Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Montecito Heights Healthcare & Wellness Centre, Lp during CMS and state inspections, most recent first.
Unsafe Food Storage, Dating, and Temperature Control: Surveyors found multiple unlabeled, undated, expired, and spoiled foods in kitchen and resident refrigerators, including milk, bread, vegetables, cereal, and condiments. Raw chicken was stored above ready-to-eat foods, and refrigerator temperatures were inconsistent, with milk measured in the danger zone and later served to residents. The DON confirmed expired and undated foods were present and that the facility’s monitoring policy was not being followed.
Failure to Submit PBJ Staffing Data: The facility failed to submit PBJ direct care staffing data to CMS for a quarter after corporate payroll staff believed a TPV had submitted it. The CPC stated the omission was not discovered until later, he did not check the CASPER report because he did not know he could access it, and the ADM stated the facility had no policy or procedure for PBJ submission.
A resident with a nephrostomy tube, UTI, CKD, and cervical cancer had tubing observed touching the floor while the drainage bag was hooked to a walker for convenience. Staff, including LVNs and the DON, stated the tubing should not contact the floor and should be secured to prevent infection, and the resident’s care plan addressed safe drainage and infection prevention. The facility also lacked documentation of routine cold-water temperature monitoring; the MS said only hot water was monitored, while the water management plan and WICRA identified cold-water monitoring as part of the Legionella prevention program.
Reach-in refrigerator held food above the safe cold-holding range, with conflicting thermometer readings showing 35 F on the unit display, 58-65 F on internal thermometers, and milk measured at 57.5 F. The DS stated the internal thermometer was broken and staff relied on the external reading, while the unit contained milk, raw poultry, beef, eggs, dairy items, and other TCS foods during meal prep and service.
A resident with dementia, behavioral disturbances, and depression was ordered quetiapine PRN for psychosis and trazodone PRN for insomnia without a stop date, and the informed consent was signed after the orders were already entered and sent to the pharmacy. The RN and DON stated consent should have been obtained before ordering the psychotropic medications, and the facility policy required written informed consent and limited PRN psychoactive medications to 14 days.
Inaccurate MDS Coding for Anticoagulant Use and Dialysis Access: The facility failed to accurately code a resident’s anticoagulant use on the MDS even though MAR documentation showed Eliquis was given during the look-back period, and staff confirmed the MDS should have reflected it. The facility also documented conflicting dialysis access information for another resident, with records showing a Permacath on the left chest while other entries referenced a CVC and AV shunt with bruit and thrill, and staff stated the resident never had an AV shunt.
Medication management was not accurate for two residents. One resident with CKD, DM2 with diabetic polyneuropathy, and muscle weakness had a lidocaine patch applied and removed without clear documentation matching the order and progress notes, while another resident with a right femur fracture had a tramadol count sheet showing removal of a tablet that was not documented on the eMAR. The DON stated missing narcotic documentation could lead to unnecessary additional dosing, misuse, and/or drug diversion.
A cook served diced fried potatoes using the same larger scoop for both CCHO and regular diet trays, resulting in twice the intended potato portion for CCHO meals. The RD stated a smaller scoop should have been used for the therapeutic diet, and the facility menu and policy specified different portion sizes for regular versus CCHO diets.
Kitchen staff used a cornstarch slurry instead of gravy on MM5 Salisbury Steak trays, and an RD supervisor observed the substitution and stated it did not follow the recipe. The facility recipe required gravy to moisten the texture-modified diet, and the Therapeutic Diets policy stated therapeutic diets are to be planned and prepared in consultation with the Dietitian.
Improper Preparation of IDDSI Level 5 Minced and Moist Meal: A resident’s MM5 meal was prepared at the tray line using SB6 chopped meat instead of food minced in advance to the required size. A dietary staff member mashed the meat with a scoop and added gravy, and the DS stated the meat pieces were too large and that preparing MM5 during plating was not appropriate. The facility recipe required the food to be processed to 4 x 15 mm, and the therapeutic diet policy called for diets to be planned and prepared with the Dietitian.
Failure to Document and Address Roommate Conflict: Two roommates had a verbal disagreement after one resident reported the other was provoking him and keeping the cell phone and TV volume too loud, which disrupted sleep. The DON stated there were no progress notes or care plan entries for incompatibility, no documented COC notes for the disagreement, and neither resident was offered a room change that night.
Failure to Hold IDT Meeting for Nephrostomy Tube Noncompliance: A resident with UTI, CKD, and cervical cancer was observed with her nephrostomy tube touching the floor while the bag was hooked to her walker for convenience. Staff stated that noncompliance with a treatment plan or a resident preference for this setup required an IDT meeting and documentation, but no such meeting was conducted for the resident.
Failure to Develop Baseline Dementia Care Plan Within 48 Hours: A resident with dementia, behavioral disturbances, a hip fracture, and depression was readmitted confused and without decision-making capacity. The resident could not state place, date, or time, could not read the calendar, and did not know how to use the call light. RN stated no dementia care plan was created within 48 hours of admission or after, despite facility policy requiring a baseline care plan within 48 hours.
Failure to Initiate Anticoagulant Care Plan: A resident admitted with COPD, pneumonia, and sepsis had an order for dabigatran for A-fib, but the care plan record showed no bleeding-risk care plan related to anticoagulant use during the initial review. The DON stated nursing is responsible for initiating care plans and that policy requires completion within 48 hours, while the anticoagulant care plan was not started until later.
Care Plan Not Updated for Current Trazodone Order: A resident with insomnia, psychosis, and PTSD had a current order for Trazodone 37.5 mg at bedtime, but the care plan still listed Trazodone 50 mg and included interventions tied to the old dose. The LVN and DON both confirmed the care plan was not updated to match the current physician order, even though the resident was receiving the 37.5 mg dose.
Failure to document follow-up assessment after a COC. A resident admitted with acute respiratory failure with hypoxia, pneumonia, and immunodeficiency developed nausea, and the physician ordered a KUB and antiemetic meds for continued monitoring. However, the record contained no follow-up assessment notes after the COC, and staff interviews confirmed the resident was not documented as being monitored for the expected 72-hour period.
A resident with COPD, CHF, CKD, malnutrition, and other significant diagnoses had ongoing poor PO intake, with repeated meal refusals and 0-25% intake documented over multiple days. Although the resident was cognitively intact and able to express food preferences, monthly weights were not documented for several months, despite prior weight loss and staff statements that weights should be monitored monthly. The resident reported the meals were repetitive and unappetizing, and CNA confirmation showed meal refusal occurred.
Oxygen Cannula on Floor During Use: A resident with COPD, dementia, and dependence on supplemental oxygen was observed receiving O2 via NC while the cannula rested on the floor. The LVN stated the tubing could become kinked or contaminated, and the RN supervisor and DON stated tubing found on the floor should be changed for infection control. The resident had orders for O2 at 2 L/min via NC, with humidifier and tubing changes as needed.
Inaccurate dialysis weight and catheter documentation: A resident with ESRD receiving HD had an incorrect post-dialysis weight recorded, while the outside dialysis RN reported a different post-treatment weight and facility staff confirmed the resident was not weighed after dialysis. The facility also documented bruit and thrill on NSG Skilled Evaluations for a permcath, even though staff stated a permcath would not have a bruit or thrill and the DON said the form should have identified the catheter as a permcath instead.
Failure to obtain a recommended Valproic Acid level for a resident receiving the medication for behavior control. The consultant pharmacist identified the need for monitoring during the monthly MRR, but the DON found no progress notes, lab results, physician orders, or refusal documentation showing the level was completed. The resident had cognitive impairment, required assistance with ADLs, and was also receiving antipsychotic and hypnotic medications.
Food preferences, allergies, and texture requests were not consistently reflected on tray cards or honored during meal service for three residents. One resident with an egg allergy and multiple food intolerances received items that did not match stated dislikes and preferences, another resident with impaired cognition and ESRD did not receive soup with meals or the requested smooth texture, and a third resident with intact cognition reported that cottage cheese and yogurt preferences were not provided despite being documented by RD and DS. The report states the tray cards, meal service, and resident requests did not align.
Incomplete and Late Documentation of Infection Prevention Education: The facility failed to timely document infection prevention education for a cognitively intact resident with a nephrostomy tube and diagnoses including UTI and CKD. The resident’s care plan included education and symptom reporting to prevent infection, but the DON stated the physician order to monitor for infection signs was entered in May and the first documented education was not until later; staff also stated education must be documented when provided and as soon as possible.
Two residents receiving opioid pain medications did not have their pain levels or vital signs assessed and documented as required by physician orders and facility policy. Pain reassessment after medication administration was not completed within the required timeframe, and pre-administration assessments were inconsistently performed, resulting in inadequate monitoring and documentation of pain management.
Surveyors found that boxed food items were stored directly on the floor and a dispensing scoop was left inside a salt container, contrary to facility policy requiring food to be stored at least six inches off the floor and scoops to be stored separately for infection control.
A resident with multiple chronic conditions and cognitive intactness was not provided with a Notice of Medicare Non-Coverage (NOMNC) when the facility initiated discharge from Medicare Part A skilled services. Staff interviews and record review confirmed the NOMNC was not given, despite facility policy and CMS guidelines requiring notification prior to the end of covered services.
Two residents were affected by inaccurate MDS assessments: one was incorrectly documented as using trunk restraints despite staff and observation confirming no restraints, and another was inaccurately assessed as frequently incontinent and not on a bowel/bladder program, despite being generally continent and expressing a need for scheduled toileting assistance. These discrepancies between MDS documentation and actual resident status were confirmed by staff and had the potential to impact care.
A resident admitted with ESRD, hypertension, and a left femoral permcath for dialysis did not have their dialysis access site addressed in the baseline care plan, despite physician orders to monitor the site and facility policy requiring comprehensive care planning within 48 hours. Both nursing staff and the DON acknowledged the omission of this critical information from the care plan.
Two residents did not have individualized, person-centered care plans developed to address their specific needs. One resident with severe cognitive impairment and frequent incontinence had a care plan that only included medication administration, lacking other necessary interventions. Another resident with dementia and an order for oxygen therapy did not have a care plan addressing oxygen use. Staff confirmed that these care plans were insufficient and did not meet facility policy requirements.
A resident with impaired mobility and multiple risk factors for pressure injuries was not provided with bilateral heel protectors as ordered by the physician and outlined in the care plan. Instead, the resident's heels were placed on a pillow while in bed. Both an LVN and the DON confirmed the omission, which was not in accordance with facility policy for pressure injury prevention.
A resident with a seizure disorder, paraplegia, and other medical conditions was not provided with bilateral padded side rails as ordered by the physician for seizure precautions. Despite care plans and facility policy requiring this intervention, observations and staff interviews confirmed the absence of padding on the bedrails, placing the resident at risk for injury.
Two residents did not receive appropriate urinary and bowel care services, including failure to maintain continence support for a resident with a history of UTIs and improper catheter management for another resident, resulting in a dependent loop and urine backflow. These deficiencies were inconsistent with facility policies aimed at preventing UTIs and skin breakdown.
Two residents receiving oxygen therapy did not receive care according to facility protocols: one resident's oxygen humidifier bottle was allowed to run empty despite continuous use and a stated need for humidification, while another resident's nasal cannula was not labeled with the date of last change as required. Staff interviews and observations confirmed these lapses, which were not in line with the facility's policies for respiratory care.
A resident with ESRD and a left femoral permcath for hemodialysis did not receive proper assessment and monitoring of the dialysis access site, as required by facility policy. Admission documentation was inaccurate regarding the resident's dialysis status and access site, and pre and post dialysis assessments were incomplete on multiple occasions, failing to include necessary evaluations of the access site.
Two rooms were found to exceed the regulatory limit of four residents per room, with one room housing seven beds and another five beds. Observations and interviews with a resident and a CNA indicated that there was adequate space for care and movement, and all residents had privacy curtains, call-lights, dressers, and bedside tables.
A facility failed to monitor the placement and functionality of bed and wheelchair alarms for a resident with dementia and mobility issues. Although physician orders were given to apply these alarms for safety, monitoring did not begin until several months later. Staff interviews confirmed the delay, and the facility's policy required regular checks and documentation of these devices.
A resident with a history of CHF and hypertension was found with an altered level of consciousness and low oxygen saturation. The facility failed to provide adequate oxygen therapy, initially administering only 4L via nasal cannula instead of a non-rebreather mask. Paramedics later corrected this, improving the resident's condition. Documentation of the oxygen therapy was lacking, contrary to facility policy.
Two residents signed Assisted Living Waiver forms in a language they did not understand, resulting in them and their families being unaware of the contents. Despite being cognitively intact and preferring communication in their own language, the facility provided the documents in English without proper interpretation. Interviews revealed that neither the residents nor their families received copies of the signed documents, contrary to the facility's policies on resident rights and translation services.
A resident scheduled for discharge to a lower level of care did not receive the required Notice of Proposed Transfer and Discharge. Despite being cognitively intact and needing assistance with daily activities, the resident was not informed in writing about the discharge date and reasons. The DON confirmed the oversight, which was against the facility's policy requiring notice 30 days prior or as soon as practicable.
The facility did not post the actual daily hours worked by staff for four days in June 2024, displaying only projected hours instead. This was confirmed by the DSD, who stated that actual hours were kept in a separate binder. The facility's policy requires posting actual nursing hours to ensure patient safety and adequate staffing.
The facility failed to ensure call lights were within reach for two residents, potentially delaying care. One resident with hemiplegia had the call light on the floor, while another with muscle weakness had it hanging far away. Staff confirmed the inaccessibility, contradicting the facility's policy requiring call lights to be within reach.
The facility failed to update care plans for two residents after discontinuing treatments. One resident's care plan was not revised to reflect the end of antibiotic therapy, while another's was not updated after the removal of an indwelling catheter. This oversight was confirmed through record reviews and staff interviews, highlighting a deficiency in care planning.
A resident with Type 1 diabetes did not receive insulin injections in accordance with professional standards, as the facility failed to rotate the injection sites as ordered by the physician. The resident received Basaglar injections in the same site on the right arm for four consecutive days, contrary to the physician's instructions and facility policy, which required site rotation to prevent skin complications.
A resident continued to receive Enoxaparin, a blood thinner, without a physician's order due to a failure in communication and follow-through by the DON. Despite a pharmacist's recommendation to discontinue the medication, it was administered daily, placing the resident at risk for adverse effects. The oversight was discovered during a surveyor interview, highlighting a lapse in following the facility's medication administration policies.
A resident with dementia and dysphagia was served coffee with a thin consistency instead of the prescribed nectar thick liquid, contrary to the Physician's Order. The error was acknowledged by a CNA, and both the RD and DON confirmed the importance of following the therapeutic diet to prevent choking and aspiration risks.
A resident with hemiplegia and other conditions was not provided with a dycem, a non-slip mat, during meals as required by their care plan. Despite having a divided plate, the dycem was missing, which was confirmed by the resident and observed by surveyors. Facility staff acknowledged the importance of the equipment, but records showed it was not consistently provided.
A resident with a history of UTI, Type II diabetes, and paralysis was observed with an indwelling catheter bag touching the floor while seated in a wheelchair. A CNA acknowledged the infection control issue, and the DON confirmed the CNA's responsibility to prevent such occurrences, as per facility policy.
The facility exceeded the room capacity regulation by accommodating more than four residents in two rooms, with one room housing seven and another five residents. Despite this, observations showed adequate space for care, privacy curtains, and safe egress. Interviews with residents and CNAs revealed no concerns about space or care provision. A room waiver request was submitted, aligning with residents' special needs, and the Department recommended its continuation.
Unsafe Food Storage, Dating, and Temperature Control
Penalty
Summary
The facility failed to maintain safe and sanitary food storage and distribution practices in multiple areas of the kitchen and resident food storage. During observation of the kitchen refrigerator, surveyors found opened milk with no open date, chopped garlic in water with no open date, and bread stored in a resealable bag with no label or date. In the walk-in refrigerator, onions had no received or use-by date, celery was stored inside a tub of coleslaw with no date, and individually sealed cups of orange juice were stored in an unlabeled tub with no use-by dates on the cups. The facility’s posted refrigerator sign required receive date, open date, and expire date on items stored in the cooler. Surveyors also observed expired and spoiled food in storage. A box of zucchini squash received on 6/11/26 and marked use by 6/18/26 was bruised and covered with black spots and fuzzy white and gray growth. Bread labeled with a receive date of 6/2/26 and use by 6/16/26 still contained seven bags of brown loaves. In dry storage, an unsealed bag of Krispy cereal had a use-by date of 11/25/25, a container of paprika had a use-by date of 9/27/25, and a sealed bag of chow mein noodles was dated use by 6/6/26. The RD stated that expired and moldy foods had to be discarded because of the risk of foodborne illness and gastrointestinal symptoms. Surveyors further observed raw chicken marinating in a shallow metal pan loosely covered with foil and resting on top of boxes of oven roasted sliced turkey breast and fully cooked sliced bacon. The RD stated that placing raw foods above ready-to-eat foods created a risk for cross-contamination. In addition, the reach-in refrigerator was observed with conflicting temperature readings, including a digital display of 35 F and an analog thermometer reading 60 F, while the temperature log recorded 34 F. Later observations showed the refrigerator internal thermometers reading 58 F and then 65 F, and milk being prepared and served from that unit while the milk temperature measured 57.5 F. The same day, milk and pureed potatoes were served to residents during lunch service. In the resident refrigerator in the employee lounge, surveyors found multiple unlabeled or undated foods, including tacos, liquids, grapes, cookies, milk, yogurt, and meatloaf, and the DON confirmed the expired and undated items and stated the facility’s monitoring policy was not being followed.
Failure to Submit PBJ Staffing Data
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to CMS through the Payroll Based Journal (PBJ) for the first quarter, covering 10/1/2025 through 12/31/2025. A review of the CMS PBJ Staffing Data Report dated 6/16/2026 showed that the facility did not submit staffing data for that quarter. During an interview on 6/24/2026, the Corporate Payroll Consultant stated the facility's corporate payroll staff used a third-party vendor to submit PBJ data and believed the data for the first quarter had been submitted to the vendor, but later discovered in March 2026 that it had not been submitted to CMS. The Corporate Payroll Consultant also stated he did not check the CASPER Report because he did not know he could access it. The Administrator stated he was aware the first quarter PBJ had not been submitted after speaking with the Corporate Payroll Consultant, and stated the facility did not have any policy and procedure for PBJ submission.
Nephrostomy tubing contacted the floor and cold-water monitoring documentation was missing
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a nephrostomy tube. Resident 25 was admitted and readmitted with diagnoses including UTI, chronic kidney disease, and malignant neoplasm of the cervix uteri. The MDS dated 4/30/2026 indicated the resident was cognitively intact, used a walker to ambulate, and required varying levels of assistance with activities of daily living. During an observation on 6/22/2026 at 10:08 a.m., the resident’s nephrostomy tubing was noted touching the floor, and the drainage bag was hooked to the walker. The resident stated she hooked the bag on the walker for convenience when ambulating. Staff interviews later confirmed the tubing should not have been on the floor and that CNAs and LVNs were responsible for ensuring it was not in contact with the floor to prevent infections. The DON stated the nephrostomy should be clipped to the resident’s gown or bed to prevent infection. The resident’s care plan addressed maintaining safe and effective drainage while preventing infection, and the facility’s nephrostomy tube management policy included infection prevention techniques and monitoring for signs and symptoms of infection. The facility also failed to maintain documentation of routine cold-water monitoring for its water distribution system. The Maintenance Supervisor stated the facility routinely monitored and documented hot water temperatures throughout the building but did not maintain a log for cold water temperature monitoring and did not check cold water temperatures. Review of the Water Temperature Logbook for 6/8/2026, 6/13/2026, and 6/19/2026 showed routine hot water monitoring at the North Station, South Station, and designated shower rooms, but no documentation of cold water temperature monitoring. The facility’s undated Risk Management Plan for Waterborne Pathogen Control identified the cold water distribution system as a potential area for the growth and transmission of Legionella and other opportunistic waterborne pathogens and stated routine cold water temperature monitoring was required. The WICRA dated 01/06/2026 identified multiple water system components requiring monitoring, including cold water storage tanks, hot water storage tanks, water heaters, water filters, faucets, showerheads, the municipal water supply, and other building water system components as part of the Legionella prevention program.
Reach-in refrigerator held food at unsafe temperatures
Penalty
Summary
The facility failed to maintain the kitchen reach-in refrigerator in safe operating condition when surveyors found conflicting temperature readings and evidence that the unit was holding food above the safe cold-holding range. During observation, the refrigerator’s digital display read 35 F, while an analog thermometer inside the unit read 60 F, and the posted temperature log recorded 34 F. On follow-up observation, the external thermometer read 39 F, but the internal thermometer still read 58 F. The Dietary Supervisor stated the internal thermometer was broken and that staff relied on the external digital reading, then removed the internal thermometer. During the same kitchen observations, staff were preparing milk for lunch service and returned the milk to the reach-in refrigerator. Upon request, a cup of milk from an unopened gallon jug measured 57.5 F, and later both internal thermometers placed in the unit read 65 F. The refrigerator contained multiple potentially hazardous foods, including gallons of milk, raw chicken thighs, ground beef, turkey roasts, liquid whole eggs, pasteurized shelled eggs, mayonnaise, sour cream, cottage cheese, peach chunks, soy sauce, and chopped garlic in water. The Maintenance Supervisor stated there had been no known issues or maintenance requests for the refrigerator and that coils were cleaned every three months, but there was no log, schedule, or record of that maintenance being performed.
Informed Consent and PRN Psychotropic Ordering Deficiency
Penalty
Summary
The facility failed to ensure informed consent was obtained before ordering psychotropic and antidepressant medications for a resident who was confused and lacked decision-making capacity. The resident was admitted with diagnoses including a left hip fracture, dementia with behavioral disturbances, and depressive episodes. During record review, quetiapine 12.5 mg every 24 hours as needed for psychosis and trazodone 50 mg as needed for insomnia were ordered without a stop date, and the registered nurse stated that PRN psychotropic medications should be ordered for only 14 days with a stop date to allow reevaluation. The record review and interviews showed that the psychotherapeutic drug informed consent form was signed by the resident's representative after the medication order had already been entered into the electronic system and sent to the pharmacy, and the physician signed the consent later. The RN and DON both stated that consent should have been obtained before placing the order because psychotropic drugs are high-risk medications, and the facility policy required written informed consent for psychoactive drugs and limited PRN psychoactive medications to no more than 14 days. The policy also stated that antipsychotic and antidepressant medications are not to be administered on a PRN basis.
Inaccurate MDS Coding for Anticoagulant Use and Dialysis Access
Penalty
Summary
The facility failed to accurately complete the MDS for Resident 6 by not coding anticoagulant use. Resident 6 was admitted with diagnoses including type 2 DM, hyperlipidemia, dysphagia, muscle weakness, hemiplegia, hemiparesis, and benign prostatic hyperplasia. The MAR showed the resident received Eliquis 2.5 mg by mouth for DVT prophylaxis during the MDS look-back period, but the MDS dated 5/21/2026 indicated the resident was not taking anticoagulant medication. During the concurrent review, the MDS nurse stated that the look-back period for anticoagulants was seven days and that if an anticoagulant was given during that period, it should have been coded on the MDS. The DON gave the same explanation and stated the MDS should be coded accurately. The CMS RAI Manual excerpt reviewed during the investigation stated that anticoagulants received during the 7-day look-back period must be coded, including medications such as TSOACs, and that a medication should be coded even if given only once during the look-back period. The facility also failed to accurately assess and document Resident 7’s dialysis access site on the MDS. Resident 7 was admitted and later readmitted with diagnoses including pleural effusion, acute respiratory failure with hypoxia, ESRD, and HD dependence. The record contained conflicting documentation about the access site, including references to a left chest Permacath, right chest CVC, left tunneled dialysis catheter, and left arm AV shunt with bruit and thrill. Staff stated that Resident 7 never had an AV shunt and that bruit and thrill assessments apply only to AV shunts, not Permacaths. The treatment nurse also stated the resident never had an AV shunt, while the record showed documentation identifying a Permacath on the left chest and orders to observe the Permacath site on the left chest.
Medication Documentation Errors With Lidocaine Patch and Tramadol
Penalty
Summary
Safe and accurate medication management was not ensured for two residents. One resident with chronic kidney disease, diabetes mellitus type 2 with diabetic polyneuropathy, and muscle weakness had a lidocaine patch on the right shoulder observed during a medication pass, and the nurse removed the old patch and applied a new one. The old patch was dated the prior day, and the nurse reviewed the pharmacy label showing the patch was ordered for 12 hours on and 12 hours off. The eMAR for the day showed the patch was not administered and referenced progress notes. Review of the administration notes showed one note stating the resident was out on appointment and another stating no patch had previously been applied. The DON later stated the doctor had instructed that the patch be applied later in the day when the resident returned, but that this instruction was not documented in the progress notes. For another resident admitted with a right femur fracture, the tramadol 50 mg accountability record showed a last removal of one tablet at 12:22 AM, but the eMAR for June showed no administration record for that dose. Review of the prior month’s eMAR showed the last documented tramadol dose had been given on 5/30/2026. The DON stated that failing to document narcotic administration could allow a resident to receive an additional dose unnecessarily and could involve misuse and/or drug diversion. The facility policy for controlled substances stated that when a controlled substance is administered, the licensed nurse must immediately enter the information on the accountability record and the medication administration record.
Incorrect CCHO Portioning During Meal Service
Penalty
Summary
The facility failed to provide 24 of 68 residents with the correct Carbohydrate-Controlled (CCHO) diet portion when kitchen staff served twice the amount of potatoes required for the therapeutic diet. During lunch tray line observation, a cook used a scoop with a grey-colored handle to plate potatoes for a tray marked for a CCHO diet order and then continued using the same scoop for both CCHO and regular diet orders. In interview, the RD stated that a smaller scoop with a blue-colored handle should have been used for CCHO portions and confirmed that the larger portion size would nullify the intended therapeutic effect of the CCHO diet. The facility’s Summer Menus specified diced fried potatoes should be served with a number 8 scoop for regular diets and a number 16 scoop for CCHO diets, and the Therapeutic Diets policy stated the DS and RD will observe meal preparation and serving to ensure portions match written portion sizes.
Improper Gravy Substitution on Texture-Modified Meal Trays
Penalty
Summary
The facility failed to follow the menu and recipe for Salisbury Steak with Onions when kitchen staff used a cornstarch slurry instead of gravy for Minced-and-Moist, Level 5 texture-modified meal trays. During lunch tray line service, a staff member poured an opaque, white-colored liquid with a gel-like consistency over chopped Salisbury Steak, and confirmed during interview that the cornstarch slurry was being used as gravy for MM5 diets. The Regional Dietary Supervisor observed the cornstarch slurry being used in place of gravy and stated that it was not an appropriate substitution and did not adhere to the recipe. The supervisor also stated that using the slurry instead of gravy altered the nutrition of the meals provided and negatively impacted resident expectations and meal satisfaction. The facility recipe indicated that MM5 diets had to be moistened with gravy to achieve the appropriate thickness, and the Therapeutic Diets policy stated that therapeutic diets are to be planned and prepared in consultation with the Dietitian.
Improper Preparation of IDDSI Level 5 Minced and Moist Meal
Penalty
Summary
The facility failed to prepare food in accordance with the IDDSI framework for a resident who required Level 5 minced and moist foods. During lunch tray line service in the kitchen, a staff member used a scoop utensil designated for Level 6 small-and-bite-sized foods to plate chopped Salisbury Steak from the steam table for a tray that called for MM5 texture. The staff member then used the edge of the scoop utensil to mash some of the meat and stated during interview that the SB6 texture was used to create MM5 because it was soft and gravy was added. The Regional Dietary Supervisor reviewed an MM5 tray prepared for lunch and stated that the meat was too large and posed a risk of choking to residents. The supervisor also stated that preparing MM5 texture during plating was not appropriate and that texture-modified food should have been prepared in advance. The facility’s recipe for Salisbury Steak with Onions directed that IDDSI #5/minced and moist food be placed into a food processor and minced until the food was 4 x 15 mm, and the facility’s Therapeutic Diets policy stated that therapeutic diets were to be planned and prepared in consultation with the Dietitian.
Failure to Document and Address Roommate Conflict
Penalty
Summary
The facility failed to promote and maintain residents' quality of life by not conducting and documenting a change of condition assessment for two roommates, Residents 90 and 89, who were involved in an interpersonal conflict. Resident 90 was admitted with CHF, anemia, and DM, and his H&P stated he could understand and make his own medical decisions. Resident 89 was admitted with osteomyelitis of the left ankle and foot, DM, and a foot ulcer, and his H&P also stated he could understand and make his own medical decisions. On 6/21/26, Resident 89 reported that Resident 90 provoked him and kept the cell phone and TV volume too loud, and Resident 90 could not sleep. The DON stated the SSD planned to change the room, and that the facility was aware of the verbal disagreement between the two residents. The DON also stated there were no progress notes or care plan entries for incompatibility, no documented change of condition notes for the disagreement causing inconvenience and sleep disruption, and that neither resident was offered a room change that night. A review of social services progress notes dated 6/21/26 found no documented progress notes about the disagreement for either resident.
Failure to Hold IDT Meeting for Nephrostomy Tube Noncompliance
Penalty
Summary
The facility failed to ensure an Interdisciplinary Team (IDT) meeting was conducted for Resident 25 regarding noncompliance with keeping her nephrostomy tube off the floor. Resident 25 was admitted and later readmitted with diagnoses including UTI, chronic kidney disease, and malignant neoplasm of the cervix uteri. Her MDS dated 4/30/2026 indicated she was cognitively intact, used a walker to ambulate, and required varying levels of assistance with activities of daily living, including toileting and dressing. During an observation on 6/22/2026, Resident 25's nephrostomy tube was touching the floor and the nephrostomy bag was hooked to her walker. The resident stated she placed the nephrostomy bag on the walker for convenience when ambulating to the restroom. Staff interviews indicated that when a resident is noncompliant with a treatment plan or prefers to keep a nephrostomy bag on a walker, an IDT meeting should be held and documented to ensure resident safety and consistent care. The DON also stated there could have been an IDT meeting for Resident 25 for noncompliance. The facility policy titled Interdisciplinary Team Skilled Review stated the IDT will gather information and collect data within 72 hours of admission to determine resident expectations and goals.
Failure to Develop Baseline Dementia Care Plan Within 48 Hours
Penalty
Summary
The facility failed to develop a dementia care plan within 48 hours of admission for Resident 87. Resident 87 was initially admitted on 1/22/2026 and then readmitted on 6/18/2026 with diagnoses that included fracture of the neck of the left femur, dementia with behavioral disturbances, and depressive episodes. The admission record and history and physical dated 6/19/2026 indicated the resident was confused and did not have decision-making capacity. During observation on 6/22/2026, Resident 87 was sitting in bed and could not state the current place, date, or time. The resident stated she could see the calendar but could not read it and did not know what the call light was or how to use it. During interview and record review on 6/25/2026, RN 1 stated there was no care plan for dementia created within 48 hours of admission or after. The facility policy titled Person-Centered Care Planning stated the baseline care plan must include the minimum healthcare information necessary to properly care for each resident immediately upon admission and must be developed and implemented within 48 hours.
Failure to Initiate Anticoagulant Care Plan
Penalty
Summary
The facility failed to initiate an anticoagulant care plan for one of one sampled resident, Resident 82. Resident 82 was admitted on 6/15/2026 with diagnoses including COPD, pneumonia, and sepsis. The resident's H&P dated 6/16/2026 indicated limited decision-making capacity. An order dated 6/15/2026 prescribed Dabigatran Etexilate Mesylate 110 mg by mouth twice daily for A-fib. A review of the Care Plan Report for 06/2026 found no care plan for bleeding risk related to anticoagulant medication. During a concurrent interview and record review on 6/25/2026, the DON stated that nursing is responsible for initiating, implementing, and revising care plans and that policy requires care plan initiation within 48 hours. The Care Plan Report showed the anticoagulant care plan was started on 6/24/2026, and the facility's Person-Centered Care Planning policy dated 5/22/2025 stated comprehensive care plans are developed within 48 hours of admission.
Care Plan Not Updated for Current Trazodone Order
Penalty
Summary
The facility failed to update and revise the care plan for a resident receiving Trazodone, resulting in the care plan not matching the current physician order. The resident was re-admitted with diagnoses including insomnia, unspecified psychosis, and PTSD. The Minimum Data Set indicated the resident was cognitively intact and required varying levels of assistance with eating, oral hygiene, bathing, dressing, toileting hygiene, and footwear, and also indicated the resident was taking antidepressant medication. The resident had a physician order for Trazodone 37.5 mg by mouth at bedtime for depression manifested by inability to sleep, and the MAR showed the resident received 23 doses of Trazodone 37.5 mg. However, the care plan dated later still identified Trazodone 50 mg, with interventions written for administering 50 mg, monitoring for adverse reactions to 50 mg, and educating the resident/family/caregivers about 50 mg. During interview and record review, the LVN stated the resident had been receiving 37.5 mg as ordered and that the care plan had not been updated to reflect the current order. The DON also confirmed that the resident had a current order for Trazodone 37.5 mg and that the care plan still reflected 50 mg. The DON stated the care plan was not updated and revised when the medication order changed and that it should have been updated to reflect the resident's current plan of care. The facility policy stated comprehensive care plans must be developed, implemented, reviewed, and revised by the interdisciplinary team after each assessment and include the services to be furnished to meet the resident's needs.
Failure to Document Follow-Up Assessment After Change of Condition
Penalty
Summary
The facility failed to document a follow-up assessment after a change of condition for one resident who had been admitted with acute respiratory failure with hypoxia, pneumonia, and immunodeficiency. The resident’s MDS dated 6/19/2026 indicated the resident was cognitively intact, used a walker, and required varying levels of assistance with eating, oral hygiene, dressing, toileting, and showering. The resident’s COC record dated 6/22/2026 at 2:32 p.m. documented nausea in the morning, and the physician ordered a KUB and antiemetic medications for continued monitoring. The assessment record contained no follow-up assessment notes on 6/23/2026 or 6/25/2026 after the change of condition was identified. Staff interviews confirmed that when a change of condition occurs, the physician is notified, orders are implemented, and the resident is monitored and documented, typically for about 72 hours; the DON acknowledged there was no documentation showing the resident was being monitored after the COC and stated the COC policy was not followed.
Failure to Monitor Weight During Poor Meal Intake
Penalty
Summary
The facility failed to ensure monthly weights were obtained and recorded for a resident with ongoing poor meal intake. Resident 17 was admitted with diagnoses including COPD, iron deficiency anemia secondary to chronic blood loss, chronic diastolic CHF, CKD stage 3, respiratory failure with hypoxia, unspecified protein-calorie malnutrition, hypertension, an unstageable sacral pressure ulcer, and depression. The resident’s MDS indicated she was cognitively intact with a BIMS score of 13, could communicate her needs and participate in care decisions, and required setup and clean-up assistance while eating. Weight records showed 158.0 pounds in 2/2026 and 164.0 pounds in 4/2026, but no monthly weight documentation was available for 1/2026, 3/2026, 5/2026, or 6/2026. The record also documented repeated meal intake of 0-25% on multiple dates from 5/29/2026 through 6/24/2026, including several days with refusal or very limited intake across one, two, or three meals. The resident stated she was receiving repetitive food selections and often chose not to eat because the food did not taste good and did not look good. During interviews, Resident 17 stated she refused meals and requested tray removal because the food was disgusting, and reported eating only dessert and an Ensure at one meal. CNA 2 confirmed the resident refused lunch. The RNA stated weights were maintained in a weight-loss log and obtained monthly, while the RD stated newly admitted or readmitted residents were weighed weekly x4 and then monthly, and that no resident was not being weighed monthly. The DON stated residents with unplanned weight loss or poor meal intake were expected to have nutritional status monitored through meal intake documentation, routine weight monitoring, nursing assessments, and RD follow-up. The care plan dated 2/04/2026 identified unplanned weight loss related to food preferences and reflected a 22-pound, 12.4% weight loss over three months.
Oxygen Cannula Found on Floor During Use
Penalty
Summary
The facility failed to ensure that one resident receiving oxygen therapy had the nasal cannula kept off the floor while the oxygen was in use. Resident 1 was admitted and later readmitted with diagnoses including COPD, muscle weakness, reduced mobility, dementia, and dependence on supplemental oxygen. The resident’s record also showed a history of pneumonia and septicemia, and the resident was assessed as usually able to make himself understood and understand others, while being dependent for several activities of daily living. During a concurrent observation and interview, Resident 1’s oxygen nasal cannula was seen resting on the floor while the resident was receiving oxygen through it. The LVN stated that tubing on the floor could become kinked or contaminated and said she would replace it and label and date the new tubing. The RN supervisor and DON both stated that if oxygen tubing was found on the floor, it should be changed for infection control. The resident had physician orders for oxygen at 2 L/min via nasal cannula, along with orders to change the humidifier and oxygen tubing as needed.
Inaccurate dialysis weight and catheter documentation
Penalty
Summary
Resident 33 was admitted with diagnoses including type 2 DM, hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, and ESRD requiring hemodialysis. The resident’s MDS indicated he could usually make himself understood and usually understand others, while the H&P stated he did not have capacity to make his own medical decisions. Physician orders included hemodialysis on Mondays, Wednesdays, and Fridays, and to observe the permcath site on the right upper chest each shift for redness, tenderness, bleeding, and drainage. The facility failed to accurately document Resident 33’s post-dialysis weight after dialysis. The untitled weight record showed a post-dialysis weight of 153.4 lbs., but the dialysis RN from the outside clinic stated the resident weighed 178.2 lbs. after dialysis. During interview, RN 1, LVN 6, and the DON stated the facility did not check the resident’s weight after dialysis on that date, and the DON stated the weight entry was crossed off as incorrect documentation after speaking with the RD. The facility also failed to accurately assess and document Resident 33’s dialysis catheter on the NSG Skilled Evaluation forms dated 6/17/2026, 6/22/2026, and 6/23/2026. RN 1 and LVN 6 stated the forms incorrectly documented the resident as having a bruit and thrill, and they stated a permcath would not have a bruit or thrill. The DON reviewed the electronic form and stated staff should have skipped the bruit/thrill question and documented at the bottom of the form that the resident had a permcath. The facility policy stated medical records should be complete and accurate, and the dialysis management policy stated bruit/thrill checks were for AV fistulas, while a central venous catheter was to be monitored for redness, tenderness, bleeding, and drainage.
Failure to Obtain Recommended Valproic Acid Level
Penalty
Summary
The facility failed to obtain a Valproic Acid level for a resident receiving Valproic Acid for behavior control, despite the consultant pharmacist’s monthly medication regimen review recommending that a Valproic Acid level be obtained on the next available lab day. The resident was admitted with diagnoses including auditory hallucinations, DM, dysphagia, hypertension, and hypothyroidism, and the MDS showed moderate cognitive impairment, need for assistance with several ADLs, and use of antipsychotic and hypnotic medications. The order summary showed a physician order for Valproic Acid 2.5 ml by mouth twice daily for mood disorders manifested by sudden irritation without apparent reasons. During a concurrent interview and record review, the DON stated the resident had been receiving Valproic Acid for a while and confirmed that the pharmacist consultant recommended a Valproic Acid level. The DON reviewed progress notes, laboratory results, and physician orders and found no documentation that the level had been obtained or that the resident refused the test. The facility policy required the pharmacist to review each resident’s medical chart monthly and report irregularities to the attending physician, medical director, and DON, with those reports acted upon by the facility.
Food Preferences and Diet Orders Not Honored
Penalty
Summary
Food preferences and diet accommodations were not consistently honored for three sampled residents. The report states that the facility failed to ensure residents received food that accommodated allergies, intolerances, and preferences, with tray tickets and meal service not matching resident needs. The deficiency involved Resident 86, Resident 50, and Resident 67, and the report specifically notes that these failures had potential to cause decreased food intake, weight loss, and decreased quality of life. Resident 86 had diagnoses including metabolic encephalopathy, immunodeficiency, and chronic kidney disease, and the MDS indicated intact cognitive decision-making. During breakfast observation, the tray contained cottage cheese, oatmeal, green tea, coffee, toast, apple juice, and milk. Resident 86 stated the food was horrible, said staff had already been informed, reported an egg allergy, and said cottage cheese was being used as a protein substitute. The resident also stated she did not like apple juice and preferred cranberry juice, but apple juice continued to be served. The tray ticket listed an egg allergy, dislikes of banana, sausage, and bread, and preferences including milk, juice, cottage cheese, daily yogurt, melons, and strawberries. The RD reviewed the nutritional risk assessment and stated the tray ticket needed to be updated with allergies and dislikes so the kitchen would know what to serve, and that the kitchen should not serve foods the resident was intolerant to. Resident 86 also reported receiving a lunch tray with corn, green bell peppers, and meat, and said she refused the corn and was allergic to green bell peppers because they caused a rash. Resident 50 had diagnoses including osteoarthritis, malignant neoplasm of the nipple and areola, end stage renal disease, and bilateral ototoxic hearing loss, and the MDS indicated impaired cognitive decision-making and dependence with ADLs. A family member stated the facility had been asked to serve warm beverages and soups, but the request was not followed. During lunch observation, Resident 50 was seen spitting out food and stated the facility had served porridge, but he preferred a smooth texture without sharp or gritty components. The lunch tray contained water, pink juice, and milk, and the porridge and meat had a gritty texture. The tray ticket listed dislikes of juice, a preference for 4 oz milk, 4 oz juice, and soup with meals daily. The DA stated the tray ticket was followed, noted the soup preference, and said the resident should have been offered soup if it was listed. The RD reviewed the order summary showing a regular diet with pureed texture, regular/thin liquids, and a directive to include soup with every meal, and the DS confirmed no soup was provided during the lunch service despite the order and tray ticket. Resident 67 was admitted with diagnoses including acute embolism and thrombosis of the left lower extremity, COPD, and diabetes, and the H&P indicated capacity to understand and make decisions. The MDS showed a BIMS score of 15, independent eating with setup and cleanup assistance, and maximal assistance for toileting and hygiene. The resident stated staff and the kitchen did not provide requested cottage cheese and yogurt preferences, and that the issue had been discussed with the RD without change. Meal percentage records showed multiple meals with intake between 51 and 75 percent and several meals with intake between 26 and 50 percent. The RD’s nutritional risk assessment documented that the RD and DS had reviewed and updated preferences, noting that when a menu was not preferred, the resident requested cottage cheese or cereal with milk. A later nutrition/dietary progress note stated the resident requested cottage cheese for breakfast and yogurt for lunch, the RD agreed and communicated the preferences to the DSS, and the RD stated staff failed to honor the resident’s food preferences from 6/9 through 6/21. The facility policy stated resident preferences were to be documented in the medical record and tray card and updated promptly, and that meals were to be consistent with preferences and physician orders.
Incomplete and Late Documentation of Infection Prevention Education
Penalty
Summary
The facility failed to document infection prevention education for one resident in a consistent and timely manner. Resident 25 was originally admitted and later readmitted with diagnoses including UTI, chronic kidney disease, and malignant neoplasm of the cervix uteri. The resident’s MDS dated 4/30/2026 indicated she was cognitively intact, used a walker to ambulate, and required varying levels of assistance with eating, oral hygiene, dressing, toileting, and showering. During observation on 6/22/2026, Resident 25’s nephrostomy tube was touching the floor and the nephrostomy bag was hooked on her walker; the resident stated she hooked the bag on the walker for convenience when ambulating. The care plan dated 4/29/2026 and revised on 5/21/2026 stated she would show no signs or symptoms of infection using resident education and reporting of symptoms as interventions. The DON stated the physician order to monitor for signs and symptoms of infection was entered in May 2026, but the first documentation of infection prevention education was not until 6/18/2026. Staff interviews stated education must be documented when provided and that documentation should occur as soon as a task is completed or as soon as possible, and the facility policy required documented entries to be recorded in a timely manner.
Failure to Follow Pain Assessment and Monitoring Protocols for Residents Receiving Opioid Pain Medications
Penalty
Summary
The facility failed to provide safe and appropriate pain management for two residents by not adhering to physician orders and facility policies regarding pain assessment and monitoring. For one resident with a history of lumbar spinal fusion, low back pain, and end-stage renal disease, the care plan required administration of oxycodone as needed, with pain reassessment within one hour after administration. However, medication administration records showed that pain was not reassessed within the required timeframe, with follow-up assessments occurring more than one to five hours after medication was given. Both the registered nurse and the director of nursing confirmed that the facility's protocol and policy required pain reassessment within one hour, and acknowledged that this was not done as required. For another resident with multiple fractures, respiratory failure, and a history of falls, physician orders and the care plan required pain assessment and documentation every shift, as well as assessment of respiratory rate prior to administering hydromorphone. Medication administration records indicated that pain levels and respiratory rates were not consistently assessed or documented prior to medication administration on several occasions. Interviews with nursing staff and the director of nursing confirmed that these assessments were necessary and should have been documented each time pain medication was administered. The facility's policies on pain management and medication administration required licensed nurses to complete pain assessments for residents identified as having pain, administer pain medication as ordered, and re-evaluate and document the resident's pain level within one hour after medication. The failure to follow these protocols resulted in inadequate monitoring and documentation of pain management for both residents.
Improper Food Storage and Unsanitary Food Preparation Practices
Penalty
Summary
Surveyors observed that the facility failed to follow safe and sanitary food storage and preparation practices in the kitchen. Specifically, boxed food items, including rice, non-dairy creamer packets, parsley, mayonnaise, and salt, were found stored directly on the floor in the dry storage room. Additionally, a dispensing scoop was stored inside a clear storage container of salt. These practices were observed during a concurrent interview and observation with a kitchen staff member, who confirmed that the items should have been stored at least six inches off the floor and that the scoop should not be kept inside the salt container due to sanitation concerns. Further interviews with the dietary supervisor revealed that the food items were left on the floor after cleaning other portions of the dry storage area. The dietary supervisor also acknowledged that facility policy requires food to be stored six inches off the floor and that scoops should not be left inside food containers for infection control purposes. A review of the facility's policy and procedure on food storage and handling confirmed these requirements.
Failure to Provide Required Notice of Medicare Non-Coverage
Penalty
Summary
The facility failed to provide a Notice of Medicare Non-Coverage (NOMNC) to a resident whose Medicare Part A skilled services were ending. The resident, who was admitted with multiple diagnoses including type 2 diabetes, schizoaffective disorder, major depressive disorder, hypertension, and anxiety disorder, was cognitively intact and required assistance with several activities of daily living. According to the resident's records, the last covered day for Medicare Part A services was identified, and the discharge from Medicare services was initiated by the facility before benefit days were exhausted. However, the NOMNC was not provided to the resident because she left the facility to go home. Interviews with the Business Office Manager and the Director of Nursing confirmed that the resident should have received the NOMNC, as the discharge was planned and initiated by the facility. Both staff members acknowledged that the NOMNC is necessary to inform residents of their last covered day and their right to appeal the discharge. Review of facility policy and CMS guidelines further supported the requirement to provide the NOMNC at least two days before the end of covered services, which was not done in this case.
Inaccurate MDS Assessments for Restraint Use and Bowel/Bladder Status
Penalty
Summary
The facility failed to ensure accurate completion of the Minimum Data Set (MDS) assessments for two residents, resulting in deficiencies related to restraint use and bowel/bladder documentation. For one resident with dementia, difficulty walking, and muscle weakness, the MDS inaccurately indicated the use of trunk restraints. Observations and interviews with staff confirmed that the resident did not have restraints, and both the MDS Coordinator and Director of Nursing acknowledged the inaccuracy in the MDS documentation regarding restraint use. For another resident admitted with a history of antimicrobial resistance, urinary tract infection, acute kidney failure, and difficulty walking, the MDS assessment inaccurately documented the resident as frequently incontinent of bowel and bladder, and not on a bowel and bladder program. However, the care plan indicated the resident was continent, and interviews with the resident and staff confirmed the resident was generally able to control bowel and bladder function, with rare episodes of incontinence. The resident expressed a desire for scheduled reminders and assistance to the restroom, which was not reflected in the MDS or care plan alignment. Facility policy and procedure reviews confirmed the requirement for accurate resident assessments and the use of the Resident Assessment Instrument (RAI) process to ensure proper care planning. The discrepancies between the MDS assessments and actual resident status had the potential to result in inadequate care, as acknowledged by facility staff during interviews.
Incomplete Baseline Care Plan for Dialysis Access Site
Penalty
Summary
The facility failed to develop a complete baseline care plan for a resident admitted with end stage renal disease, hypertension, and an acquired absence of the left leg below the knee. Upon admission, the resident had a left femoral permcath in place for dialysis access, as well as arteriovenous fistulas in both upper arms. Physician orders required monitoring of the left femoral permcath site for signs of infection or complications during every shift. The resident's cognitive skills were intact, and they required partial to moderate assistance with daily activities. Despite these needs and orders, the baseline care plan created within 48 hours of admission did not include any information regarding the resident's left femoral dialysis access site. Both the registered nurse and the director of nursing confirmed that the baseline care plan was incomplete and did not address the dialysis access site, which was necessary for the resident's immediate care. Facility policy required that baseline care plans include all essential health information to ensure proper care upon admission, but this was not followed in this instance.
Failure to Develop Individualized Care Plans for Incontinence and Oxygen Use
Penalty
Summary
The facility failed to develop and implement individualized, person-centered care plans for two residents with specific clinical needs. For one resident with hemiplegia, hemiparesis, severe cognitive impairment, and frequent incontinence of bowel and urine, the care plan only included an intervention to administer medications as ordered and document their effectiveness. There were no additional interventions listed to address the resident's incontinence, such as assistance with toileting or changing soiled briefs. Both the MDS Coordinator and the Director of Nursing acknowledged during interviews that the care plan was insufficient and did not adequately address the resident's needs for incontinence care. For another resident with diagnoses including cough, dementia, and type 2 diabetes mellitus, and who had a physician order for oxygen administration via nasal cannula as needed to maintain oxygen saturation above 92%, the facility did not develop a comprehensive care plan to address oxygen use. The resident's Minimum Data Set indicated severe cognitive impairment and a need for substantial to maximal assistance with activities of daily living. Despite these needs and the physician's order, the care plans reviewed did not include interventions or monitoring related to oxygen therapy. The facility's policy required the development and implementation of comprehensive, person-centered care plans with measurable objectives and timeframes to meet each resident's identified needs. The lack of appropriate care planning for both residents was confirmed by staff interviews and record reviews, indicating that the facility did not follow its own policy and failed to ensure that care plans described the services necessary to maintain the residents' highest practicable well-being.
Failure to Provide Ordered Heel Protectors for At-Risk Resident
Penalty
Summary
A deficiency occurred when staff failed to follow a physician's order for a resident at risk for pressure injuries. The resident, who had diagnoses including diabetes mellitus, failure to thrive, and paraplegia, was identified as being at moderate risk for pressure ulcer development due to impaired mobility, incontinence, and poor nutrition. The care plan and physician orders specified the use of bilateral heel protectors while the resident was in bed to prevent pressure injuries. However, during observation, the resident was found in bed without the required heel protectors, with their heels instead placed on a pillow. Interviews with both an LVN and the DON confirmed that the resident should have been wearing bilateral heel protectors as per the physician's order and care plan. The facility's policy on pressure injury prevention also required staff to implement such interventions. The failure to provide the ordered heel protectors constituted a lapse in following prescribed care for a resident at risk for pressure injuries.
Failure to Provide Ordered Padded Side Rails for Seizure Precautions
Penalty
Summary
The facility failed to follow physician orders for a resident with a seizure disorder by not providing bilateral padded side rails as required for seizure precautions. The resident, who had diagnoses including diabetes mellitus, failure to thrive, and paraplegia, was admitted and readmitted with a care plan that included interventions to protect the resident from injury during seizures. Physician orders specifically directed the use of bilateral padded side rails, and the facility's policy also listed side rail padding as a seizure precaution. Despite these orders and policies, observations on multiple occasions revealed that the resident's bedrails did not have any padding. Interviews with nursing staff and the Director of Nursing confirmed that the resident had an order for padded side rails, and that the padding was necessary to protect the resident from injury during a seizure. The facility's failure to implement these precautions constituted a deficiency in providing a safe environment and adequate supervision for the resident.
Deficient Urinary and Bowel Care Services for Two Residents
Penalty
Summary
The facility failed to provide appropriate urinary and bowel care services for two residents. For one resident, who was admitted with a history of resistance to multiple antimicrobial drugs, urinary tract infection (UTI), acute kidney failure, and difficulty walking, the care plan indicated the resident was continent of bowel and bladder with a goal to keep the resident dry, clean, and comfortable. However, the Minimum Data Set (MDS) assessment reflected frequent incontinence and did not offer a bowel and bladder program. The resident reported awareness of the need to urinate and have bowel movements, rarely soiled herself, and expressed embarrassment after an incident of incontinence, stating that scheduled reminders and assistance would be helpful. Staff interviews confirmed that the care plan and MDS were inconsistent and that the resident should have been started on a bowel and bladder program to prevent UTIs and skin breakdown, as outlined in facility policy. For the second resident, who was admitted with diagnoses including a displaced avulsion fracture, difficulty walking, muscle weakness, and obstructive and reflux uropathy, the care plan required that the indwelling catheter bag and tubing be positioned below the level of the bladder. During observation, the resident's catheter tubing was found to have a large dependent loop containing yellow liquid with sediment, which had backflowed to the urine drainage port. A registered nurse confirmed that the tubing was improperly looped and that urine was not draining correctly, which could lead to infection. The DON stated that catheter tubing should always remain straight to prevent UTIs, especially for residents with a history of obstruction. Facility policies reviewed indicated the importance of providing appropriate treatment and services to minimize UTIs, restore bowel and bladder function, and prevent skin breakdown. The policies also specified that catheter collection bags should be kept below the level of the bladder to prevent backflow. The observed failures in care for both residents were inconsistent with these policies and resulted in deficiencies in providing necessary urinary and bowel care services.
Failure to Follow Oxygen Therapy Protocols for Two Residents
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care services for two residents by not following established protocols for oxygen therapy. For one resident with COPD and heart failure, the physician ordered oxygen at four liters per minute as needed, and the care plan required humidification to prevent symptoms of poor oxygen absorption. Observations revealed that the resident's oxygen humidifier bottle was nearly empty on one occasion and completely empty on another, despite the resident using oxygen continuously and stating a need for humidification. A nurse confirmed the humidifier bottle was empty and acknowledged that lack of humidification could lead to nasal dryness and bleeding. The Director of Nursing stated that humidifier bottles should be checked daily and changed before running out, in line with facility policy. For another resident with respiratory failure and a history of fractures, the physician ordered continuous oxygen therapy via nasal cannula. The facility's policy required that nasal cannulas be changed every seven days and labeled with the date of change to prevent infection. During an observation, the resident's nasal cannula was not labeled with the date it was last changed. A nurse confirmed the cannula should be labeled and changed weekly, and the DON reiterated the importance of labeling to prevent bacterial growth and respiratory infections. The facility's own policies and procedures for oxygen therapy were not followed in both cases. The humidifier bottle for one resident was allowed to run empty, and the nasal cannula for another resident was not labeled as required. These lapses were confirmed by staff interviews and direct observation, and were contrary to the facility's written protocols for respiratory care.
Failure to Ensure Accurate Assessment and Monitoring of Dialysis Access Site
Penalty
Summary
The facility failed to provide appropriate dialysis care and services for a resident with end stage renal disease who required hemodialysis. The resident was admitted with a history of ESRD, hypertension, and a left leg amputation, and had a left femoral artery permcath as the current dialysis access site. However, the clinical admission form did not indicate that the resident underwent dialysis, and the admission progress note incorrectly documented the dialysis access site as a right upper arm AVF instead of the left femoral permcath. This resulted in inaccurate documentation of the resident's dialysis needs and access site. Further review revealed that the facility did not complete thorough pre and post dialysis assessments for the resident on multiple occasions. Specifically, assessment forms for several dialysis dates were incomplete and did not include required evaluations of the dialysis access site after treatment. Both the RN and DON confirmed that licensed staff were required to assess the dialysis access site before and after each dialysis session, but this was not done as required. The facility's own policy mandated daily assessment and documentation of the vascular access site, as well as completion of pre and post dialysis evaluations by a licensed nurse. Observations and interviews confirmed that the resident was aware of her dialysis schedule and access site, but facility documentation and assessments did not accurately reflect her current treatment or provide the necessary monitoring. The lack of accurate admission documentation and incomplete pre and post dialysis assessments led to a failure in ensuring safe and appropriate dialysis care for the resident.
Non-Compliance with Resident Room Occupancy Limits
Penalty
Summary
The facility failed to ensure that two rooms did not accommodate more than four residents, as required by regulations. Review of the facility's room waiver request letter indicated that these rooms exceeded the four-bed limit, with one room containing seven beds and another containing five beds. The waiver letter stated that the rooms had adequate space for each resident and that the arrangement would not adversely affect residents' health and safety. Observations confirmed that each resident had privacy curtains, working call-lights, a dresser, and a bedside table. During multiple observations, nursing staff were seen providing care with adequate space in the affected rooms. Interviews with a resident and a CNA revealed that neither had concerns about the available space, and both felt there was sufficient room for movement and care activities. Despite these observations, the rooms did not comply with the regulation limiting occupancy to four residents per room.
Failure to Monitor Assistive Signaling Devices
Penalty
Summary
The facility failed to ensure the proper monitoring of assistive signaling devices, specifically bed and wheelchair alarms, for a resident with dementia and mobility issues. The resident was admitted with diagnoses including dementia, difficulty walking, and generalized muscle weakness, and had a history of falls. Physician orders were given to apply a bed alarm on December 23, 2024, and a wheelchair alarm on January 3, 2025, for the resident's safety. However, the facility did not begin monitoring the placement and functionality of these alarms until March 18, 2025, which was a significant delay from when the alarms were initially applied. Interviews with facility staff, including licensed vocational nurses and the director of nursing, confirmed that the monitoring of these alarms only started on March 18, 2025. The facility's policy required that the placement and functionality of signaling devices be verified every shift and documented in the resident's medical record. The lack of monitoring had the potential for the alarms to malfunction without the facility's knowledge, increasing the risk of the resident leaving the bed or wheelchair unnoticed, which could lead to accidents.
Failure to Administer Adequate Oxygen Therapy
Penalty
Summary
The facility failed to administer adequate supplemental oxygen to a resident in accordance with professional standards of practice. The resident, who had a history of congestive heart failure and hypertension, was found with an altered level of consciousness and an oxygen saturation of 64%, which is significantly below the normal range. Despite the critical condition, the resident was initially given only four liters of oxygen via a nasal cannula, which was insufficient for the resident's needs. The paramedics later found the resident cyanotic and cold to the touch, with an oxygen saturation of 70% after receiving the nasal cannula oxygen. The paramedics promptly placed the resident on a non-rebreather mask at 15 liters per minute, which increased the resident's oxygen saturation to 87%. Interviews with the nursing staff revealed a lack of documentation regarding the amount of oxygen administered and the device used, which was acknowledged by the Director of Nursing as a critical oversight. The facility's policy and procedures require that progress notes reflect changes in the resident's condition and that oxygen therapy be administered safely to meet resident needs, which was not adhered to in this case.
Failure to Provide Documents in Residents' Preferred Language
Penalty
Summary
The facility failed to ensure that two residents and their families were fully informed and understood the documents they signed, specifically the Assisted Living Waiver (ALW) forms and consents. Both residents, who were cognitively intact, required assistance with various activities of daily living and preferred communication in their own language. Despite this, the ALW forms and consents were provided in English, a language the residents did not understand, and no interpreter was used at the time of signing. This resulted in the residents and their families being unaware of the contents of the documents they signed. Interviews with the residents and their family members revealed that they did not remember what they signed and were not provided copies of the documents. The facility's administrator, who spoke the residents' language, claimed to have interpreted the documents during the signing process. However, the facility's policies on resident rights and translation services were not adhered to, as the residents were not informed in a language they could understand, nor were they provided with competent translation services as required by the facility's procedures.
Failure to Provide Timely Notice of Discharge
Penalty
Summary
The facility failed to provide a Notice of Proposed Transfer and Discharge to a resident who was scheduled for a planned discharge to a lower level of care. The resident, who was cognitively intact and required supervision and assistance with various activities of daily living, was originally admitted in 2017 and readmitted with diagnoses including diabetes, reduced mobility, and difficulty in walking. The interdisciplinary team met with the resident and a family member to discuss the discharge plan, but the required notice was not given. The Director of Nursing acknowledged during an interview that the notice should have been provided to the resident as soon as the discharge date was known. The facility's policy requires that such notice be given 30 days prior to discharge or as soon as practicable, and a copy should be kept in the medical record. However, this procedure was not followed, resulting in the deficiency.
Failure to Post Actual Staff Hours
Penalty
Summary
The facility failed to comply with federal requirements by not posting the actual daily hours worked by staff in an area accessible to the public for four out of six days in June 2024. Observations made on June 3rd, 4th, 5th, and 6th revealed that the Census and Direct Care Service Hours Per Patient Day (DHPPD) displayed in the facility lobby only reflected the projected working hours of staff rather than the actual hours worked. This discrepancy was confirmed during an interview with the Director of Staff Development (DSD), who acknowledged that the actual hours were kept in a separate binder and not posted as required. The facility's policy, titled 'Nursing Department - NHPPD Staffing Audit Guidelines,' dated March 14, 2024, mandates the posting of actual nursing hours performed by direct caregivers per patient day. The DSD emphasized the importance of posting actual nursing hours to ensure patient safety and adequate staffing for the current patient census. The failure to provide residents, family, or visitors with the actual number of staff could lead to feelings of unease among them, as they would not have access to accurate staffing information.
Inaccessible Call Lights for Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for two residents, leading to a potential delay in care and services. Resident 10, who was admitted with hemiplegia and hemiparesis following a cerebral infarction, was found with the call light on the floor, out of reach. The resident's care plan emphasized the importance of having the call light within reach due to the risk of falls and dependency on staff for activities of daily living. During an observation, a Licensed Vocational Nurse confirmed that the call light was not accessible to Resident 10, acknowledging that it should be within reach to allow the resident to call for help. Similarly, Resident 113, admitted with diagnoses including alcohol and stimulant abuse and muscle weakness, was observed with the call light hanging from the wall, far from reach. The resident was unaware of the call light's location, and a Certified Nursing Assistant confirmed its inaccessibility. The facility's Director of Nursing stated that call lights are required to be accessible at all times, and the facility's policy mandates that call cords be placed within residents' reach. These observations highlight the facility's failure to adhere to its policy, potentially impacting residents' ability to request assistance.
Failure to Revise Care Plans for Discontinued Treatments
Penalty
Summary
The facility failed to revise care plans for two residents, leading to a deficiency in care planning. Resident 20's care plan was not updated to reflect the discontinuation of antibiotic therapy. The resident was initially prescribed Ceftriaxone Sodium Injection for a urinary tract infection and later switched to Keflex. Despite the completion of these antibiotic courses, the care plan continued to indicate that the resident was on antibiotic therapy. This oversight was confirmed during a review of the resident's medical records and interviews with the Minimum Data Set Coordinator and the Director of Nursing. Similarly, the care plan for Resident 47 was not revised following the removal of an indwelling catheter. The resident was admitted with a urinary tract infection and had an indwelling catheter in place. The physician ordered the removal of the catheter, but the care plan was not updated to reflect this change. Observations and interviews confirmed that the catheter had been removed, yet the care plan still indicated its presence. The Director of Nursing acknowledged that the care plan should have been revised to accurately reflect the resident's current status. The facility's policy on comprehensive person-centered care planning requires that care plans be reviewed and revised after each assessment and upon changes in a resident's condition. The failure to update the care plans for these residents placed them at risk for inconsistent care, as the plans did not accurately reflect their current medical needs and treatments.
Failure to Rotate Insulin Injection Sites
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice by not rotating the site for administration of a subcutaneous injection of Basaglar, a long-acting insulin. This deficiency was identified for one of the three sampled residents, who was diagnosed with Type 1 diabetes and required insulin administration. The physician's order specifically indicated that the injection sites should be rotated to prevent complications, but this was not adhered to. The resident, who had intact cognition and required moderate assistance with daily activities, received the Basaglar injection in the same site on the right arm for four consecutive days. This practice was confirmed during a review of the resident's medical record with the MDS Coordinator, who acknowledged the need for site rotation to prevent skin complications. The Director of Nursing also confirmed that the licensed nurses were required to rotate the injection sites as per the physician's order and the facility's policy on subcutaneous injections.
Failure to Discontinue Unnecessary Medication
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary medication by not following the physician's order to discontinue Enoxaparin, a blood thinner, on a specified date. The resident continued to receive the medication for several days without a physician's order, which placed the resident at risk for adverse effects such as internal bleeding. The Director of Nursing (DON) acknowledged the oversight, stating that she forgot to follow through on the pharmacy's recommendation to discontinue the medication. The resident, who was initially admitted with a fracture of the left femur and other mobility issues, had intact cognition and required assistance with certain activities. The resident's care plan included administering Enoxaparin as ordered and monitoring for adverse reactions. Despite a pharmacist's note recommending the discontinuation of Enoxaparin, the medication was administered daily until the oversight was discovered during a surveyor interview. The facility's policy indicated that changes in medication orders should be documented and carried out promptly, which did not occur in this case.
Failure to Serve Therapeutic Diet as Prescribed
Penalty
Summary
The facility failed to ensure that a therapeutic diet was served according to the Physician's Order for a resident diagnosed with dementia, muscle weakness, and requiring assistance with personal care. The Physician's Order specified a no added salt diet, mechanical soft texture, and nectar thick consistency liquids due to mild signs of dysphagia. Despite these orders, the resident was observed consuming coffee with a thin consistency, which was not in compliance with the prescribed nectar thick liquid requirement. During observations and interviews, it was revealed that the staff served the resident coffee with a thin consistency instead of the required nectar thick consistency. The Certified Nursing Assistant (CNA) acknowledged the error but was unaware of which staff member served the coffee. Both the Registered Dietician and the Director of Nursing confirmed the necessity of following the Physician's Order for nectar thick liquids to prevent risks such as choking and aspiration. The facility's policy on therapeutic diets emphasized the importance of adhering to physician orders, which was not followed in this instance.
Failure to Provide Adaptive Eating Equipment
Penalty
Summary
The facility failed to provide a dycem, a non-slip mat, to a resident who required it for eating, as part of their adaptive equipment needs. This deficiency was identified for a resident with hemiplegia, hemiparesis, diabetes Type II, and muscle weakness, who was admitted on 8/8/2023. The resident's care plan, revised on 8/9/2023, specified the need for a divided plate and dycem at each meal to assist with self-feeding. Despite this, observations on 6/5/2024 revealed that the resident was not provided with a dycem during lunch, although a divided plate was present. The resident confirmed that the blue mat, previously used to prevent the food tray from slipping, was missing and had not been replaced. Interviews with facility staff, including the Director of Rehabilitation and the Director of Nursing, confirmed the importance of providing adaptive equipment to the resident to support independent eating. The facility's policy, reviewed on 3/14/2024, indicated that adaptive equipment should be provided by the occupational therapist to the dietary department for daily meal services. However, a review of the Medical Administration Record for May 2024 showed no documentation of the adaptive equipment being provided at each meal, indicating a lapse in following the prescribed care plan and physician's orders.
Catheter Bag Touching Floor in LTC Facility
Penalty
Summary
The facility failed to ensure that an indwelling catheter bag was not touching the floor for one of the residents, which could potentially lead to a urinary tract infection. The resident, who was admitted with diagnoses including a urinary tract infection, Type II diabetes mellitus, and paralysis on the right side of the body, required assistance with daily activities. During an observation, the resident was seen sitting in a wheelchair with the catheter bag hanging and touching the floor. A Certified Nursing Assistant acknowledged that the catheter bag should not be touching the floor due to infection control concerns. The Director of Nursing confirmed that the CNA should have ensured the catheter bag was not in contact with the floor, as per the facility's policy and procedure on catheter care.
Room Capacity Exceeded in Two Resident Rooms
Penalty
Summary
The facility failed to comply with the regulation that limits the number of residents per room to four, as two rooms were found to accommodate more than the allowed number of residents. Specifically, one room housed seven residents, and another housed five, exceeding the regulatory limit. Despite this, observations indicated that nursing staff had adequate space to provide care, and privacy curtains were available for residents. Additionally, the rooms had two modes of egress, ensuring safety. Interviews with residents and CNAs revealed no concerns regarding space adequacy or care provision. A room waiver request was submitted, indicating that the room arrangements were in line with the residents' special needs and did not adversely affect their health or safety. The Department recommended the continuation of the Room Waiver Request.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Los Angeles
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Highland Park Skilled Nursing And Wellness Center | 0.9 mi | ★★★★★ | 25 | 0 |
| Huntington Healthcare Center | 1.5 mi | ★★★★★ | 21 | 0 |
| York Healthcare & Wellness Centre | 1.8 mi | ★★★★★ | 18 | 0 |
| Kei-ai Los Angeles Healthcare Center | 2 mi | ★★★★★ | 33 | 0 |
| College Vista Post-acute | 2.3 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.