Above average — CMS composite of the measures below.
The next survey window likely opens around June 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 Monterey Park Conv Hosp during CMS and state inspections, most recent first.
Food storage and kitchen equipment were found out of compliance with policy when a container of mashed potatoes was left improperly closed, a blender pitcher had a lingering odor with peeling cover and residue, a peanut butter jar lid was smeared, and the can opener and food grater had dried food residue. A torn freezer bag exposed beef patties and other items, the label was unreadable, and another blender had a chipped, calcified paddle with dried residue. Dietary staff and the DS confirmed the conditions did not meet food safety and storage standards.
Hand hygiene and glove-use practices were not followed during incontinent care for two residents. One CNA cleaned feces from a resident, doffed gloves, put on new gloves without hand hygiene, and then touched the resident and clean bed sheets while repositioning. Another CNA used the same gloves after incontinent care to reposition a resident and touch bed sheets and side rails. Both residents had severe cognitive impairment and required extensive assistance with personal care, and the IP and DON stated staff should perform hand hygiene after glove removal and before donning new gloves.
Call Light Not Kept Within Reach: A resident with hemiplegia, hemiparesis, and contractures had a call light observed coiled on the contracted side of the bed and hanging toward the floor, out of reach. A CNA stated the resident could not reach it, and an RN confirmed the facility policy required the call light to be within reach and secure as needed.
Failure to notify physician of new behavioral change: A resident with dementia, Alzheimer's disease, and depression developed new pinching and grabbing behaviors, including during feeding and interactions with staff and a surveyor. The AD said this was the first time the resident had acted this way, and RN and DON both identified the behavior as a significant COC that required physician notification, but the doctor was not notified.
A resident with anxiety and depression was prescribed Buspirone for anxiety as manifested by restlessness/inability to relax, but the order did not identify the resident’s specific behaviors. Staff described the resident’s restlessness differently, the CNA did not know the signs and symptoms, and the RN noted the MAR did not reflect the resident’s anxiety level. The DON stated the documentation was not accurate because staff had different ideas of what restlessness meant, and the facility policy required psychotropic use only for a specific, diagnosed, and documented condition.
Failure to care plan a resident’s impaired hearing. A resident with dementia and a history of hard of hearing was observed unable to hear normal conversation and stated he refused to use his hearing aid. The SSD and RN confirmed no care plan had been initiated for the hearing impairment or hearing aid refusal, and the DON stated the condition should have been care planned per facility policy and MDS triggers.
Failure to revise fall risk care plan after resident fall. A resident with repeated falls, dementia, weakness, and impaired cognition had an actual fall after sliding off the bed due to poor safety awareness. The COC, progress notes, and IDT fall conference documented the event and recommended frequent visual checks and help maintaining position in bed, but the fall risk care plan was not revised to reflect the new interventions.
Failure to Assist with Toileting and Perineal Care: A resident with cognitive impairment and dependence for toileting hygiene was not assisted to the restroom and was told by a CNA to urinate in her diaper because the CNA was busy. The resident and her roommate reported that after wet diaper changes, the CNA did not provide perineal cleansing before applying a clean diaper. The DON, CNA, and LVN confirmed the resident required toileting assistance and should have been cleaned and treated with dignity.
A used vacutainer needle was observed not fully placed into a sharps container on a medication cart in a hallway where staff, residents, and visitors were passing through, and an LPN stated it should have been disposed of properly. In a separate event, a resident with a history of falls, Parkinson’s disease, osteoporosis, and cognitive impairment was left seated unattended in a hallway in an unlocked wheelchair; an LPN and the DON stated the wheelchair brakes should have been locked.
A resident with a GT, GERD, interstitial pulmonary disease, and dementia was observed receiving medications via the GT without the nurse confirming tube placement. The LVN stated she did not check GRV before administering the medications, and the RN and DON stated GT placement and residuals should be checked prior to medication administration, although the facility policy did not include GRV checking.
A resident with acute respiratory failure with hypoxia and severe cognitive impairment was ordered oxygen via NC at 2 to 5 LPM to keep O2 saturation at or above 95%. During observation, the resident was lying in bed with the NC on the side of the face instead of in the nose while the concentrator was set at 2.5 LPM. RN and DON stated the NC should be in the nose to deliver oxygen as ordered.
Inaccurate Meal Intake Documentation: A resident with dementia, muscle weakness, DM, and a mechanically altered therapeutic diet had meal intake documented as 51 to 75% even though an observation and the ST indicated the resident ate only about 10% of the meal. CNA later stated she did not see how much the resident ate before charting the intake, and the DON confirmed the documentation should not have been entered without verifying the amount consumed.
Lint Buildup in Dryer Lint Trap: One of two dryers was observed running with lint buildup in the lint trap after the lint door was opened during a laundry tour. The MSS stated the lint trap should be cleaned every 2 hours for fire safety, and an LA stated she forgot to clean Dryer 2's lint trap. Facility policy required laundry equipment to be maintained per manufacturer instructions and kept in a safe, operable condition.
Dirty G-tube Pump and Room Floor: A resident with Parkinson’s disease, DM, and impaired cognition was observed sleeping in bed while connected to a turned-off G-tube pump that had visible dried milk residue, and the room floor also had visible dried milk residue. A CNA confirmed the pump and floor were dirty, and an LVN stated food or milk drippings should be cleaned right away. RN review showed the care plan called for a safe environment with a floor free from spills and clutter, and the facility did not follow its cleaning and disinfection policy.
Two residents, one with cognitive impairment and another lacking decision-making capacity, were admitted without the required advance directive acknowledgement being completed within 72 hours, as mandated by facility policy. Both the Social Services Director and DON confirmed the omission during record reviews and interviews.
A dietary aide with facial hair was observed in the kitchen and food storage areas without a beard mask, in violation of facility policy requiring hair restraints to prevent food contamination. Both the aide and the dietary service supervisor acknowledged the risk of hair falling into food and the importance of wearing a beard mask to prevent the spread of germs.
Staff failed to follow infection prevention and control practices, including not wearing required PPE when entering the room of a resident on contact isolation, transporting a resident on transmission-based precautions to communal areas, and not performing hand hygiene or changing gloves after providing peri-care or before administering medications to residents with indwelling devices.
The facility did not ensure the kitchen ceiling was free from water stains, bubbling, and peeling paint following a recent leak, and allowed a dumpster to overflow and remain uncovered, contrary to facility policy. These actions resulted in an unsanitary and unhomelike environment, with the potential for food contamination and pest intrusion as acknowledged by the Maintenance Director.
Six residents with severe cognitive impairments and high care needs were found with bed rails in the half-length position, contrary to physician orders specifying quarter-length rails. Staff interviews revealed confusion about bed rail types, and one resident was injured after becoming trapped on a bed rail. The facility did not follow its own policies or physician orders regarding bed rail use and monitoring, placing residents at risk for entrapment and injury.
A resident with cognitive impairment and multiple care needs was found with food particles on their chest and stomach after a meal, attempting to clean themselves. An RN confirmed the issue and stated a CNA should have provided assistance. The DON acknowledged this did not meet dignity standards, and facility policy requires staff to maintain resident cleanliness and respect.
A resident with multiple mental health diagnoses was prescribed Xanax for anxiety with a physician's order referencing repetitive movements, but there was no documentation of monitoring for these symptoms. Staff interviews revealed confusion about the resident's behaviors, and nursing staff could not specify or monitor the required symptoms, contrary to facility policy on psychotropic medication use.
A resident with acute respiratory failure and other serious conditions did not have an individualized care plan for oxygen therapy, despite physician orders and facility policy requiring one. The resident was observed without the nasal cannula in place and experiencing rapid breathing, and staff confirmed that a care plan for oxygen use was missing.
Two residents were not provided with appropriate safety interventions: one was transported in a wheelchair without footrests, risking injury, and another with a seizure disorder did not have padded bedside rails as required by their care plan and facility policy.
A resident with acute respiratory needs did not have the nasal cannula prongs properly placed in the nostrils while receiving oxygen, as observed by staff. The resident was noted to be hyperventilating, and staff confirmed that the nasal cannula should be correctly positioned to deliver oxygen as ordered.
A resident with end stage renal disease and a fluid restriction order was left with a full pitcher of water and a large bottle of juice at bedside, without proper signage indicating fluid limits or AV shunt precautions. Staff interviews revealed inconsistent monitoring of fluid intake and lack of awareness of the specific fluid restriction, resulting in failure to follow physician orders and facility policy for hemodialysis care.
The facility did not ensure that the Daily Staffing Report was complete and clearly posted in a visible location, as it was placed behind another form and lacked required direct care hours for RNs, LVNs, CNAs, and RNAs on multiple days. Staff interviews confirmed the report should be visible and complete, in accordance with facility policy.
A multiple occupancy room was found to house three residents in a space measuring 223 square feet, which is below the required 80 square feet per resident. Each resident had a bed, bedside table, nightstand, and wheelchair, and no complaints were reported by residents or staff regarding the room size.
A resident at high risk for falls experienced two falls due to inadequate supervision and a non-functional sensor alarm. Despite severe cognitive impairment and a need for assistance, the care plan was not updated to include necessary supervision. The resident suffered injuries from falls, highlighting deficiencies in the facility's care practices.
The facility failed to remove an expired Humulin R insulin vial and improperly stored five unopened Insulin Glargine Flex Pens at room temperature instead of in the refrigerator. The DON confirmed these deficiencies, acknowledging the potential ineffectiveness of the insulin due to expiration and improper storage.
The facility failed to follow proper food handling practices, as observed by surveyors. A broken rice container lid, an unsealed cookie container, a dirty and rusty can opener, and an overflowing trash can were noted. The Dietary Supervisor confirmed these issues, which contradict the facility's policies on maintaining cleanliness and preventing foodborne illnesses.
The facility failed to properly dispose of kitchen garbage, as two bags of trash were found on the ground outside the kitchen. The maintenance supervisor confirmed that the trash should have been in the dumpster to prevent vermin attraction, which is an infection control issue. The Dietary Supervisor noted that the trash company sometimes leaves the dumpster on the street, leading to improper disposal. The facility's policy requires garbage to be disposed of in the dumpster to prevent attracting insects and rodents.
A resident with impaired cognitive skills and total dependence on staff did not receive adequate privacy during a medication administration via G-tube. An LVN failed to close the door or pull the privacy curtain, compromising the resident's dignity. The facility's policy on resident rights, which mandates personal privacy during medical treatment, was not followed.
The facility failed to provide a clean and safe environment in three sampled rooms. In two rooms, a bathroom toilet was found with fecal matter, and in another room, a bathroom light had exposed wires and no cover. An LVN and the Maintenance Supervisor confirmed these issues, citing the facility's policy for a safe and homelike environment.
A resident admitted with end-stage renal disease and requiring hemodialysis did not have a baseline care plan developed within 48 hours of admission. The facility's policy mandates such a plan to ensure effective and person-centered care, including special needs like dialysis. The absence of this plan was confirmed by the MDSN and acknowledged by the DON, highlighting a deficiency in meeting the resident's immediate needs.
A resident with diabetes and cerebral infarction, who had intact cognitive skills, often refused timely medication administration. Despite this, the facility failed to develop a care plan to address the resident's non-compliance, as confirmed by an LVN, QAN, and DON. The facility's policy mandates comprehensive care plans for such issues, but this was not followed, potentially affecting the resident's health.
A resident with Alzheimer's and hyperlipidemia received eye drops without proper lacrimal duct pressure application by an LVN, risking systemic absorption. The LVN also failed to use separate tissues for each eye, potentially causing cross-contamination. The facility's policy required these steps, which were not followed.
A resident with a sacral pressure ulcer was found to be using a malfunctioning Low Air Loss (LAL) mattress, which was intended to prevent and treat pressure ulcers. Despite the facility's policy on pressure injury prevention, the mattress was observed to be soft and slightly deflated, and staff acknowledged its inconsistent functionality. The resident's care plan required a functioning LAL mattress, but the issue persisted, leaving the resident at risk of worsening their condition.
A resident receiving hemodialysis at an LTC facility was not provided with appropriate care and services due to incomplete and inaccurate documentation of the dialysis access site. The facility failed to assess the resident's right upper chest access site on several occasions, and the dialysis communication records lacked essential information. The errors were confirmed by nursing staff, highlighting the need for accurate documentation to ensure proper care.
A resident with Parkinson's disease and impaired cognitive skills did not receive their prescribed Calcitonin Solution nasal spray, a medication for bone loss, due to an LVN's oversight during medication administration. The omission was acknowledged by the LVN and confirmed by the DON, highlighting a failure to follow physician orders as per the facility's medication administration policy.
A resident with visual impairment and cognitive decline was not provided with the necessary assistance and adaptive feeding equipment during meals, as required by a physician's order. Despite having a plate guard on the meal tray, the resident was observed eating with her hands without using the provided utensil. Staff interviews revealed a lack of verbal cues and hand-over-hand assistance, and the absence of a care plan addressing the resident's needs. Facility policies on assistive devices and activities of daily living were not adequately followed.
A facility failed to ensure staff followed infection control policies for a resident on Enhanced Standard Precaution (ESP) due to a gastrostomy tube and a history of infections. A CNA was observed not wearing a gown during high-contact care, despite facility policies and staff interviews confirming the need for gowns and gloves to prevent infection spread.
A resident with Parkinson's disease in an LTC facility was found to have an inaccessible call light in their bathroom, as the call light switch was positioned three feet above ground without a pull string. This deficiency was confirmed by the Maintenance Supervisor and acknowledged by the DON, highlighting a failure to adhere to the facility's policy requiring accessible call systems.
The facility did not meet the minimum square footage requirement for Room E, which housed three residents in a space measuring 223 square feet, falling short of the 80 square feet per resident standard. Despite this, residents appeared comfortable, and no complaints were reported. A waiver request was submitted, and the Department recommended its approval.
Food Storage and Equipment Not Kept Clean or Properly Covered
Penalty
Summary
Food handling and food service sanitation were not maintained in accordance with the facility’s policy and procedure during observations in the kitchen. A clear container of mashed potatoes was not properly closed. Blender 1 had a lingering vegetable smell, a top cover that was peeling off, and food residue present. A classic peanut butter jar had peanut butter smeared on the outside of the red lid, and the can opener had dry crusted food residue. A bag containing beef patties, cinnamon rolls, and chocolate chip cookies was torn, exposing the contents, and the label on the bag was unreadable. The food grater had dry food residue, and Blender 2 had a chipped gray plastic insert paddle, calcification, and dried food residue. During interviews, the Dietary staff confirmed the observed conditions and stated that food containers should be labeled and properly closed, blenders should be in good condition without peeling, chipping, or calcification, and equipment used in food handling should be clean and sanitized. The Dietary Supervisor reviewed the facility’s policies on date marking and food storage and stated that food should be clearly marked, refrigerated food should be labeled and monitored for use by date, foods should be kept covered or in tightly sealed containers, and all equipment used in handling food must be cleaned and sanitized to prevent contamination. The Dietary Supervisor also stated the policies were not followed.
Hand Hygiene and Glove Use Not Followed During Incontinent Care
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when staff failed to follow hand hygiene and glove removal practices during incontinent care for two residents. Resident 9 had diagnoses including gastrostomy status, GERD, interstitial pulmonary disease, and dementia, and the MDS indicated severe cognitive impairment, dependence for multiple ADLs, and that the resident was always incontinent of bowel and bladder. During observation, CNA 7 provided incontinent care, cleaned feces from the resident, doffed gloves while touching the outside of the dirty gloves, put on a new pair of gloves without performing hand hygiene, and then touched the resident while repositioning and touched clean bed sheets. Resident 13 had diagnoses including benign prostatic hyperplasia and encounter for palliative care, and the MDS indicated severe cognitive impairment with dependence for toileting hygiene, shower/bathing, lower body dressing, and footwear. During observation, CNA 8 provided incontinent care and then used the same gloves while repositioning the resident and touching the resident's bed sheets and side rails. Both CNAs stated they should have changed gloves and performed hand hygiene after incontinent care. The IP and DON stated staff are supposed to perform hand hygiene after glove removal and before donning new gloves, and that gloves are not a substitute for hand hygiene.
Call Light Not Kept Within Reach
Penalty
Summary
The facility failed to ensure that Resident 78’s call light was within reach. Resident 78 was admitted with diagnoses including hemiplegia, hemiparesis, contracture of the left shoulder, and type 2 diabetes mellitus. The resident’s MDS dated 4/13/2026 indicated moderate cognition with cognitive skills for daily decision making, and the resident required partial moderate assistance with eating, was dependent for personal hygiene, and needed help rolling left and right. The care plan, revised on 4/5/2025, identified an alteration in musculoskeletal status related to left knee contractures, left shoulder internal rotator contracture, and degenerative changes of the thoracic spine, and included interventions to anticipate and meet needs, ensure the call light is within reach, and respond promptly to requests for assistance. During a concurrent observation and interview on 6/29/2026 at 10:03 AM, Resident 78’s call light was observed coiled on the left side of the bed rails and hanging toward the floor. The CNA stated the call light was on the resident’s contracted side and that the resident was not able to reach it to call for staff when assistance was needed. An LVN later stated the call light should be on the resident’s right, dominant side so the resident could reach it and use it to call for help. An RN reviewed the facility’s policy on call light accessibility and stated staff are required to ensure the call light is within reach and secure as needed, and that the policy was not followed.
Failure to Notify Physician of New Behavioral Change
Penalty
Summary
The facility failed to inform the physician when Resident 71 had a change of condition on 6/29/2026. Resident 71 was admitted with diagnoses including dementia, Alzheimer's disease, and depression, and the MDS dated 6/15/2026 indicated the resident was moderately impaired in cognitive skills for daily decision making and required substantial to maximal assistance with several activities of daily living, including eating, oral hygiene, toileting hygiene, dressing, footwear, and personal hygiene, and was dependent for showering/bathing. The MDS also indicated the resident's behavior status, including care rejection or wandering, was worse compared to the prior assessment. During observations on 6/29/2026, Resident 71 was seen pinching the surveyor, grabbing the Activities Director's arm, and pinching the Speech Therapist while being fed. The AD stated this was the first time the resident had done this and that it was a new behavior. The ST reported that a CNA had initially been feeding Resident 71 but became scared when the resident started grabbing and pinching, so the ST took over feeding. RN 2 later stated the pinching and grabbing was a new behavior and a significant change of condition, and that the doctor should have been notified but was not. The DON also stated the behavior was a significant change of condition and that a COC form should have been completed, the resident's behavior monitored, and the physician called.
Unclear indication documented for Buspirone use
Penalty
Summary
The facility failed to ensure that one sampled resident reviewed for unnecessary medications had a specific indication documented for the use of Buspirone. The resident was admitted with diagnoses including anxiety and depression, and the physician order dated 6/2/2026 directed Buspirone HCL 15 mg by mouth twice daily for anxiety as manifested by restlessness/inability to relax, but the order did not identify the resident’s specific behavior associated with restlessness or inability to relax. The resident’s MDS dated 6/5/2026 indicated moderate cognitive impairment and need for partial/moderate assistance with several activities of daily living, and also noted anxiety and depression. During interviews, staff gave different descriptions of the resident’s restlessness, including pacing, asking about appointments, complaining of pain, inability to sleep, walking around, and asking for pain medication. One CNA stated she did not know the resident’s signs and symptoms of restlessness. RN 2 stated the MAR for 6/30/2026 should have reflected the resident’s anxiety level but did not. The resident’s RP stated the resident’s sign of restlessness was isolating himself and reported that the resident texted her about having anxiety from 10:30 AM until 7 PM on 6/30/2026. The DON reviewed the MAR and stated it was not accurate because staff had different ideas of what restlessness was, and stated the resident should have the correct manifestation of anxiety reflected in the physician order and MAR. The facility policy stated psychotropic medications are to be used only when a practitioner determines the medication is appropriate to treat the resident’s specific, diagnosed, and documented condition.
Failure to Care Plan Hearing Impairment
Penalty
Summary
The facility failed to develop an individualized, resident-centered care plan with measurable objectives, timeframes, and interventions to address Resident 33’s impaired hearing. Resident 33 was admitted with diagnoses including dementia, muscle weakness, and abnormal gait and mobility, and the H&P documented a history of hard of hearing. The MDS dated 6/5/2026 indicated the resident was moderately impaired in cognitive skills for daily decision making and had minimal difficulty hearing. During an observation and interview on 6/29/2026, Resident 33 was lying in bed and stated he could not hear the surveyor during a normal conversation, that he was hard of hearing, and that he refused to use his hearing aid. The SSD stated the resident had difficulty hearing, refused to use the hearing aid, and had no care plan initiated for impaired hearing. RN 2 later confirmed there was no care plan for the resident’s impaired hearing and that one should be in place to address the hearing impairment and refusal to use the hearing aid so staff could communicate effectively. The DON stated that a resident with impaired hearing should be care planned according to facility policy and that hearing impairment triggered on the MDS should be care planned, including refusal to use the hearing aid.
Failure to Revise Fall Risk Care Plan After Resident Fall
Penalty
Summary
The facility failed to revise Resident 41’s care plan for risk for falls after the resident had an actual fall on 6/7/2026. Resident 41 was admitted with diagnoses including repeated falls, dementia, muscle weakness, and difficulty walking. The resident’s MDS dated 5/13/2026 indicated severe impairment in cognitive skills for daily decision making and the need for substantial to maximal assistance with several activities of daily living, including oral hygiene, toileting hygiene, dressing, footwear, and personal hygiene, and dependence for showering/bathing. A Change in Condition evaluation dated 6/7/2026 documented that Resident 41 had a fall and was crying intermittently. Progress notes from 6/7/2026 at 6:20 AM stated the resident was on the floor and had been witnessed by a CNA at 6:10 AM. An IDT fall incident care conference dated 6/8/2026 stated the resident fell in the room after sliding off the bed due to poor safety awareness and noted the resident was confused, with recommendations including frequent visual checks and assistance in maintaining position in bed. Review of the care plan showed the risk-for-falls plan, initiated 3/12/2025 and revised 2/24/2026, was not revised after the fall and did not indicate interventions such as frequent visual checks were added after 6/8/2026.
Failure to Assist with Toileting and Perineal Care
Penalty
Summary
The facility failed to provide assistance with toileting and perineal care for one resident who was dependent for toileting hygiene and required extensive assistance with personal hygiene. The resident was admitted with generalized muscle weakness and other musculoskeletal signs and symptoms, and the MDS dated 3/28/2026 indicated moderate cognitive impairment for daily decision making, dependence with toileting hygiene, showering, lower body dressing, and footwear, and substantial to maximal assistance with oral hygiene and upper body dressing. The care plan revised on 3/28/26 identified an ADL self-care deficit and called for extensive assistance with personal hygiene. During observation and interview, the resident stated that a CNA told her not to use the call light and to just urinate in her diaper because the CNA had a lot to do. The resident also stated that the CNA did not clean her before placing a new diaper on her. The roommate stated she heard the resident repeatedly press the call light, heard the CNA tell the resident not to use it and to wait, and observed that when the wet diaper was removed the resident asked to be wiped but the CNA said no because she was too busy. The roommate further stated that later the same night and again the next morning, the resident asked whether she would be cleaned after diaper changes, and she was not. CNA 5, the DON, and LVN 2 each stated the resident required assistance to use the restroom and should have been assisted and cleaned, and the DON stated the resident should not have been told to urinate on her diaper because the CNA was busy.
Improper Sharps Disposal and Unlocked Wheelchair in Hallway
Penalty
Summary
The facility failed to ensure a hallway area was free from accident hazards when a used vacutainer needle was observed not fully placed into the sharps container attached to Medication Cart A in the hallway in front of Room A. During the observation, the clear tubing contained blood residue, and LVN 1 stated that staff, residents, and visitors were passing through the hallway. LVN 1 later stated that the vacutainer should have been disposed of properly to prevent accidents and ensure the safety of residents, staff, and visitors. RN 1 reviewed the facility’s Bloodborne Pathogens/Contaminated Sharps Occupational Exposure and Standard Precautions Infection Control policies and stated that proper disposal of injection equipment in a sharps container was required for safety. The facility also failed to ensure Resident 85’s wheelchair was secured while the resident was left seated unattended in the hallway. Resident 85 had diagnoses including history of falling, Parkinson’s disease, and osteoporosis, and the admission record, fall risk assessment, and MDS indicated the resident had intermittent confusion, moderate cognitive impairment, used a wheelchair, and required varying levels of assistance with daily care. During observation, Resident 85 was seated in the wheelchair in the hallway with the wheelchair unlocked. LVN 2 stated the wheelchair brakes should be locked on both sides as a safety precaution, and the DON stated the brakes should be in the locked position to keep the wheelchair steady and prevent it from rolling if the resident stood up.
Failure to Verify GT Placement Before Medication Administration
Penalty
Summary
The facility failed to ensure appropriate gastrostomy tube care for Resident 9 by not confirming GT placement before medication administration. Resident 9 was admitted and later readmitted with diagnoses including gastrostomy status, GERD, interstitial pulmonary disease, and dementia. The MDS dated 3/30/26 indicated the resident was severely impaired in cognitive skills for daily decision making, dependent for multiple activities of daily living, and had a feeding tube with a therapeutic diet. Physician orders dated 2/21/2026 directed continuous enteral feeding of Jevity 1.2 at 40 ml/hour for 20 hours via GT. During a concurrent observation and interview on 7/1/2026 at 9:51 AM, LVN 5 was observed preparing and administering medications to Resident 9 without confirming GT placement. LVN 5 stated she did not check the resident's gastric residual volume prior to giving medications, but should have done so to prevent aspiration. RN 2 and the DON later stated that GT placement and residuals should be checked prior to medication administration, and both acknowledged that checking GRV was not included in the facility policy even though the policy stated tube placement should be verified before administering fluids or medications.
Oxygen Not Properly Delivered via Nasal Cannula
Penalty
Summary
The facility failed to ensure oxygen was administered in accordance with the physician’s order and facility policy for one sampled resident. Resident 44 was admitted with diagnoses including acute respiratory failure with hypoxia and encephalopathy. The MDS dated 5/28/2026 indicated the resident had severe cognitive impairment, was on oxygen therapy, and was dependent for eating, oral care, toileting, personal hygiene, showering, dressing, and footwear. A physician’s order dated 6/4/2026 directed oxygen via nasal cannula at 2 to 5 LPM to maintain oxygen saturation at or above 95% every shift, and the care plan was revised to reflect humidified oxygen via nasal cannula at 2 to 5 LPM to maintain oxygen saturation at or above 95% every shift. During a concurrent observation on 6/29/2026 at 10:33 AM, Resident 44 was observed lying in bed with the nasal cannula on the left side of the face while the oxygen concentrator was set at 2.5 LPM. During interviews, RN 3 stated the nasal cannula should be placed correctly in the resident’s nose for the resident to receive oxygen, and the DON stated the nasal cannula should always be in the resident’s nose to help maintain oxygen saturation at 95% and above. The facility policy titled Oxygen Administration stated oxygen is administered to residents who need it, consistent with professional standards of practice and comprehensive person-centered care plans, and under physician orders.
Inaccurate Meal Intake Documentation
Penalty
Summary
The facility failed to maintain an accurate clinical record when it documented an incorrect meal percentage for one resident. Resident 41 was admitted with diagnoses including repeated falls, dementia, muscle weakness, and diabetes mellitus. The resident’s MDS dated 5/13/2026 indicated severe cognitive impairment, substantial/maximal assistance with several activities of daily living, dependence for showering/bathing, and a mechanically altered and therapeutic diet. During a 6/29/2026 lunch observation, Resident 41 was seen eating only three bites of food, with about 90% of the meal still on the plate. The ST who was present stated the resident took a couple bites and consumed 10% of the meal. However, the meal record entered at 1:01 PM documented that the resident ate 51 to 75% of the meal. CNA 6 later stated she did not see how much Resident 41 ate before documenting the intake and said she should have checked first. RN 2 stated accurate documentation was important so changes in eating habits could be identified, and the DON stated the CNA should not have documented 51 to 75% without seeing how much the resident ate.
Lint Buildup in Dryer Lint Trap
Penalty
Summary
Essential laundry equipment was not maintained in safe operating condition when one of two dryers was found operating with lint buildup in the lint trap. During a laundry tour, Laundry Aid 1 opened the lint door underneath Dryer 2 and observed lint buildup on the lint trap while the dryer was running without any items inside. The Maintenance Service Supervisor stated the dryer lint trap should be cleaned every 2 hours for fire safety and prevention, and Laundry Aid 2 stated she forgot to clean the lint trap of Dryer 2 at 2 PM and that the dryer should be regularly cleaned and free from lint buildup. Facility policy for Laundry stated equipment will be used and maintained according to manufacturer instructions, and the Preventative maintenance program policy stated the maintenance director is responsible for maintaining a schedule so buildings, grounds, and equipment are kept in a safe and operable manner.
Dirty G-tube Pump and Room Floor
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, sanitary, and home-like environment for Resident 17 by not keeping the resident’s G-tube pump free of dried milk residue and not keeping the flooring in the resident’s room free of dried milk residue. Resident 17 was admitted on 8/8/2025 with diagnoses including Parkinson’s disease, diabetes mellitus, and lack of coordination. The resident’s MDS dated 4/9/2026 indicated moderately impaired cognitive skills for daily decision-making and that the resident needed partial to moderate assistance with personal hygiene and sit-to-stand. During an observation in the resident’s room on 6/29/2026 at 9:27 AM, Resident 17 was sleeping in bed and connected to a G-tube pump that was turned off. The pump had visible dried milk drippings, and the room flooring also had visible dried milk drippings. During a later observation and interview, a CNA stated that the G-tube pump was dirty with visible dry milk on it and that there was dried milk on the floor. An LVN stated that the G-tube pump and floor were supposed to always be clean and that food or milk drippings should be cleaned right away for safety and infection control. RN 1 reviewed the care plan and facility policies and stated the care plan called for keeping the resident’s environment safe with a floor free from spills and clutter, and that the facility did not follow its policy for cleaning and disinfecting resident care equipment.
Failure to Provide Advance Directive Information Upon Admission
Penalty
Summary
The facility failed to follow its policy regarding advance directives for two residents. For the first resident, who was admitted with immunodeficiency and schizoaffective disorder and was assessed as moderately impaired in cognitive skills, there was no documentation of advance directive acknowledgement in the medical chart or electronic health record. The Social Services Director confirmed that this acknowledgement should have been completed within 72 hours of admission but was not done. For the second resident, admitted with sepsis, acute respiratory failure, and immunodeficiency, and documented as lacking capacity to make decisions, there was also no advance directive acknowledgement in the chart or electronic record. The Social Services Director and the Director of Nursing both confirmed that the facility's policy requires this acknowledgement within 72 hours of admission, but it was not completed for this resident either.
Failure to Ensure Dietary Staff Wore Required Beard Restraint
Penalty
Summary
During an observation in the kitchen, a dietary aide was seen with a mustache and beard and was not wearing a beard mask while present in the kitchen and food storage areas. The dietary aide acknowledged forgetting to wear the beard mask that day. Both the dietary aide and the dietary service supervisor confirmed that hair could fall into food and cause contamination, and agreed on the importance of wearing a beard mask to prevent the spread of germs. Review of the facility's policy and procedures indicated that dietary staff are required to wear hair restraints, including beard restraints, to prevent hair from contacting food. This failure to follow policy had the potential to result in cross contamination and harmful bacterial growth for a large number of medically compromised residents who receive food from the kitchen.
Failure to Follow Infection Prevention and Control Practices
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices were followed for multiple residents, as observed and documented by surveyors. In one instance, a nurse entered the room of a resident on contact isolation for ESBL of the urine without donning an isolation gown, contrary to the facility's policy and the resident's care plan. Additionally, this resident, who was under transmission-based precautions, was transported to and left in the dining room area for activities, which was not permitted under the facility's policy for residents on such precautions. Another deficiency was observed with a nurse providing care to a resident on enhanced barrier precautions due to the presence of a gastrostomy tube. The nurse failed to change gloves and perform hand hygiene after touching multiple surfaces and before administering medications via the gastrostomy tube and an insulin injection. This was inconsistent with the facility's policy on enhanced barrier precautions, which requires glove and gown use and hand hygiene during high-contact care activities for residents with indwelling medical devices. Further observations revealed that staff did not remove gloves or perform hand hygiene after providing peri-care to three different residents, and subsequently touched the residents' bodies, bed sheets, or applied lotion without changing gloves. These actions were in direct violation of the facility's hand hygiene policy, which mandates hand hygiene after assisting with personal body functions and after glove removal. Interviews with staff confirmed awareness of the correct procedures, but these were not followed during the observed care activities.
Failure to Maintain Sanitary Kitchen Ceiling and Proper Dumpster Management
Penalty
Summary
The facility failed to maintain a safe and sanitary environment by not ensuring that the kitchen ceiling was free from water leak stains, bubbling, and peeling paint, and by allowing one of four dumpsters to overflow and remain uncovered. During observation, the kitchen ceiling was found to have water stains, paint patches, bubbling, and peeling paint, which the Dietary Service Supervisor attributed to a rain event two weeks prior. The Maintenance Director confirmed that the water leak had been repaired but had not inspected the kitchen ceiling and was unaware of the water stain and peeling paint until recently. The Maintenance Director acknowledged that the peeling paint could fall into food being prepared, potentially leading to contamination. Additionally, one of the facility's dumpsters was observed overflowing with boxes and not completely closed, which the Maintenance Director stated could allow insects or animals to access the trash and potentially spread germs and disease within the facility. Review of facility policies indicated that dumpsters should have tightly fitting lids and be emptied according to contract, with schedules adjusted as needed based on volume. The policies also required preventative maintenance to maintain a safe environment, which was not followed in these instances.
Failure to Follow Physician Orders and Proper Use of Bed Rails
Penalty
Summary
The facility failed to ensure the proper use and adherence to physician's orders regarding bed rails for six residents. In multiple instances, residents were observed with bed rails in the half-length position when physician orders specified quarter-length rails. This discrepancy was confirmed through interviews with nursing staff and the Director of Nursing, who acknowledged that the bed rails in use did not match the orders. Additionally, some staff members demonstrated a lack of understanding regarding the differences between quarter, half, and full side rails, further contributing to the improper use of bed rails. Several residents involved had significant cognitive impairments and were dependent on staff for most activities of daily living, including transfers, hygiene, and dressing. The residents had diagnoses such as dementia, Alzheimer's disease, depression, schizophrenia, osteoporosis, hemiplegia, and sepsis. Care plans and physician orders for these residents consistently indicated the need for quarter-length side rails to assist with mobility and repositioning, with instructions to monitor for potential entrapment. However, observations revealed that half-length rails were used instead, and the required monitoring and risk assessments were not adequately performed or documented. As a result of these failures, one resident experienced an incident where they became trapped on the bed rail, resulting in a cut on the nose bridge and a precarious position with the upper body off the bed and head touching the floor. The facility's own policies required a person-centered approach, correct installation, and maintenance of bed rails, as well as adherence to physician orders. The lack of compliance with these policies and orders placed multiple residents at risk for entrapment and injury.
Failure to Maintain Resident Dignity and Cleanliness After Mealtime
Penalty
Summary
A deficiency was identified when a resident, who was moderately impaired in cognitive skills and required varying levels of assistance with activities of daily living, was observed with yellow and brown food particles on their bare chest and stomach after a meal. The resident was seen attempting to remove the food particles themselves and expressed a desire to be clean. A registered nurse confirmed the presence of food particles and stated that a CNA should have cleaned the resident after the meal. The Director of Nursing acknowledged that the resident should not have had food particles on their body, as this impacts the resident's dignity. Review of facility policies indicated that staff are required to treat residents with respect and dignity, and to assist them in maintaining their quality of life and well-being. The failure to clean the resident after the meal was not in accordance with these policies.
Failure to Ensure Appropriate Use and Monitoring of Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident's psychotropic medication, specifically Xanax, was appropriate to treat a specific and documented condition in accordance with facility policy. The resident, who had diagnoses including dementia, Alzheimer's disease, depression, schizophrenia, and anxiety, had a physician's order for Xanax to be administered daily for anxiety as manifested by constant restlessness and repetitive physical movement. However, there was no documented evidence in the Medication Administration Record or Treatment Administration Record that the resident was monitored for these symptoms as required for the use of Xanax. Observations showed the resident was frequently sleeping, and staff interviews revealed inconsistencies and lack of clarity regarding the presence or nature of the resident's repetitive movements. Some staff described the movement as scratching, while others stated there were no repetitive movements. Nursing staff, including LVNs and RNs, were unable to specify or monitor the symptoms as indicated in the medication order, and the DON acknowledged the need for clarification. The facility's policy required psychotropic medications to be used only for specific, diagnosed, and documented conditions, with monitoring and documentation of the resident's response, which was not followed in this case.
Failure to Develop Individualized Oxygen Therapy Care Plan
Penalty
Summary
The facility failed to develop an individualized, resident-centered care plan with measurable objectives, timeframes, and interventions to address a resident's oxygen needs. The resident in question was admitted with diagnoses including sepsis, acute respiratory failure, and immunodeficiency, and was determined to lack the capacity to make decisions. Physician orders specified oxygen administration via nasal cannula at 1 liter per minute, with titration to maintain oxygen saturation at or above 95% as needed. However, review of the resident's care plans revealed that no care plan addressing oxygen use had been developed, contrary to facility policy and professional standards. During observation, the resident was seen without the nasal cannula in place and was hyperventilating while moving around. A registered nurse had to adjust the nasal cannula to ensure proper oxygen delivery. Staff interviews confirmed that a care plan for oxygen use was missing and should have been in place to guide staff in providing appropriate care. Facility policies reviewed indicated that care plans should describe the services necessary to maintain the resident's highest practicable well-being and that oxygen administration should be consistent with the care plan and resident's needs.
Failure to Prevent Accidents and Implement Seizure Precautions
Penalty
Summary
The facility failed to implement necessary interventions to prevent injuries for two residents. In the first instance, a resident with a history of a displaced comminuted fracture of the left femur and severe cognitive impairment was observed being transported in a wheelchair without the use of footrests. The resident's feet were on the floor while being pushed by a CNA, despite facility policy and staff interviews confirming that footrests should be used during transport to prevent the resident's feet from dragging and potentially causing injury. In the second instance, a resident with epilepsy and a care plan indicating seizure precautions was found to have unpadded metal bedside rails. Observations and interviews with the resident and nursing staff confirmed that the bedside rails were not padded as required to protect the resident from injury during seizure activity. The facility's policy on seizure precautions specifies that residents should be protected from injury according to current standards of practice, including the use of padded rails.
Failure to Ensure Proper Placement of Nasal Cannula for Oxygen Therapy
Penalty
Summary
A deficiency occurred when a resident with a history of sepsis, acute respiratory failure, and immunodeficiency, who lacked decision-making capacity, did not receive oxygen therapy as ordered. The physician's orders specified oxygen via nasal cannula at 1 liter per minute, with titration to maintain oxygen saturation at or above 95%. During an observation, the resident was found with the nasal cannula prongs not inserted in the nostrils while receiving oxygen, and was noted to be moving around and hyperventilating. A registered nurse was observed correcting the placement of the nasal cannula and confirmed that the prongs should be in the nostrils to deliver oxygen as ordered. The Director of Nursing also stated that the nasal cannula should be properly placed in the nostrils for effective oxygen administration. Review of the facility's policy confirmed that the equipment and placement depend on the delivery system ordered, such as a nasal cannula for oxygen through the nostrils.
Failure to Provide Safe Hemodialysis Care and Enforce Fluid Restriction
Penalty
Summary
Facility staff failed to provide safe and appropriate hemodialysis care for a resident with end stage renal disease who required strict fluid restriction and special precautions for an arteriovenous (AV) shunt. Observations revealed that a full pitcher of water and a large bottle of juice were left at the resident's bedside, despite a physician's order and care plan specifying a 1000 cc per day fluid restriction. There was no sign posted in the resident's room indicating the fluid restriction or specifying which arm had the AV shunt to prevent blood pressure readings, IV access, or laboratory sticks on that arm. Interviews with staff indicated a lack of knowledge regarding the exact fluid restriction amount and inconsistent monitoring of the resident's fluid intake. The resident, who had moderate cognitive impairment and required assistance with daily activities, reported that staff did not measure or limit fluid intake and was unaware of the fluid restriction. Multiple staff members confirmed that fluid intake was not being accurately monitored and that appropriate signage was not in place. The facility's policy required adherence to physician orders and care plans for residents receiving hemodialysis, including not using the AV shunt arm for certain procedures, but these protocols were not followed for this resident.
Incomplete and Improperly Posted Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the Daily Staffing Report was both complete and posted in a manner that was visible and accessible to residents, visitors, and staff on multiple consecutive days. On three separate days, the report was observed to be placed behind another facility form, making it not visible. Additionally, on two of those days, the report did not include the actual direct care hours for RNs, LVNs, CNAs, and RNAs for the day shift, as required by facility policy. Interviews with the Director of Staff Development and nursing staff confirmed that the Daily Staffing Report should be visible and complete, including the actual direct care hours for each category of nursing staff. Review of the facility's policy indicated that the report must be posted daily in a prominent place and include the total number and actual hours worked by licensed and unlicensed nursing staff per shift. The failure to post complete and visible staffing information was directly observed and acknowledged by facility staff.
Room Size Below Minimum Requirement for Multiple Occupancy
Penalty
Summary
The facility failed to ensure that one of its multiple resident rooms, Room A, met the minimum square footage requirement of 80 square feet per resident. During an observation, Room A was found to house three residents, each with their own bed, bedside table, nightstand, and wheelchair, but the total room size was only 223 square feet, which is less than the required 240 square feet for three residents. Interviews with residents and staff revealed no complaints about the room size, and all residents appeared comfortable at the time of observation. Documentation reviewed confirmed the room's measurements and current occupancy.
Failure to Provide Supervision and Functional Alarm Leads to Resident Falls
Penalty
Summary
The facility failed to provide adequate supervision and ensure the proper functioning of a sensor alarm for a resident at high risk for falls. Resident 34, who was admitted with diagnoses including muscle weakness, repeated falls, and lack of coordination, experienced two falls due to these deficiencies. The resident's Minimum Data Set (MDS) indicated severe cognitive impairment and a need for partial moderate assistance with daily activities, including toileting and transfers. Despite these needs, the facility did not update the care plan to include necessary supervision, and the sensor alarm intended to alert staff when the resident got out of bed was not functioning. On two separate occasions, Resident 34 suffered falls that resulted in injuries. The first fall occurred on February 13, 2024, leading to a laceration on the forehead that required hospital transfer for possible suturing. The second fall happened on March 23, 2024, when the resident was found on the bathroom floor without supervision. Interviews with staff, including the Quality Assurance Nurse and the Director of Rehab, confirmed that the resident required supervision and assistance, which was not provided at the time of the incidents. The facility's policies and procedures emphasized the need for alarms and comprehensive care plans to ensure resident safety. However, the care plan for Resident 34 was not revised to reflect the resident's high fall risk and need for supervision. The failure to update the care plan and ensure the alarm's functionality contributed to the resident's falls and subsequent injuries, highlighting a significant oversight in the facility's care practices.
Improper Storage and Expiration of Insulin
Penalty
Summary
The facility failed to adhere to its Medication Storage policy by not removing an expired Humulin R insulin vial from the refrigerator. During an observation and interview with the Director of Nursing (DON), it was noted that the Humulin R insulin vial was labeled with an open date and a discard date, indicating it should have been discarded within 28 days of opening. The DON acknowledged that the insulin vial was expired and should have been removed, as expired insulin may be ineffective in controlling a resident's blood sugar, potentially leading to medical complications. Additionally, the facility did not store five unopened Insulin Glargine Flex Pens in the refrigerator as required. These pens were found at room temperature in a plastic bag on the countertop. The DON confirmed that the insulin pens should have been refrigerated according to product labeling. Since the storage duration at room temperature was unknown, the pens were considered expired and unsafe for administration. The improper storage of insulin could render it ineffective, posing a risk of medical complications for residents.
Deficiencies in Food Handling and Sanitation Practices
Penalty
Summary
The facility failed to adhere to proper food handling practices as observed during a survey. A container of rice was found with a broken lid, compromising its integrity and potentially allowing contamination. Additionally, a container of cookies was not sealed properly, which could lead to exposure to pests and pathogens. The can opener in the kitchen was observed to be dirty, with dried food residue and rust, indicating a lack of proper cleaning and maintenance. Furthermore, the trash can was overflowing, which could attract pests and contribute to unsanitary conditions. During an interview, the Dietary Supervisor acknowledged these issues, confirming that the food containers should be tightly closed to prevent pest infestation and that the can opener should be cleaned after each use. The facility's policy and procedure documents, which were reviewed, emphasize the importance of maintaining cleanliness and sanitation in food service areas to prevent foodborne illnesses. These deficiencies in food handling and sanitation practices have the potential to expose residents to pathogens, increasing the risk of foodborne illnesses.
Improper Disposal of Kitchen Garbage
Penalty
Summary
The facility failed to properly dispose of garbage and refuse from the kitchen, as observed when two bags of kitchen trash were found on the ground outside the back of the facility kitchen. During an observation and interview with the maintenance supervisor, it was noted that the trash should have been placed inside the dumpster to prevent the attraction of vermin such as rats and insects, which pose an infection control issue. The maintenance supervisor acknowledged that the kitchen staff left the trash on the ground instead of disposing of it in the dumpster. In an interview with the Dietary Supervisor, it was revealed that the company responsible for trash collection sometimes leaves the dumpster on the street, preventing the staff from disposing of trash properly. As a result, trash is left outside the building temporarily. The facility's policy and procedure on garbage disposal, revised in December 2022, states that garbage should not accumulate or be left outside the dumpster, and storage areas should be maintained to prevent attracting insects and rodents. This failure to adhere to the policy had the potential to attract vermin and pose a disease threat to residents.
Failure to Maintain Resident Privacy During Medication Administration
Penalty
Summary
The facility failed to uphold the privacy, dignity, and respect of a resident during a medication administration procedure. The resident, who was admitted with diagnoses including gastrostomy and hypertension, was observed to have impaired cognitive skills and was totally dependent on staff for basic needs. During a medication pass, a Licensed Vocational Nurse (LVN) did not close the resident's door or pull the privacy curtain while administering medication via the resident's G-tube. This oversight occurred despite the resident being in a vulnerable state, lying in bed with their blouse lifted and abdominal binder adjusted for the procedure. The LVN acknowledged the failure to provide privacy during an interview, recognizing the importance of maintaining the resident's dignity by ensuring privacy measures such as closing doors and curtains. The Director of Nursing also affirmed that the resident's privacy and dignity should always be maintained, as outlined in the facility's policy on resident rights. The policy emphasizes the resident's right to personal privacy during medical treatment and care, which was not adhered to in this instance.
Facility Fails to Maintain Sanitary and Safe Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment in three of the five sampled rooms, leading to unsanitary and unsafe conditions. In Rooms A and B, the bathroom toilet was found to have fecal matter, specifically a dry dark brown to blackish stool, during an observation. This was confirmed by a Licensed Vocational Nurse (LVN 3), who acknowledged that the toilet should have been cleaned to prevent infection, as per the facility's Policy and Procedure (P&P) titled 'Safe and Homelike Environment.' The P&P emphasizes the importance of providing a sanitary environment to ensure residents can receive care safely. In Room D, the bathroom light was observed to be in disrepair, with the light bulb and wires exposed due to the absence of a cover. This was noted during an observation and confirmed by the Maintenance Supervisor (MS), who stated that the lights should be covered to protect residents and staff in case of a light bulb explosion. The MS also referenced the facility's P&P, which underscores the necessity of maintaining a safe and homelike environment for residents.
Failure to Develop Baseline Care Plan for Hemodialysis
Penalty
Summary
The facility failed to develop an individualized baseline care plan within 48 hours of admission for a resident receiving hemodialysis. The resident, who was admitted with diagnoses including end-stage renal disease, dependence on renal dialysis, and hypertension, required substantial assistance with daily activities and was receiving hemodialysis three times a week. Despite these needs, the baseline care plan did not include interventions for hemodialysis, which was confirmed during a record review and interview with the Minimum Data Set Nurse (MDSN). The Director of Nursing (DON) acknowledged the absence of a baseline care plan for the resident's hemodialysis, emphasizing its importance for guiding staff in delivering appropriate care. The facility's policy required the development of a baseline care plan that includes instructions for effective and person-centered care, addressing special needs such as dialysis. The failure to include hemodialysis in the baseline care plan was identified as a deficiency, potentially impacting the resident's safety and wellbeing.
Failure to Develop Care Plan for Medication Non-Compliance
Penalty
Summary
The facility failed to develop a care plan for a resident, identified as Resident 285, who exhibited non-compliance with medication administration. The resident was admitted with diagnoses including diabetes mellitus and cerebral infarction and was noted to have intact cognitive skills for decision-making. Despite this, the resident often refused to take medications on time, as observed during an interaction with an LVN. The LVN acknowledged that a care plan should have been created to address the resident's non-compliance, which was not done. The Quality Assurance Nurse and the Director of Nursing both confirmed that a care plan should have been initiated to manage the resident's behavior of refusing medication, particularly insulin, which is critical for managing diabetes. The facility's policy requires the development of comprehensive care plans that include measurable objectives and timeframes, and documentation of any refusal of treatment. However, this was not adhered to, leaving the resident without a structured plan to address their non-compliance with medication, potentially impacting their health.
Failure to Follow Eye Drop Administration Protocol
Penalty
Summary
The facility failed to meet professional standards of quality in the administration of eye medication for one resident. During a medication pass, a Licensed Vocational Nurse (LVN) administered Artificial Tear Ophthalmic Solution to a resident without applying gentle pressure to the lacrimal duct, as required by the facility's policy. This step is crucial to prevent systemic absorption of the medication. The LVN also allowed the resident to use the same tissue to wipe excess medication from both eyes, which could lead to cross-contamination. The resident involved had a history of Alzheimer's disease and hyperlipidemia and was cognitively intact, requiring moderate assistance with daily activities. The Director of Nursing confirmed that the LVN should have applied pressure to the tear duct and used a clean tissue for each eye. The facility's policy clearly outlined these procedures, indicating that the LVN's actions were not in compliance with the established standards of practice.
Failure to Maintain Functioning Pressure Ulcer Prevention Equipment
Penalty
Summary
The facility failed to ensure that a Low Air Loss (LAL) mattress, intended to prevent and treat pressure ulcers, was functioning properly for a resident. The resident, who was admitted with diagnoses including abnormalities of gait and mobility, repeated falls, and a pressure ulcer in the sacral region, was observed on multiple occasions with a LAL mattress that was soft and slightly deflated. This malfunction was noted by both a Licensed Vocational Nurse (LVN) and a Treatment Nurse (TN), who acknowledged that the mattress sometimes worked and sometimes did not. The facility had contacted the mattress company to address the issue, but the problem persisted, leaving the resident at risk of their pressure ulcer worsening. The resident's Minimum Data Set (MDS) indicated they were at risk for developing pressure ulcers and had existing unhealed pressure ulcers. The resident's care plan included the use of a LAL mattress for wound management, yet the mattress was not functioning as required. The facility's policy on pressure injury prevention and management emphasized the importance of pressure-redistributing support surfaces, but the lack of a properly functioning mattress contradicted this policy. The resident's Braden Scale score indicated a moderate risk for pressure injury development, further underscoring the need for effective pressure ulcer prevention measures.
Inadequate Dialysis Care and Documentation for a Resident
Penalty
Summary
The facility failed to provide appropriate dialysis care and services for a resident, identified as Resident 182, who was receiving hemodialysis treatment. The deficiency was noted in the failure to assess the resident's right upper chest dialysis access site on specific dates, as required by the facility's policy. This oversight had the potential to lead to complications such as bleeding or infection from the central venous catheter. Resident 182 was admitted with diagnoses including end-stage renal disease, dependence on renal dialysis, and hypertension, and required substantial assistance with daily activities. The facility's records indicated that Resident 182 was scheduled for hemodialysis every Monday, Wednesday, and Friday. However, the dialysis communication records for several dates were incomplete and inaccurate. The records failed to document essential information such as the type of dialysis access site, and incorrectly noted the presence of bruit and thrill, which are not applicable for a central venous catheter. The documentation errors were confirmed by both a registered nurse and the Director of Nursing, who acknowledged the incomplete and incorrect assessments. The facility's policy required ongoing assessment and communication with the dialysis center to ensure proper care. However, the dialysis communication records lacked critical information, including access site assessment, lab results, food consumed, medications given, and the resident's response to dialysis treatment. The Director of Nursing stated that the receiving nurse should have contacted the dialysis center to address the incomplete records, emphasizing the importance of accurate documentation to ensure proper care for the resident.
Failure to Administer Calcitonin Solution
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident by not administering Calcitonin Solution nasal spray as indicated on the physician's order. This medication is used to treat bone loss, and its omission could potentially lead to the resident's bones becoming more fragile or low in bone mass, increasing the risk of fractures. The resident, who was admitted with a diagnosis including Parkinson's disease, had severely impaired cognitive skills and required assistance with daily activities. During a medication administration observation, an LVN prepared and administered several medications to the resident but failed to include the Calcitonin Solution. The LVN later acknowledged the omission, recognizing that failing to administer medication per the physician's order could lead to medical complications. The Director of Nurses confirmed that the Calcitonin should have been administered as ordered, and its omission could result in bone weakening. The facility's policy on medication administration requires that medications be administered as ordered by a physician.
Failure to Provide Adaptive Feeding Equipment and Assistance
Penalty
Summary
The facility failed to ensure that a resident who required adaptive feeding equipment utilized a plate guard during meals, as indicated by the physician's order. The resident, who was admitted with diagnoses including bilateral nuclear cataract, dementia, and abnormalities of gait and mobility, was observed eating without using the provided utensil and plate guard. The resident's Minimum Data Set indicated severely impaired cognitive skills and a need for extensive assistance with daily activities, including eating. Despite the presence of a plate guard on the meal tray, the resident was seen eating with her hands, and staff did not provide the necessary reminders or assistance to use the adaptive equipment. Interviews with staff, including a Restorative Nurse Assistant, Occupational Therapist Assistant, Director of Rehabilitation, Licensed Vocational Nurse, and Registered Nurse, revealed that the resident required verbal cues and hand-over-hand assistance due to visual impairment. The staff acknowledged the need for periodic checks during meals to ensure proper use of utensils and the plate guard. However, it was noted that the resident did not have a care plan addressing her visual impairment and the need for cuing and adaptive equipment. The facility's policies on Activities of Daily Living and Use of Assistive Devices emphasized the importance of providing necessary services and assistance to maintain residents' abilities and dignity, which were not adequately followed in this case.
Failure to Follow Infection Control Policy for Resident on ESP
Penalty
Summary
The facility failed to ensure staff adhered to its infection control policy for a resident who was on Enhanced Standard Precaution (ESP) due to a gastrostomy tube and a history of sepsis and urinary tract infection. The resident, who lacked the capacity to make decisions and had severe cognitive impairment, required staff to use gowns and gloves during high-contact care activities to prevent the transmission of multi-drug resistant bacteria. However, during an observation, a Certified Nursing Assistant (CNA) was seen entering the resident's room without wearing a gown while intending to clean the resident's soiled diaper, which is considered a high-contact activity. Interviews with the Quality Assurance Nurse, Infection Preventionist Nurse, and Director of Nursing confirmed that the resident was on ESP and that staff should wear appropriate personal protective equipment (PPE) such as gowns and gloves during high-contact care activities. The facility's policy and procedure documents also indicated the necessity of using gowns and gloves for such activities to prevent the spread of infections. The CNA admitted to forgetting to wear a gown, acknowledging the requirement due to the resident's ESP status.
Inaccessible Call Light in Resident's Bathroom
Penalty
Summary
The facility failed to ensure that a working call system was available in the bathroom for one of the residents, identified as Resident 39. During an observation, it was noted that the call light in Resident 39's bathroom did not have a string attached, making it inaccessible to the resident, especially if they were on the floor. The call light switch was positioned about three feet above ground level, between the bathroom door and the toilet, which was confirmed by the Maintenance Supervisor to be unreachable in such a situation. This deficiency was highlighted during an interview with Resident 39, who expressed a need for a pull string cord light to feel safe and secure in the bathroom, particularly during emergencies. Resident 39 was admitted to the facility with a diagnosis of Parkinson's disease, which affects motor skills and requires the resident to have partial assistance for toilet hygiene and lower body dressing. The resident's care plan included the use of a bell to call for assistance, but the lack of an accessible call light in the bathroom posed a risk of delayed care. The Director of Nurses acknowledged that the bathroom should have a call light with a string to allow the resident to call for help. The facility's policy on call lights emphasized the need for accessibility at each toilet and bath or shower facility, including for residents lying on the floor.
Room Size Deficiency in Multiple Resident Room
Penalty
Summary
The facility failed to ensure that one of its 29 resident rooms, specifically Room E, met the minimum square footage requirement of 80 square feet per resident for multiple resident rooms. Room E, which measured 223 square feet, was occupied by three residents, resulting in less than the required space per resident. Despite this deficiency, observations during the survey period indicated that the residents appeared comfortable, and there were no complaints from residents or staff regarding the room size. The facility had submitted a room waiver request, indicating that the residents' needs were accommodated without adverse effects on their health, safety, or welfare. The Department recommended the waiver request for Room E.
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 7,484 citations issued within 25 miles in the last 12 months — including the 30 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 Monterey Park
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Heritage Manor | 0.2 mi | ★★★★★ | 29 | 0 |
| Del Mar Convalescent Hospital | 1.1 mi | ★★★★★ | 19 | 0 |
| Sunny Village Care Center | 1.4 mi | ★★★★★ | 23 | 0 |
| Atherton Baptist Home | 1.7 mi | ★★★★★ | 10 | 0 |
| Alhambra Healthcare & Wellness Centre, Lp | 1.7 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Monterey Park Conv Hosp.
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 August 2026) and official state health department websites.