safety of Residents policy stated the facility would provide a safe environment for residents and staff.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Provide Adequate Nail Care and Hygiene for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment, autism, and dementia, who was dependent on staff for most activities of daily living (ADLs), was not provided adequate care and services to maintain good grooming and personal hygiene. The resident was observed with untrimmed fingernails that had sharp edges, a pea-sized bruise near the left eye, and scratches on the right forehead. Staff interviews confirmed that nail care was part of their responsibilities and that the resident's fingernails should have been assessed and trimmed regularly to prevent self-injury. Further review revealed that there was no care plan addressing the resident's behavior of self-scratching or specific interventions for nail care. The facility's Director of Nursing confirmed the absence of a care plan for these issues and acknowledged that the facility did not have a policy and procedure specific to nail care, relying instead on a general ADL policy. The lack of individualized care planning and oversight led to the resident being at risk for skin injuries from untrimmed nails.
Failure to Develop and Implement Foley Catheter Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident's Foley catheter care as ordered by the physician. The resident, who had a history of left femur fracture, left artificial hip joint, and unspecified fall, was admitted and readmitted to the facility. The Minimum Data Set assessment indicated the resident had severely impaired cognitive skills and was dependent on staff for all activities of daily living. Despite physician orders for Foley catheter care and monitoring of urine output, there was no corresponding care plan documented or implemented in the resident's records. Interviews with facility staff, including an LVN, medical records staff, and the Director of Nursing, confirmed that no care plan was developed or updated to address the Foley catheter care and urine output monitoring. The facility's own policy requires the interdisciplinary team to develop a comprehensive, person-centered care plan for each resident, incorporating measurable objectives and timetables, and to update the plan with any new physician orders or changes in the resident's condition. This policy was not followed in the case of this resident.
Inaccurate Documentation of Pressure Injuries on Weekly Summary
Penalty
Summary
The facility failed to ensure accurate and concise documentation of a resident's skin condition on the Weekly Summary Documentation (WSD) dated 4/17/2025. Despite the resident having multiple documented pressure injuries—including a stage 3 pressure injury on the left buttock and deep tissue injuries (DTIs) on both heels, as confirmed by the Treatment Administration Record (TAR) and the wound care doctor's Weekly Wound Assessment (WWA)—the WSD incorrectly indicated that the resident had no skin issues. This error was acknowledged by the LVN who completed the WSD, stating that the section for skin integrity was checked incorrectly and should have reflected the presence of skin problems. The resident involved had a complex medical history, including a hip fracture, left artificial hip joint, and a history of falls, and was assessed as severely cognitively impaired and fully dependent for all activities of daily living. The discrepancy in documentation was identified during interviews and record reviews, with the Director of Nursing (DON) confirming that the WSD was inconsistent with other clinical records. Facility policy requires nursing documentation to be clear, accurate, and reflective of the resident's condition, but this was not followed in this instance, potentially impacting the monitoring and care of the resident's wounds.
Failure to Monitor and Document Catheter Care and UTI Signs
Penalty
Summary
The facility failed to provide appropriate care and services for a resident with an indwelling catheter by not consistently monitoring for signs and symptoms of urinary tract infection (UTI) as required by the resident's care plan and facility policy. The resident, who was admitted with diagnoses including urine retention, hemiplegia, hemiparesis, and muscle weakness, had a care plan that specified monitoring for infection, urine characteristics, and discomfort, with documentation and prompt reporting to the physician if abnormalities were observed. Despite these directives, there were multiple instances where staff did not document or monitor the resident's urine for sediment, color changes, or pain, particularly during shifts when changes in the resident's condition were noted, such as the presence of white sediments, pinkish urine, and lower abdominal pain. Observations and interviews revealed that staff, including the DON, LVNs, and CNAs, acknowledged lapses in documentation and monitoring. The DON confirmed that there was no documentation of urine monitoring for several shifts when the resident had documented changes in urine appearance and discomfort. Staff interviews indicated that some did not check for sediments or document findings, and there was inconsistency in following the care plan interventions. The facility's policy required observation and documentation of urine characteristics and signs of UTI, but these procedures were not followed. Record reviews further showed that the required monitoring and documentation were missing during critical periods when the resident exhibited symptoms such as sediment in the catheter tubing, pinkish urine, and bladder pain. The DON stated that the facility lacked a clear policy on documenting changes of condition every shift for 72 hours, and staff were not consistently addressing or documenting the resident's change of condition. This failure to adhere to care plan interventions and facility policy resulted in a deficiency related to catheter care and UTI prevention.
Failure to Cover Urinary Collection Bags Compromises Resident Dignity
Penalty
Summary
The facility failed to maintain or enhance the dignity and respect of two residents by not ensuring their urinary collection bags were covered with privacy bags, as required by facility policy and care plans. For one resident with end stage renal disease and chronic kidney disease, documentation showed the need for an indwelling Foley catheter and a care plan intervention to provide a privacy bag. During observation, the resident's Foley catheter bag was found uncovered and hanging on the side of the bed. Interviews with nursing staff and the DON confirmed that the catheter bag should have been covered to promote privacy and dignity. Another resident, admitted with kidney and ureter disorders and dehydration, was also observed with an uncovered urine collection bag. This resident was severely cognitively impaired and dependent on staff for all activities of daily living, including toileting and hygiene. Staff interviews again confirmed that the urine collection bag should not have been exposed, as this compromises the resident's dignity. A review of the facility's policy on dignity emphasized that residents must be cared for in a manner that promotes well-being and self-esteem, specifically prohibiting practices that compromise dignity, such as leaving urinary catheter bags uncovered. The failure to follow these policies and care plan interventions resulted in a deficiency related to the residents' right to privacy and dignity.
Failure to Prevent Accident Hazards and Inadequate Supervision
Penalty
Summary
A deficiency was identified when a razor blade was found on the floor in the room of a resident with severe cognitive impairment and significant physical limitations. The resident required partial or moderate assistance with eating and hygiene, and was fully dependent for toileting, dressing, repositioning, and transfers. The razor blade was observed by staff during a room check, and it was confirmed that razor blades are not permitted in resident rooms due to the risk of injury. Staff interviews indicated that the razor blade was likely left behind by a CNA after assisting the resident with shaving, and both the Infection Preventionist Nurse and Registered Nurse Supervisor acknowledged that this was a violation of facility policy and posed a hazard to the resident and staff. Another deficiency was observed when medication was left unattended on the bedside table of a resident with moderate cognitive impairment and multiple medical conditions, including diabetes, end stage renal disease, and dysphagia. The medication, identified as Tums, was left by a nurse for the resident to take at their convenience. Staff interviews confirmed that medication should not be left at the bedside, regardless of whether it is over-the-counter, as it could be accessed by the resident or others, potentially leading to harm. The nurse responsible acknowledged the error and stated that it was a mistake not to check the room during rounds. Facility policy review indicated that environmental hazards include unattended equipment and sharp objects accessible to vulnerable residents. Both incidents involved a failure to maintain an environment free from accident hazards, as required by facility policy, and were confirmed through staff interviews and direct observation.
Expired and Improperly Stored Medications Found During Survey
Penalty
Summary
Surveyors observed that the facility failed to ensure the safe provision of pharmaceutical services by not removing and discarding expired medications and by not storing certain medications according to manufacturer requirements and facility policy. Specifically, expired insulin vials, suppositories, topical ointments, enemas, and vitamin bottles were found in medication carts and storage rooms. Additionally, eye drops were not discarded within the labeled 28-day period after opening, and unopened insulin vials were not refrigerated as required. These findings were confirmed through interviews with nursing staff, who acknowledged that the medications were expired or improperly stored and should have been discarded or stored according to policy. The Director of Nursing confirmed that medications should be stored and discarded per manufacturer instructions and facility policy, including the use of multi-dose vials within 28 days and proper refrigeration of insulin. The facility's policy and procedure also require that discontinued, outdated, or deteriorated medications be returned or destroyed as directed by the dispensing pharmacy, and that medications for external use be clearly marked and stored separately. The observed deficiencies were based on direct observation, staff interviews, and review of facility policy.
Failure to Provide Menus and Follow Prescribed Diets for Residents
Penalty
Summary
The facility failed to provide menus and ensure nutritional adequacy for three residents by not supplying meal menus in advance, not following prescribed meal portions, and not honoring food preferences as documented in care plans and physician orders. For one resident with multiple diagnoses including diabetes, end stage renal disease, and chronic kidney disease, the facility did not provide the ordered double portion and fortified oatmeal for breakfast, resulting in the resident waiting over two hours for the correct meal and being unable to take morning medications due to an empty stomach. Observations and interviews confirmed that the resident's meal ticket specified double portions and oatmeal, but these were not delivered as ordered. Another resident, dependent on staff for most activities of daily living and at nutritional risk due to wound healing needs, reported never receiving a menu and not being informed about meal options. This resident expressed dissatisfaction with the food, was not offered substitutions, and often ate less than 25% of meals, leading to persistent hunger. Staff interviews confirmed that menus were not distributed to residents and that communication about meal options was lacking, especially for those who were bedbound or did not attend the activity room. A third resident, with significant medical history including diabetes with neuropathy and multiple amputations, also did not receive a menu and was not informed about meal options. This resident frequently found the meals unappetizing and insufficient in portion size, often resorting to limited substitution options such as a cold turkey sandwich. Staff and dietitian interviews corroborated that menus were only posted in common areas and not provided individually, making it difficult for residents, especially those confined to their rooms, to make informed meal choices or request timely substitutions. Facility policies required that food preferences be honored and menus be reviewed with residents, but these practices were not followed.
Deficient Food Storage, Equipment Maintenance, and Sanitation Practices Identified
Penalty
Summary
Surveyors observed multiple failures in food storage, preparation, and equipment maintenance within the facility's kitchen. Seventeen pre-filled orange juice cups and two orange juice pitchers were found in a refrigerator without any use by or expiration dates. Dietary staff confirmed these items should have been labeled to ensure expired food is not served to residents. Additionally, the conventional oven's temperature knobs had no visible settings, requiring staff to guess the temperature during cooking. Staff acknowledged that this could result in food not being cooked to the required temperature, with the gas department previously noting the oven was not heating properly and had since been adjusted, possibly leading to overheating. Further observations revealed that eighteen large metal baking trays had visible grease build-up, and two large food pans were dented. Staff indicated that using trays with caked-on grease could pose a fire hazard. A blender used for preparing mechanical soft diets was found to have small cracks at the bottom and was dirty and dusty, despite being relatively new. Staff stated the importance of having equipment in good condition to ensure proper food preparation for residents requiring pureed diets. The dishwashing machine was observed to have visible calcification, corrosion, and discoloration. Staff reported that the machine is serviced annually and tested daily, but acknowledged that the corrosion could present electrical hazards and impact the machine's ability to properly sanitize dishes. Facility policies and procedures reviewed by surveyors required proper labeling and dating of refrigerated foods, maintenance of clean and undamaged equipment, and safe food handling practices, all of which were not followed as observed during the survey.
Failure to Follow Infection Control Practices During Resident Care and Equipment Handling
Penalty
Summary
Facility staff failed to adhere to infection prevention and control practices for four of five sampled residents, as observed through direct care activities and interviews. For one resident with a history of sepsis, cellulitis, and dementia, a CNA did not wear a gown while providing incontinent care, used the same gloves to touch the resident and room surfaces after care, and did not perform hand hygiene. During wound care for the same resident, a treatment nurse failed to change gloves and perform hand hygiene between removing a soiled dressing and applying a clean one, contrary to facility policy and the resident's care plan for enhanced standard precautions due to MDRO risk. Another resident with a urinary tract infection and dementia was subject to similar lapses. A CNA touched surfaces belonging to another resident and then handled the resident's cup and straw without performing hand hygiene. The same CNA also failed to change gloves and perform hand hygiene after providing peri-care, subsequently touching the resident's hand and bed rail. Interviews with the Infection Prevention Nurse confirmed that these actions did not comply with facility policy and increased the risk of infection transmission. Additional deficiencies included improper management of medical equipment. One resident with an indwelling Foley catheter was observed with the catheter bag resting on the floor, which was confirmed by nursing staff as a violation of policy intended to prevent infection. Another resident receiving respiratory treatments had their mask and nasal cannula stored on top of an undated and unlabeled plastic bag, rather than inside a clean, dated, and labeled bag as required. Staff interviews corroborated that these storage practices did not meet infection control standards outlined in facility policies.
Failure to Provide Accessible Call Light for Visually Impaired Resident
Penalty
Summary
The facility failed to accommodate the needs of a resident with significant visual impairment and muscle weakness by not ensuring the call light was within reach and by not providing an appropriate touch pad call light. The resident, who was blind and dependent on staff for most activities of daily living, was observed with a standard push button call light that was not accessible. Staff interviews confirmed that the call light was not within reach and was not suitable for the resident's condition, as the resident would not know where or how to use it due to blindness. The resident's care plan specifically indicated that the call light should be placed within reach, and facility policy required accessible call systems or alternative communication methods for residents with disabilities. Despite these directives, observations showed the call light was left in the middle of the bed while the resident was in a wheelchair against the wall, making it inaccessible. Staff acknowledged the oversight and the need for a more appropriate call light device for the resident's needs.
Inaccurate MDS Assessment of Resident's Personal Hygiene Needs
Penalty
Summary
The facility failed to ensure an accurate assessment of a resident's functional ability for personal hygiene on the Minimum Data Set (MDS), as required by facility policy. The resident in question was admitted with diagnoses including osteoarthritis, contracture, muscle weakness, and dementia, and was documented as severely impaired in cognitive skills for daily decision making. Multiple reviews of the resident's MDS indicated inconsistencies: while the MDS at one point recorded the resident as requiring only partial/moderate assistance with personal hygiene, other documentation, including care conference notes and subsequent MDS assessments, indicated the resident actually required substantial/maximal assistance. Observations of care and interviews with staff confirmed that the resident had consistently needed maximal assistance for personal hygiene for at least a year. Interviews with the DON and MDS Nurse revealed that the MDS had been inaccurately completed, listing a lower level of assistance than was actually required. Both acknowledged the importance of accurate MDS assessments for care planning. The facility's policy assigns responsibility for ensuring accurate and timely MDS submissions to the assessment coordinator or designee, in accordance with federal and state guidelines. The inaccurate assessment had the potential to impact the development and implementation of a resident-centered care plan tailored to the resident's actual needs.
Failure to Develop and Implement Required Care Plans for Smoking Safety and Fluid Restriction
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, as required by facility policy and physician orders. For one resident with severe cognitive impairment and dependence in daily activities, there was no care plan addressing the resident's smoking behavior and consistent refusal to wear a protective smoker's apron. Observations confirmed the resident's refusal, and staff interviews acknowledged the absence of a care plan to address this risk, despite facility policy requiring such issues to be documented and communicated to all personnel. For another resident with stage 4 chronic kidney disease, type 2 diabetes, and acute systolic heart failure, the facility did not create a care plan reflecting a physician-ordered fluid restriction. The order specified detailed fluid limits for both nursing and dietary staff, but review of the care plan and staff interviews confirmed that no care plan was in place to guide staff in monitoring and implementing the fluid restriction. Facility policy required care plans to be updated with new physician orders or changes in condition, but this was not done for the resident. Both deficiencies were identified through observation, record review, and staff interviews. The facility's own policies outlined the need for individualized, measurable care plans that incorporate physician orders and address identified risks, but these were not followed for the two residents in question.
Incorrect LALM Setting for Resident with Pressure Ulcers
Penalty
Summary
The facility failed to set a low air loss mattress (LALM) at the correct setting for a resident with multiple pressure ulcers, as required by the facility's policy and physician's order. The resident, who was admitted with a Stage 4 sacral pressure ulcer, five unstageable pressure ulcers, and a history of diabetes mellitus, was dependent on staff for all activities of daily living and had severe cognitive impairment. According to the resident's care plan and physician's order, the LALM was to be set based on the resident's weight, which was documented as 94 lbs. During an observation, the LALM was found set at 160 lbs, significantly higher than the resident's actual weight. Both the LVN and DON confirmed that setting the LALM above the resident's weight would make the mattress too hard, potentially worsening the resident's wounds. The facility's policy on skin integrity management required staff to implement pressure ulcer prevention measures and to provide care in accordance with physician orders, which was not followed in this instance.
Failure to Label Enteral Feeding Formula
Penalty
Summary
A deficiency was identified when a resident receiving enteral feeding was observed to have an unlabeled feeding formula infusing through a gastrostomy tube. The resident, who had diagnoses including malnutrition, muscle weakness, and diabetes mellitus, required tube feeding as ordered by the physician and as documented in the care plan. The care plan specified that the registered dietitian should monitor caloric intake and that staff should administer tube feeding as ordered. However, during multiple observations, the enteral feeding in the resident's room was found to be infusing without a label indicating the feeding rate, date, or time hung. Interviews with staff, including an LVN and the DON, confirmed that the enteral feeding should have been labeled according to the facility's policy and procedure, which requires labeling the formula with the date and time it was hung. The DON emphasized the importance of labeling to ensure the correct resident receives the correct formula and rate of feed, as this directly impacts the resident's nutritional status. The failure to label the enteral feeding was not in compliance with the facility's established policy and procedure.
Failure to Monitor and Record Fluid Intake for Resident on Fluid Restriction
Penalty
Summary
The facility failed to accurately monitor and record the fluid intake for a resident with a physician-ordered fluid restriction of 1200 ml per 24 hours, divided between nursing and dietary staff. The resident, who had diagnoses including stage 4 chronic kidney disease, type 2 diabetes, and acute systolic heart failure, was observed consuming coffee in addition to milk during lunch. The certified nursing assistant (CNA) who provided the coffee acknowledged knowing about the fluid restriction but did not verify with a nurse before giving the additional fluid. Further interviews revealed that the actual fluid intake for the resident was not being recorded by nursing staff, and there was no documentation of fluid intake for each shift in the resident's medical record. The facility's policies required accurate recording and division of fluids for residents on restriction, but these procedures were not followed, resulting in a failure to implement the physician's order for fluid restriction.
Incomplete Administration of Medications via G-Tube
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to fully administer two prescribed medications, Acetazolamide and Oyster Shell Calcium/Vitamin D, to a resident with severe cognitive impairment and total dependence for daily activities, who was receiving medications via a gastrostomy tube. The LVN prepared the medications by crushing and mixing them in water, but did not ensure the entire dose was delivered, leaving approximately 70% of the Oyster Shell Calcium and 50% of the Acetazolamide in the medication cup. This resulted in the resident not receiving the full prescribed doses as ordered by the physician. The resident involved had a history of urinary tract infection and congestive heart failure, and was dependent on a feeding tube for medication administration. The facility's policy and procedure required that medications be administered in accordance with prescriber's orders and tailored to resident needs. Both the LVN and the Director of Nursing confirmed that the medications were not completely administered, which was not in accordance with the facility's policy.
Missed Monthly Medication Regimen Review for a Resident
Penalty
Summary
The facility failed to conduct a required monthly Medication/Drug Regimen Review (MRR) for one of five sampled residents during the month of February 2025. Specifically, a resident with diagnoses including cerebral infarction, unspecified psychosis, and diabetes mellitus did not have their medication regimen reviewed by the consulting pharmacist as required by the facility's policy and procedure. The resident's admission record and Minimum Data Set (MDS) indicated various care needs and intact cognitive skills, but there was no documented evidence that their medications were reviewed during the specified month. Interviews with the Director of Nursing (DON) and the Pharmacy Consultant confirmed that the resident's name was not included in the MRR list for the month in question, and therefore, the review was not performed. The facility's policy requires that the consultant pharmacist review each resident's medication regimen at least monthly, including upon admission, to ensure appropriate medication management. The absence of the MRR was verified through record review and staff interviews, confirming non-compliance with established procedures.
Medication Error Rate Exceeds Acceptable Threshold Due to Incomplete Administration
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required, with two medication errors identified out of 25 observed opportunities, resulting in an eight percent error rate. During medication administration for a resident with severe cognitive impairment, dependent on a feeding tube, a Licensed Vocational Nurse (LVN) prepared and administered medications using the same G-tube syringe for all crushed medications. The LVN did not fully administer Acetazolamide and Oyster Shell Calcium/Vitamin D as prescribed, leaving significant residue in the medication cup. The LVN acknowledged that only 30% of the Oyster Shell Calcium and 50% of the Acetazolamide were administered, with the remainder left in the cup and not given to the resident. The Director of Nursing confirmed that the medications were not administered in accordance with the physician's orders. Facility policy requires medications to be administered as prescribed, but this was not followed in this instance.
Failure to Properly Contain and Cover Waste Bins
Penalty
Summary
Surveyors observed that two large trash bins located in the facility parking lot were repeatedly left uncovered, with their lids open and visible trash scattered on the ground around them. These observations were made on multiple occasions, and staff interviews confirmed that the bins were not being kept closed as required by facility policy. Dietary staff, the DON, the Maintenance Supervisor, and the Infection Preventionist all acknowledged that the trash bin lids should remain closed at all times to prevent contamination and pest infestation. The bins were also noted to be overfilled, further preventing the lids from being closed properly. A review of the facility's policies and procedures revealed clear requirements for garbage and refuse containers to be kept in good condition, covered with tight-fitting lids, and free of surrounding litter. The policies also specified that garbage areas should be maintained to prevent pests and that food-related waste should be stored in a manner inaccessible to pests. Despite these policies, the facility failed to ensure proper containment and coverage of waste, as evidenced by the open bins and littered area.
Failure to Provide Adequate Nutritional Care
Penalty
Summary
The facility failed to provide adequate nutritional care services for a resident experiencing impaired nutrition. The resident experienced a significant weight loss of six pounds, which was noted on July 3, 2024. However, the facility did not notify the resident's primary physician or the Registered Dietician (RD) about this change of condition. Additionally, the resident's meal intake was consistently 50% or less over several days, yet there was no communication to the primary physician or RD regarding this poor intake. The facility also failed to initiate a resident-centered care plan to address the resident's weight loss and poor meal intake. Despite the resident's declining condition, including general weakness and poor meal intake, no care plan was developed to address these issues. The lack of a care plan and failure to notify the appropriate medical staff placed the resident at risk for further health complications, leading to a hospital admission with diagnoses of dehydration, anorexia, and general weakness. Interviews with facility staff revealed that the Registered Dietician and primary physician were not informed of the resident's condition changes in a timely manner. The facility's policies and procedures for documenting changes in condition and notifying medical staff were not followed. The Director of Nursing acknowledged the absence of a care plan and the lack of an Interdisciplinary Team meeting to address the resident's nutritional needs, which contributed to the resident's deteriorating health condition.
Sanitation Deficiency in Laundry Room
Penalty
Summary
The facility failed to maintain a sanitary environment in the laundry room, as observed during a survey. Two cockroach traps were found behind the dryer machines, covered with dust and lint, and containing dead insects. The maintenance assistant (MA) acknowledged that the traps appeared old and were not dated, and he was unaware of when they were placed or when to dispose of the dead insects. The laundry staff also confirmed the presence of dead cockroaches in the traps for several days but did not know who was responsible for discarding them. The infection preventionist nurse (IPN) expressed concerns about the unsanitary conditions, noting that cockroaches could potentially contaminate clean linen carts and pose a health risk to residents. The assistant administrator (AA) stated that the traps were placed by a pest control company to monitor cockroach activity, but there were no instructions on when to dispose of them. The facility's policy and procedure (P&P) on pest control, last revised in 2008, did not specify when to change or dispose of cockroach traps. The director of nursing (DON) confirmed that the P&P lacked necessary instructions and emphasized the potential health risks posed by cockroaches. Additionally, the facility's Environmental Services Operations Manual, revised in 2017, indicated the importance of keeping equipment clean to prevent germ breeding.
Resident Access to Hazardous Cleaning Solution Due to Inadequate Supervision
Penalty
Summary
The facility staff failed to ensure a safe environment for Resident 4, who was found holding a bottle of cleaning solution in the shower area. Resident 4, who has a history of wandering and impaired cognitive skills due to dementia, was left unsupervised, allowing access to the cleaning solution. The resident was observed tilting the bottle towards their mouth, which posed a significant risk of ingestion and potential harm. Resident 4's medical history includes hypercalcemia, dementia, and dysphagia, and they require moderate assistance with daily activities. The care plan for Resident 4 highlighted the risk of wandering due to impaired cognition and safety awareness, with interventions to redirect the resident to safe areas. However, on the day of the incident, the resident was not adequately monitored, leading to the exposure to the cleaning solution. Interviews with facility staff, including the Housekeeping Supervisor, Licensed Vocational Nurse, and Certified Nursing Assistants, revealed that cleaning solutions are supposed to be stored securely in locked carts or closets. However, a housekeeper left the bottle in the shower, and the shower door was left open, allowing Resident 4 to access the area. The Director of Nursing confirmed that the facility's policies require cleaning solutions to be stored safely to prevent resident access and potential poisoning.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to observe infection control measures as indicated in their policy. Specifically, a Certified Nursing Assistant (CNA) was observed providing care to a resident in an Enhanced Standard Precaution room while only wearing gloves and not a gown. The CNA acknowledged that she should have worn a gown to prevent the spread of infection. The Infection Preventionist Nurse confirmed that CNAs are required to wear gowns and gloves while providing close contact care in such rooms. The facility's policy mandates the use of appropriate precautions and personal protective equipment to prevent the transmission of communicable diseases and infections. Additionally, the facility did not fully implement its Legionella Water Management Program policy and procedure. The Maintenance Director admitted to not using any toolkit to test the water for Legionella since 2018 and only conducted visual inspections and random hot water temperature checks. The data was recorded in a building management platform that did not log information on weekends, and there was no monitoring of cold-water temperatures or comprehensive documentation of water system inspections. The Infection Preventionist and Administrator confirmed that the water management monitoring was not performed daily as required by the policy. The facility's policy on water management emphasizes the importance of proactive steps to prevent Legionella growth and spread. The policy outlines the need for a water management program team, control measures, and regular monitoring to ensure the program's effectiveness. However, the facility failed to adhere to these guidelines, potentially compromising the safety and health of residents, staff, and visitors by not ensuring a safe and sanitary water supply.
Failure to Ensure Call Light Accessibility for Residents
Penalty
Summary
The facility failed to ensure the call light was within reach for two residents, Resident 94 and Resident 24, which had the potential to delay necessary care and services. Resident 94, who was admitted with hemiplegia affecting the right side and muscle weakness, was observed with a call light placed on the bed beside the resident's right shoulder, despite being unable to move her right arm. Interviews with the Director of Staff Development (DSD) and Physical Therapy (PT) confirmed that Resident 94's right elbow could only move 45 degrees actively, making it impossible for the resident to reach the call light. The Director of Nursing (DON) also acknowledged that the call light was not within reach, which could prevent the resident from calling for help in an emergency. The facility's policy on answering call lights, revised in September 2022, indicated that call lights should be accessible to residents when in bed, from the toilet, shower, or floor, which was not adhered to in this case. Resident 24, who had a history of falls, transient ischemic attack, generalized muscle weakness, and lack of coordination, was also found to have the call light out of reach. During an observation, Resident 24 was seen trying to get up from bed and asking for help, with the call light device placed on the floor near the middle of the headboard, out of the resident's reach. Interviews with the assigned Certified Nurse Assistant (CNA) and Licensed Vocational Nurse (LVN) confirmed that the call light should have been placed on the bed close to the resident for easy reach to ensure timely assistance and prevent falls. The facility's policy on answering call lights, revised in September 2022, was again not followed, as it required the call light to be accessible to the resident in various situations. The failure to ensure the call light was within reach for both residents was a clear deviation from the facility's policy and had the potential to delay necessary care and services. Both residents had significant impairments that required them to have easy access to the call light to call for assistance, which was not provided. This deficiency was identified through observations, interviews, and record reviews conducted by the surveyors.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) accurately reflected the status of two residents, leading to potential negative impacts on their care plans. Resident 77, who was admitted with muscle weakness and dementia, had a fall incident that was not accurately documented in the MDS. Despite having a history of falls and a change of condition related to falls, the MDS did not reflect these incidents, which the Director of Nursing acknowledged should have been included to ensure an accurate care plan for the resident's needs. Resident 31, who had diagnoses including abnormal posture and contractures of the knees, did not have an accurate assessment for the restorative nursing program in the MDS. Although the resident received various restorative nursing services, such as passive range of motion exercises and the use of a cervical collar, these were not documented in the MDS. The MDS Coordinator admitted that the restorative nursing program section was not completed, which should have reflected the services provided to the resident. The facility's policy and procedure on resident assessments, revised in October 2023, indicated that MDS assessments should consistently reflect information in progress notes, care plans, and resident observations/interviews. However, the discrepancies in the MDS for both residents 77 and 31 indicate a failure to adhere to this policy, potentially affecting the development and implementation of individualized care plans for these residents.
Failure to Provide Adequate Fall Prevention Measures
Penalty
Summary
The facility failed to provide necessary care and services for two residents at risk for falls. Resident 77 experienced multiple falls, and the facility did not modify the fall/injury care plan after these episodes. The resident, who has muscle weakness and dementia, was not provided with adequate supervision, as evidenced by several incidents where the resident fell from a wheelchair or was found on the floor. The Director of Nursing (DON) acknowledged that the care plan was not revised to include structured monitoring or supervision interventions, and the resident was not supervised as required, leading to repeated falls. Resident 82, who has a history of falls, lack of coordination, and dementia, was also not provided with the necessary care as indicated in the care plan. The care plan required a fall mat to be placed on the left side of the bed to prevent injury in case of a fall. However, during an observation, the fall mat was found folded and not placed on the floor as required. Licensed Vocational Nurse 4 (LVN 4) confirmed that the fall mat was not properly placed, and the resident was at risk for falls due to improper positioning in bed. The facility's policies and procedures for fall management and comprehensive person-centered care plans were not followed. The DON and other staff members acknowledged that the care plans were not individualized or revised as needed to prevent further falls. The lack of supervision and failure to implement the required interventions put both residents at risk for injury, hospitalization, or death.
Failure to Administer Medications Timely and Accurately
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of two residents, Resident 16 and Resident 48, as per the facility's policy. During a medication pass observation, Licensed Vocational Nurse 7 (LVN 7) did not administer Resident 16's medications within the required 60 minutes of the scheduled time of 9 AM. This delay was confirmed by LVN 7, who acknowledged administering the medications after 10 AM. Resident 16's medical history includes asthma, dysphagia, and hypertension, and the resident requires various levels of assistance for daily activities. The medications scheduled for 9 AM included Advair Diskus, Ascorbic Acid, Enoxaparin sodium, Irbesartan, Isosorbide Mononitrate, Lactulose, Lorazepam, Ferrous sulfate, and Colace. The failure to administer these medications on time could potentially affect the resident's health and well-being, as noted by LVN 7 during the interview. The facility's policy mandates that medications be administered within one hour of their prescribed time unless otherwise specified, which was not adhered to in this case. In another instance, LVN 7 failed to check Resident 48's blood glucose and administer insulin before the lunch meal. Resident 48 has a medical history that includes type 2 diabetes, muscle weakness, and dementia. The physician's order required a blood sugar check and insulin administration per sliding scale before meals and at bedtime. During the observation, it was noted that Resident 48 had already started eating before the blood sugar check was performed, resulting in a blood sugar reading of 245 mg/dL. The Assistant Director of Nursing (ADON) confirmed that the blood sugar result was unreliable since it was checked after the resident had started eating. LVN 3 emphasized the importance of checking blood sugar levels and administering insulin as ordered to prevent hyperglycemia. The facility's policy on administering medications specifies that medications should be administered in a safe and timely manner, which was not followed in this case. The facility's failure to adhere to its medication administration policy for both Resident 16 and Resident 48 was observed and confirmed through interviews and record reviews. The deficiencies in medication administration timing and procedure could potentially lead to adverse health outcomes for the residents. The facility's policy clearly states that medications should be administered within one hour of their prescribed time and in accordance with prescriber orders, which was not done in these instances.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure that its medication error rate was less than five percent, resulting in a 30.3% error rate. This was observed during a medication pass where a Licensed Vocational Nurse (LVN) did not administer medications within the required time frame. Specifically, Resident 16's medications were administered more than an hour late, which could potentially affect the resident's condition, especially given their diagnoses of asthma, dysphagia, and hypertension. The LVN acknowledged the delay and its potential impact on the resident's health during an interview. Additionally, the facility failed to check Resident 48's blood glucose and administer insulin before a meal, as required by the physician's order. Resident 48, who has type 2 diabetes and dementia, had their blood sugar checked after starting their meal, rendering the result unreliable. The LVN and Assistant Director of Nursing (ADON) confirmed that the blood sugar should have been checked before the meal to ensure proper insulin administration. This failure could lead to uncontrolled blood sugar levels, which is critical for diabetic patients. The facility's policies and procedures were reviewed and indicated that medications should be administered within one hour of their prescribed time. The LVN's actions were inconsistent with these policies, leading to the observed deficiencies. The ADON emphasized the importance of timely medication administration to prevent complications and ensure the effectiveness of the treatment.
Failure to Label and Discard Expired Food
Penalty
Summary
The facility failed to label foods in the kitchen with item names and 'use by' dates, and did not discard expired food as per the facility's policy and procedure. During an observation and interview with the Accounts Manager (ACM), it was found that several food items in the kitchen's refrigerators and freezer were not labeled with item names, dates opened, or 'use by' dates. Specifically, an open bag of fries, an open bag of chicken tenders, a clear bag of hash browns, two packs of raw meat, a metal container of beans, a zip lock bag containing deli turkey, and an open loaf of bread were not properly labeled or had expired dates. The ACM acknowledged that these items should have been labeled and expired items should have been discarded to prevent serving expired food to residents. In a follow-up interview, the ACM reiterated the importance of labeling food items with expiration dates to prevent serving expired food. The Registered Dietician (RD) Consultant confirmed that there was no specific policy for discarding food items but stated that the facility followed FDA guidelines for discarding food. A review of the facility's policy and procedure indicated that all foods should be stored, wrapped, labeled, and dated to prevent cross-contamination. Additionally, the 2022 FDA Food Code requires that time/temperature control safety refrigerated foods must be consumed, sold, or discarded by the expiration date.
Failure to Maintain Safe Environment Due to Uncovered Sewer Drains and Broken Tiles
Penalty
Summary
The facility failed to maintain a safe environment by not fixing broken tiles around two uncovered sewer drains on the floor in the hallway. This issue was observed in the hallway near the rehabilitation room and the hallway in front of the kitchen and activity/dining room. The Maintenance Director (MED) acknowledged the problem, stating that all sewer drains should be covered and broken tiles should be repaired to prevent falls. However, the MED mentioned that he had not received any reports for floor repairs. The Housekeeping Supervisor (HS) confirmed that housekeeping had cleaned the hallway the previous night and had reported the uncovered sewer drains and broken tiles to the maintenance department for fixing. The facility's Policy and Procedure (P&P) on Maintenance Service, Physical Environment, revised in December 2009, indicates that the maintenance department is responsible for maintaining the building, grounds, and equipment in a safe and operable manner at all times. This includes maintaining the building in good repair and free from hazards, as well as providing routinely scheduled maintenance services. Despite these guidelines, the facility failed to address the reported issues, posing a risk of falls and injuries to residents, visitors, and staff.
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 7,330 citations issued within 25 miles in the last 12 months — including the 32 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 Montebello
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rio Hondo Subacute & Nursing Center | 1.2 mi | — | 78 | 0 |
| El Rancho Vista Health Care Center | 2.1 mi | ★★★★★ | 23 | 0 |
| Monterey Healthcare & Wellness Centre, Lp | 2.1 mi | ★★★★★ | 24 | 0 |
| Pico Rivera Healthcare Center | 2.2 mi | ★★★★★ | 21 | 0 |
| Green Acres Healthcare Center | 2.2 mi | ★★★★★ | 12 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Montebello Care 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.