Average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Motion Picture And T.v. Hosp D/p Snf during CMS and state inspections, most recent first.
A facility failed to follow fall-prevention interventions for multiple residents. One resident with Parkinson's disease had orders and a care plan for bilateral floor mats, but the right-side mat was not in place during repeated observations. Two other residents had objects placed on top of floor mats, including a trash can and a metal chair, which staff said interfered with the mats' protective purpose. The facility also failed to place the required red fall-risk identifier under a resident's door photo, despite the resident being assessed as high risk and the care plan calling for color-coded identification.
A resident with COPD received daytime O2 via NC without a current order, without MAR documentation, and without monitoring, despite staff stating oxygen must be ordered, documented, and monitored. In a separate event, another resident’s NC tubing was found on the floor, moved to the bed, and not changed, even though staff and facility procedure stated tubing should not be on the ground and should be kept in a bag and replaced as needed.
Surveyors found multiple medication storage and labeling failures, including an unlabeled open bottle of cyclosporine eye drops, Duoneb nebules without an open date despite a discard-after-opening instruction, Pataday eye drops and Milk of Magnesia stock bottles without open dates, a narcotic key left inside a med cart, and an unlocked medication waste container holding discarded meds. Staff and the CNO confirmed the facility’s dating and controlled-drug storage practices were not followed.
An open bag of shredded lettuce was found in the produce refrigerator without being sealed or labeled with an open date, and a TLW used an expired quat test strip to check sanitizing solution in the prep area. The DH, RD, and CS all confirmed that open food should be sealed and dated and that expired test strips would not provide an accurate sanitizer reading.
A resident with Parkinson's disease, chronic pain, and depression was prescribed duloxetine for pain management, but the record lacked documented informed consent for the psychotropic medication. RN and CNO interviews confirmed duloxetine was considered a psychotropic/antidepressant and that consent should have been obtained and documented before administration. Facility policy required informed consent for psychotherapeutic medications, and the resident's care plan included monitoring for duloxetine side effects.
A facility failed to keep the call light within reach for two residents. One resident with Alzheimer’s disease, diabetes, and glaucoma had the call light placed on a nightstand instead of within reach, and staff stated it was not accessible. Another resident with hemiplegia after CVA, HTN, and diabetes had the call light hanging to the floor from the siderail while lying in bed with a sling on the left arm; staff stated it was not within reach and that the care plan and facility policy were not followed.
A resident with Alzheimer's disease, severe cognitive impairment, dependence for mobility and ADLs, and high fall risk had a floor mat ordered on both sides of the bed for comfort and fall impact reduction. Surveyors observed the mat on one side of the bed torn and lifting, exposing the inner cushion, and staff stated it was not in good condition, should have been replaced, and could create a trip hazard; RN and CNO also stated it did not support a homelike environment.
A resident with Alzheimer’s disease and bipolar disorder was prescribed clonazepam daily and PRN for anxiety manifested by agitation, but nursing staff monitored only for the broad behavior of agitation and not for the resident’s specific behaviors, including demanding behavior and verbalizing a desire to elope. Staff stated the PRN order and behavior monitoring were not specific enough to ensure the medication was given and tracked for the appropriate behaviors.
A resident with intact cognition, lymphedema, OA, and anxiety had bilateral bed rails ordered and consented to as a mobility enabler, with the IDT and Bed Safety Assessment supporting their use. However, the facility did not document completion of the required Bed Rail Risk Assessment before installing the rails, despite the care plan calling for assessment of entrapment risk prior to use.
A resident with dementia, chronic pain, and polyneuropathy had a PRN order for loperamide, but the eMAR showed no use over several months. The consultant pharmacist’s MRR recommended considering discontinuation because the medication was not being used, yet the MD notes did not address the recommendation. The pharmacist, RN, and CNO all confirmed the issue was not acted on, despite the facility’s DRR policy requiring follow-up on pharmacist concerns.
Failure to provide requested meal items: A resident with dementia, CAD, and depression was served lunch without the banana and whole milk listed on his meal ticket. The resident said he had asked for those items but did not receive them, and CNA and RNA staff confirmed the tray was missing both items. The facility’s meal service policy required honoring resident food preferences and ensuring menu-ticket items were provided.
Inaccurate Weight Documentation in EHR: A resident with Alzheimer’s disease, dysphagia, and dependence for ADLs had an incorrect weight of 220 lbs. entered in the EHR, with surrounding weights showing a much lower baseline. CNAs and an LVN stated weights are documented in the chart and questionable changes should be rechecked, but the record did not show the entry was corrected or charted as an error. The RD and CS both identified the weight as an error, and the facility’s documentation policy required accurate, complete EHR entries.
A CNA failed to remove disposable gloves and perform HH before exiting a resident’s room after using lift equipment to place the resident in bed. The CNA was observed wearing gloves in the hallway and later removed them after leaving the room. The resident had HF, osteoporosis, and HTN, and was dependent on staff for multiple ADLs. RN and the CS stated the facility’s standard precautions and HH policies required glove removal and HH before leaving the room.
A resident with dementia was admitted with home medications, including Norco and Klonopin, but staff did not inventory or document these medications on the admission belongings form or in any other log. Nursing and pharmacy reviewed the medications and sent them to the pharmacy for storage, and they were later returned to the resident’s family, yet no counts or records were maintained at any point. Leadership confirmed that it was not the facility’s practice to include home medications on the Resident Belongings and Valuables form and that no separate tracking process existed, despite written policies requiring verification, counting, and documentation of patient-supplied medications and all personal effects that may affect health and safety.
A resident with dementia and multiple chronic conditions was physically harmed when a CNA, observed by another staff member, forcefully and aggressively assisted her to the commode, violating her rights to dignity and safe care. The facility's risk management confirmed the incident as staff misconduct, and documentation showed the resident's rights to be free from abuse and to be treated with respect were not upheld.
A resident with dementia and multiple chronic conditions was subjected to rough handling by a CNA, who was witnessed forcefully assisting the resident to the commode. Despite facility policy requiring immediate suspension of employees suspected of abuse, the CNA continued to work several shifts after the incident, leaving the resident exposed to possible further abuse. The facility's abuse prevention and reporting procedures were not enforced.
A resident with dementia and multiple chronic conditions was forcefully handled by a CNA during toileting assistance, as witnessed by another CNA. The incident, which constituted misconduct, was not reported to law enforcement, the ombudsman, or the licensing agency within the required 24-hour period, resulting in a delayed investigation. The facility's policy and regulatory requirements for timely reporting were not followed.
Two residents with moderate cognitive impairment were administered psychoactive medications, including lorazepam, mirtazapine, escitalopram, and gabapentin, without documented written informed consent from themselves or their responsible parties. Nursing staff confirmed that the required consents, which should include discussion of risks and benefits, were not present in the medical records, contrary to facility policy.
The facility did not develop or implement comprehensive, person-centered care plans for multiple residents, resulting in disorganized documentation and missing critical interventions. For two residents with complex medical and cognitive needs, care plans grouped all problems and interventions together, making it difficult for staff to identify appropriate actions. In another case, a resident assessed as needing a smoking apron for safety did not have this intervention included in the care plan, increasing the risk of staff missing this requirement.
The facility failed to follow professional standards in medication administration, including administering scheduled medications outside of ordered times without proper documentation or provider approval for two residents, not checking g-tube placement and patency or flushing between medications for a resident with a feeding tube, and not rotating subcutaneous insulin injection sites for a resident as required by guidelines. These actions were inconsistent with facility policy and professional standards.
Four residents with limited ROM and mobility did not receive timely or appropriate restorative nursing interventions and quarterly PT/OT joint mobility screens as recommended by therapy staff. Orders for ambulation were not updated to reflect therapy recommendations, and there were significant delays in initiating RNA programs and completing required assessments.
Multiple deficiencies were identified, including a resident on swallow precautions left unsupervised during meals, a bottle of antiseptic left at a bedside mixed with food, exposed/frayed wires on a call light, fall mats obstructed by furniture, and an unattended medication cup left accessible to a resident with dementia. These actions and inactions by staff failed to maintain a safe environment and proper supervision, as required by facility policy.
Surveyors found that a nurse administered a discontinued topical medication to a resident without a current physician's order, and that two residents received scheduled medications outside the prescribed time without proper documentation or provider notification. Additionally, a nurse failed to follow required procedures for administering medications via a gastrostomy tube, including not checking tube placement and not flushing between medications. These actions were not in accordance with facility policies and procedures.
The facility did not ensure that residents receiving high-risk medications, including antibiotics and antiplatelet agents, were monitored for adverse effects. Two residents on antibiotics and one resident on both aspirin and clopidogrel lacked orders or documentation for monitoring side effects, as confirmed by nursing, pharmacy, and leadership staff. This omission was identified through interviews and record reviews, with staff acknowledging the absence of required monitoring.
A facility was cited for a medication error rate of 25% after an LVN administered scheduled medications to two residents outside the prescribed time without proper documentation or provider approval, and failed to flush a g-tube between medications for another resident, contrary to facility policy. The LVN also did not check g-tube placement and patency at each administration as required. These actions were confirmed through observation, interviews, and record review.
Surveyors found that a resident did not have insulin injection sites rotated as required, two residents received scheduled medications outside the prescribed time window without proper documentation or provider approval, and another resident did not receive required water flushes between medications administered via g-tube. Nursing and pharmacy leadership confirmed these actions were not in accordance with facility policy or standard practice.
Surveyors identified multiple deficiencies in food storage and preparation, including unlabeled and improperly sealed food items, inaccurate container labeling, and improper storage of produce in wet conditions. Staff personal items were also found in food storage areas, contrary to facility policy. These actions were confirmed by interviews with the DHS and DLTC, who acknowledged the failures to follow established procedures.
Two residents did not have required PT and OT discharge summaries completed after their therapy services ended, despite facility policy mandating documentation within 48 hours. Therapy staff confirmed the omissions, which resulted in incomplete medical records and lack of formal communication regarding residents' therapy discharge status and recommendations.
Staff failed to follow infection control protocols by not wearing required PPE, such as masks and gowns, when entering rooms of residents on droplet or enhanced barrier precautions, and by using permeable covers on linen carts that did not adequately protect clean linens from contamination. These actions were observed during care of residents with respiratory symptoms, wounds, or indwelling devices, and staff acknowledged not following posted precautions or facility policy.
A resident with multiple chronic conditions experienced hypoxia, and although oxygen was administered per physician order, staff failed to notify the provider and responsible party of the change in condition as required by facility policy. Documentation and interviews confirmed that neither notification nor proper record of notification occurred.
A resident with severe cognitive impairment and multiple comorbidities did not receive proper pressure injury assessment and documentation. Nursing staff incorrectly restaged a pressure injury from unstageable to stage 2, contrary to professional standards, rather than documenting it as a healing unstageable PI. This error was confirmed by RNs and the DLTC, who acknowledged that accurate wound assessment and documentation were not followed according to facility policy.
A resident with a suprapubic urinary catheter was found to have the catheter tubing not anchored to the statlock device on their thigh, despite facility policy and physician orders requiring securement. Staff confirmed that the catheter should have been anchored to prevent movement or accidental dislodgement.
A discontinued topical medication was not removed from a treatment cart, leading an LVN to continue administering it to a resident with a stage 2 pressure injury. The resident, who was dependent on staff and unable to communicate, received the medication after its order had been discontinued, as the ointment remained accessible in the cart. Facility staff confirmed that policy required immediate removal of discontinued medications, but this was not followed, resulting in the deficiency.
A resident with chronic recurrent pneumonia was prescribed azithromycin twice weekly for pneumonia prophylaxis without a stop date or clear clinical guideline. Staff, including nursing, pharmacy, and infection prevention, did not clarify the appropriateness of this prolonged antibiotic use or communicate concerns as required by facility policy, resulting in a failure to ensure proper antibiotic stewardship.
The facility failed to establish and implement policies for the use of side rails (SR) and physical restraints. Both the DON and ADM acknowledged the absence of these policies, which had the potential to cause significant harm to all 87 residents.
The facility failed to keep the call light within reach of four residents, which had the potential for delaying care and services and placing them at risk for falls and injuries. Observations revealed that the call lights were not accessible to the residents, despite their care plans indicating the need for the call light to be within reach due to high fall risk. The facility's policies and procedures were not followed in these cases.
The facility failed to ensure residents' freedom from physical restraints by not assessing the need for side rails, assessing the risk for entrapment, obtaining informed consent, or securing a physician's order. This was observed in four residents, with side rails raised and beds pushed against walls without proper documentation. Chair alarms were also used without necessary assessments or consents.
The facility failed to follow manufacturer's guidelines for pressure ulcer prevention for two residents. One resident's low air loss mattress (LALM) was not set according to weight, and Heel Protectors (HP 1) were not applied as ordered. Another resident's alternating pressure mattress (APP) was set at the firmest setting, causing discomfort. The facility lacked specific policies for the use of these specialty mattresses.
The facility failed to provide ROM services and baseline assessments for four residents, leading to missed RNA treatments and lack of initial ROM evaluations, which could impact their mobility and quality of life.
The facility failed to ensure the safe and appropriate use of side rails for three residents, leading to potential risks of entrapment and injury. Assessments for the risk of entrapment and informed consent were not conducted, and there were no physician's orders for side rail use. The DON acknowledged the need for proper assessments, consents, and physician's orders.
The facility failed to provide sufficient RNA staff to meet the needs of 70 residents with physician's orders for RNA services, leading to missed treatments and potential declines in residents' mobility and overall well-being. Staffing records and staff interviews confirmed the short-staffing issue, with some days having no RNAs available.
The facility staff failed to ensure proper food storage, preparation, and distribution, including an expired sandwich in a resident's room, serving food at low temperatures, storing moldy lemons, and improper ice machine drainage, posing risks of foodborne illness and malnutrition.
The facility failed to provide necessary OT and PT services to two residents, resulting in a lack of OT evaluations and insufficient PT sessions. Both residents expressed dissatisfaction with the limited therapy services, and staff confirmed the absence of OT and inadequate PT availability.
The facility failed to maintain an infection prevention and control program, leading to potential cross-contamination during medication administration and respiratory care. Two nurses did not perform hand hygiene before preparing medications or donning gloves, and a resident's nasal cannula was not labeled or changed weekly as required.
The facility failed to maintain a resident's dignity by not ensuring that a urinary catheter drainage bag was covered with a privacy bag. The resident had severely impaired cognition and required assistance with daily activities. Both a Licensed Vocational Nurse and the Director of Nursing confirmed that the drainage bag should have had a privacy cover, as per facility policy.
The facility failed to provide a resident and their representative with information regarding the formulation of an advance directive. The resident, who had severe cognitive impairment and was dependent on staff, did not have documentation in their medical record about an advance directive. The Director of Social Services confirmed this omission, stating that the standard procedure to ask about and provide information on advance directives was not followed.
The facility failed to develop and implement comprehensive care plans for four residents regarding the use of side rails and restraints. Observations revealed that beds were pushed against walls, side rails were raised, and alarms were used without corresponding care plans. The DON and other staff confirmed the absence of these care plans, which are required by facility policy.
The facility failed to follow physician's orders to apply thromboembolic deterrent (TED) hose for two residents. One resident with acute embolism and thrombosis was found not wearing TED hose, and the CNA was unaware of the order. Another resident with a history of venous thrombosis and embolism was found wearing regular socks instead of TED hose, and the CNA did not know if the resident ever wore them. The DON confirmed the orders and acknowledged the lack of a policy for TED hose use.
The facility failed to ensure safe transfers and medication administration by allowing a CNA to transfer a resident using a Hoyer lift without assistance and leaving a bottle of lidocaine 4% roll-on at a resident's bedside, contrary to facility policies.
The facility failed to label a bottle of valproic acid solution with an expiration date, affecting a resident with dementia and Alzheimer's disease. This oversight was confirmed by both an LVN and the DON, who acknowledged the importance of proper labeling according to the facility's policy.
Failure to Follow Fall-Prevention Interventions and Identification Measures
Penalty
Summary
The facility failed to provide an environment free from accident hazards and to follow fall-prevention interventions for four residents reviewed for accidents. For one resident with Parkinson's disease, chronic pain, depression, impaired vision and hearing, immobility, and poor safety judgment, the physician's order and care plan required beveled floor mats on both sides of the bed when the resident was in bed. During multiple observations, a mat was seen on the left side of the bed, but no mat was present on the right side. Staff interviews confirmed that the resident had orders and care plan interventions for bilateral fall mats, but the right-side mat was not in place. For another resident with Alzheimer's disease, diabetes, and glaucoma, the resident was assessed as low risk for falls, and the floor mat on the right side of the bed had a trash can placed on top of it during observation. Staff stated the mat was intended to protect the resident from serious injury if a fall occurred, and that the trash can should not have been on top of the mat because it would interfere with the mat's purpose. For a third resident with Alzheimer's disease, hypertension, and depression, the resident was assessed as high risk for falls and had an order for floor mats on both sides of the bed. During observation, a metal chair was placed on top of the floor mat on the right side of the bed. Staff stated that the object on the mat compromised its effectiveness and that the resident could be injured by the chair if a fall occurred. The facility also failed to place the required color-coded fall-risk identifier on the door photo for another resident with severe cognitive impairment and high fall risk. The resident's care plan included a red identification arm band/tag and a red strip under the resident's photo by the door as part of the fall-risk identification system. Staff interviews confirmed that the facility used a red strip under the photo to identify high fall risk residents, but the door photo for this resident was not labeled with the red strip. The facility policy stated that residents are evaluated for fall risk and that color identification is used to identify low and high fall risk residents.
Oxygen Administration and Tubing Handling Not Consistent With Orders and Procedure
Penalty
Summary
Supplemental oxygen care was not provided consistently with physician orders and facility procedure for a resident with Alzheimer’s disease, bronchiectasis, COPD, and chronic use of supplemental O2. The resident had orders for nighttime oxygen at 3 LPM via NC and, until discontinued, PRN daytime oxygen if napping or if SaO2 was below 90%, followed by an order to monitor SaO2 twice daily and notify the provider if it was below 90%. Staff observations and interviews showed the resident was repeatedly seen receiving oxygen during the day, including at 2 LPM and 3 LPM via NC, even though the daytime PRN oxygen order had been discontinued. Staff stated the resident was being given oxygen during the day without a current physician order, without documentation in the MAR, and without monitoring while oxygen was in use. The clinical supervisor reviewed multiple vital sign entries showing oxygen use documented on several dates and times without a corresponding order, documentation of need and length of use, or monitoring. Interviews with nursing staff showed the facility process was to assess the resident’s need for oxygen, notify the provider, obtain an order before administering oxygen, document the administration, and monitor the resident while oxygen was being used. Staff stated supplemental oxygen was considered a medication and that oxygen given during the day without an order, documentation, or monitoring could result in a missed change in condition and delay in treatment. The facility’s oxygen therapy and medication administration procedures stated that only an RN or medical provider could initiate or adjust oxygen flow, that the medical provider’s order must be checked, and that administration must be documented in the electronic medical record. A separate deficiency involved a resident with Alzheimer’s disease, heart failure, and hypertension who had an order for continuous oxygen at 2 LPM via NC and a care plan intervention to check proper placement of oxygen tubing every shift and as needed. During observation, the resident’s NC tubing was seen connected to the concentrator but resting on the ground beside the bed rather than being kept in the provided bag. A CNA was present in the room, but the tubing remained on the floor after the CNA left. A restorative nurse assistant later confirmed the tubing was on the ground, stated it should not be there, picked it up, and placed it on the resident’s bed. An LVN stated the tubing should not be on the ground and that if it is found touching the ground it should be changed, while the clinical supervisor stated the tubing should never be on the ground and should be removed and changed rather than moved from the floor to the bed. The facility’s oxygen therapy procedure stated that oxygen tubing should be placed in a set-up bag and replaced weekly and as needed.
Medication Labeling and Controlled Drug Storage Deficiencies
Penalty
Summary
The facility failed to ensure safe pharmaceutical storage and labeling during inspection of medication carts and medication storage areas. On Medication Cart 1, Resident 38’s cyclosporine eye drops were observed open without an open date. LVN 4 stated the eye drops were supposed to be dated when opened because they are only good for 28 days, and the Clinical Supervisor confirmed the bottle and label were not dated. The Chief Nursing Officer also stated the facility policy required multidose medications such as eye drops to be labeled with an open date unless otherwise specified by the manufacturer. The facility also failed to label Resident 56’s ipratropium-albuterol sulfate (Duoneb) with an open date after the foil packaging had been opened, even though the medication label directed that it be discarded 2 weeks after opening. During inspection of Medication Cart 1, LVN 4 observed the opened box of ampules had no open date. The Clinical Supervisor confirmed the label did not show an open date and stated the nurse who opened the foil packaging should have labeled the box so staff would know when to discard the unused nebules. The CNO stated that if the medication indicated it should be discarded after opening, it should have been labeled with the open date. On Medication Cart 2, Resident 76’s Pataday eye drops were found without an open date, and a stock bottle of Milk of Magnesia was also observed without an open date. LVN 8 stated the eye drops needed an open date because they are only good for 28 days, and RN 1 and the CNO both stated eye drops require an open date after opening. The inspection also found the narcotic key left inside the medication cart, and RN 1 and Pharm 2 stated the key should always be carried by the licensed nurse and not left in the cart. In Medication Cart 3, another stock bottle of Milk of Magnesia was observed without an open date, and the CNO stated the bottle expires 60 days after opening according to the manufacturer. The inspection of medication storage also found an unlocked medication waste container containing discarded medication, including a bubble pack of Pregabalin for Resident 31 and a Liraglutide injection. RN 2 stated the waste container needed to remain locked because anyone could open it and remove the medication, and Pharm 2 stated the container is supposed to be locked at all times so unauthorized persons cannot access medications inside. The facility policy reviewed by surveyors stated multidose vials must be dated after opening, discarded after the applicable beyond-use date, and controlled drug storage areas must remain locked with keys carried by licensed staff.
Unsafe Food Storage and Expired Sanitizer Test Strip
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when an open bag of shredded lettuce was observed in the walk-in produce refrigerator without being sealed and without an open date label. During the initial kitchen tour, the Director of Hospitality stated that kitchen staff are supposed to seal and label items when opened, and that the staff member who opened the lettuce bag was supposed to seal it and label it with the open date. The Director of Hospitality also stated that if the bag remained open, it could become contaminated, and that without an open date staff would not know whether the lettuce was past its best-by date. The facility also failed to ensure that the test strip used to check sanitizing solution was not expired. In the nourishments and snacks preparation area, a Tray Line Worker demonstrated how to test the sanitizing solution using a Quat Test Paper strip, and the strip case was found to have an expiration date of 4/1/2026. The Tray Line Worker stated the strip was expired and that an expired strip would not provide an accurate result, meaning the sanitizing solution would not be effective in cleaning surfaces and could lead to cross-contamination. The Registered Dietitian stated that each kitchen staff member had a red bucket for sanitizing solution used to clean preparation area surfaces when soiled and before and after each preparation. During interview, the Director of Hospitality stated that the tray line workers might be replacing the roll of test strip when finished instead of using a new holder or container each time the test strip is changed. The Clinical Supervisor stated that the shredded lettuce should have been sealed and labeled with an open date so staff would know when to discard it. Facility policies reviewed by surveyors stated that unused portions and open packages should be covered, labeled, and dated, and that sanitizer test strips should be readily available whenever sanitizer is dispensed.
Failure to Obtain Informed Consent for Duloxetine
Penalty
Summary
The facility failed to obtain informed consent for duloxetine for one of five sampled residents. Resident 5 had diagnoses that included Parkinson's disease, chronic pain, and depression, and the Minimum Data Set indicated he usually was able to understand others and make himself understood, while also being dependent on staff for eating, oral and personal hygiene, toileting, bathing, mobility, and dressing. The resident's physician orders included duloxetine HCL 30 mg by mouth daily for chronic musculoskeletal pain, and the care plan identified monitoring for psychotropic side effects of duloxetine. During interview and record review, RN 1 stated duloxetine is an antidepressant and a psychotropic medication, and that informed consent should be obtained prior to administration of psychotropics. RN 1 stated Resident 5 was prescribed and administered duloxetine for off-label pain management and there was no documented evidence that informed consent had been received for its use. RN 1 also stated she was not sure if informed consent was needed when duloxetine was administered for pain management. The CNO later confirmed that duloxetine was a psychotropic medication and required informed consent from the primary care provider before administration. The CNO stated it was an oversight that informed consent was not obtained for Resident 5 because the medication was prescribed for pain management, but it should have been. Facility policies on psychotherapeutic medication and informed consent required informed consent to be documented, and the patient rights policy stated residents have the right to be free from psychotherapeutic drugs used as a chemical restraint except in an emergency.
Call Light Not Within Reach for Two Residents
Penalty
Summary
The facility failed to keep the call light within reach for two sampled residents. For Resident 67, the face sheet showed diagnoses including Alzheimer’s disease, type 2 diabetes mellitus with other circulatory complications, and unspecified glaucoma. The MDS dated 5/9/2026 indicated the resident could make self understood, understand others, and had intact cognitive function, but also required dependent to maximal assistance with mobility and ADLs. The FRE dated 5/1/2026 identified the resident as low risk for falls. During a concurrent observation and interview on 7/13/2026, the call light was observed on top of the nightstand in Resident 67’s room, and the RNA stated it was not within reach. The RNA stated the resident could potentially fall trying to reach for it. During a later interview and record review, the CS reviewed the FRE and stated the call light should always be within reach so the resident could call for assistance, and that the facility’s Call Light policy was not followed. For Resident 76, the face sheet listed diagnoses including hemiplegia following cerebral infarction affecting the left nondominant side, essential hypertension, and type 2 diabetes mellitus with other circulatory complications. The H&P dated 8/21/2025 stated the resident remained alert, oriented, and cooperative, while the MDS dated 6/6/2026 noted memory problems, some difficulty in new situations, and dependent to moderate assistance with mobility and ADLs. The FRE dated 5/12/2026 identified the resident as high risk for falls, and the care plan included keeping the call light within reach as an intervention. During observation, the resident was lying in bed with a sling on the left arm, and the call light was hanging down to the floor from the left upper siderail. The resident, LVN, and CS all stated the call light was not within reach, and the CS stated the care plan and facility policy were not followed.
Damaged Floor Mat Left in Resident Room
Penalty
Summary
The facility failed to maintain a safe and comfortable homelike environment for one sampled resident by not ensuring a floor mat was kept in good condition or replaced when damaged. Resident 96 was admitted with diagnoses including Alzheimer's disease, essential hypertension, and depression. The resident's H&P described continued slow/progressive cognitive and physical decline, and the MDS indicated severe cognitive impairment, rare or no ability to make self understood or understand others, and dependence for mobility and ADLs. The resident also had a high fall risk evaluation and an order for floor mats on both sides of the bed to provide comfort and reduce impact from falls. During observation, the floor mat on the left side of the bed was seen with tears, including a torn, open, lifting corner exposing the inner cushion. On a later observation, the damaged mat was still present. RNA 3 stated the mat should not have tears, was not in good condition, should have been replaced, and that people could trip on the tears. RN 1 stated the damaged mat was not promoting a homelike environment and could potentially injure staff. The CNO stated the mat should not have been in that condition because it was damaged and not on their standards, and that it would be replaced immediately.
Psychotropic Medication Not Monitored for Specific Behaviors
Penalty
Summary
The facility failed to ensure Resident 79 was free from the use of chemical restraints by not ensuring clonazepam was prescribed, administered, and monitored for specific, measurable behavioral manifestations. Resident 79 had diagnoses that included Alzheimer's disease, bipolar disorder, and hypertension, and the MDS indicated the resident could understand others and make himself understood, while requiring supervision or touching assistance for multiple activities of daily living. The resident was also identified as receiving a high-risk antianxiety medication. Physician orders included clonazepam 1 mg daily at 6 p.m. for anxiety manifested by agitation, and clonazepam 0.25 mg every 24 hours as needed for anxiety manifested by agitation. The care plan for psychological condition and psychotropic medication use included monitoring the frequency of mood or behavior changes and evaluating medication effectiveness and side effects for possible decrease or elimination of psychotropic drugs. During interviews, pharmacy staff stated psychotropic medications are high-risk medications and should be used at the lowest effective dose based on tallied behavior episodes documented by nursing. During record review and interviews, nursing staff stated Resident 79 demonstrated agitation with demanding behaviors and verbalized a desire to elope, but the behavioral monitoring changed so that from 7/12/2026 onward the resident was only monitored for agitation and not for verbalizing a desire to elope or demanding behavior. RN 1 stated agitation is broad and can look different in different residents, and that the resident's PRN clonazepam order did not identify specific behaviors. The clinical supervisor stated the medication was ordered and monitored for agitation, which was not specific enough to ensure the PRN clonazepam was administered for the appropriate behaviors and monitored for the same behaviors with a goal of decreasing the medication.
Failure to complete bed rail entrapment risk assessment before use
Penalty
Summary
The facility failed to assess the risk of entrapment before using bilateral bed rails for one resident. Resident 84 was admitted with a history of bilateral leg lymphedema, osteoarthritis, and anxiety disorder, and the H&P indicated the resident had the capacity to understand and make decisions. The MDS later indicated intact cognition and that the resident could understand others and make needs known, while also requiring extensive assistance with ADLs. The physician’s orders included bilateral bed rails, and the consent for bed rail use identified the reason as a mobility enabler and was signed by the resident representative. The Bed Safety Assessment dated 3/3/2026 recommended use of left upper and right bed rails as a non-restraint, and the IDT care conference notes also recommended both upper bed rails for positioning assistance. However, there was no documented evidence that the Bed Rail Risk Assessment was completed prior to installation of the bed rails, despite the care plan identifying assessment for entrapment risk before installation as an intervention.
Failure to Address Pharmacist Recommendation for Unused PRN Medication
Penalty
Summary
The facility failed to act on the consultant pharmacist’s medication regimen review recommendation for Resident 22 by not following up with the resident’s physician or medical provider regarding loperamide hydrochloride. Resident 22 was admitted on 4/16/2025 and had diagnoses including dementia, chronic pain of the neck and back, and polyneuropathy. The resident’s H&P described the resident as alert but disoriented to time and situation, and the MDS indicated moderately impaired cognition with the ability to understand others and make needs known. Resident 22 had a physician’s order for loperamide hydrochloride 2 mg by mouth twice daily as needed if more than 2 loose stools for chronic diarrhea. Review of the eMAR for 5/2026, 6/2026, and 7/2026 did not show that the resident received loperamide. The Pharmacy Monthly Chart Review dated 6/24/2026 included a recommendation to consider discontinuing loperamide because it was not being used. Medical provider notes dated 7/1/2026, 7/2/2026, 7/6/2026, and 7/15/2026 did not address the pharmacist’s recommendation. During interviews, the pharmacist, RN, and CNO all stated that the recommendation should have been addressed and that the resident had a medication that was no longer necessary. The facility policy on Drug Regimen Review stated that the pharmacist communicates recommendations in writing and follows up to determine that there is evidence the prescriber responds to concerns raised by the review process.
Failure to Provide Requested Meal Items
Penalty
Summary
The facility failed to honor a resident’s dietary preferences during lunch service when the resident was not provided the banana and whole milk listed on the meal ticket. Resident 23 had diagnoses including dementia, coronary artery disease, and depression. The resident’s MDS indicated he could understand others and make himself understood, and he required supervision or touching assistance with eating and several other activities of daily living. His nutrition risk assessment identified him as at risk for weight loss due to dementia and depression and directed staff to provide the diet as ordered and monitor food intake. During the lunch meal observation, Resident 23 was seated at a dining table with his lunch tray in front of him and stated that he did not always get the food he requested. He said that he had asked for a banana and milk that day but did not receive them. Review of the Monday lunch meal ticket showed personal menu items of one banana and 8.0 fl. oz. whole milk, but the tray observed did not include either item. CNA 2 confirmed that the meal ticket listed the banana and milk and that they were not on the tray. CNA 1 stated that all items on the meal ticket should be on the tray and that missing items should be called to the kitchen, but she had not called for any missing items that day. RNA 2 also confirmed that the banana and milk were listed on the meal ticket and were not provided, and did not call the kitchen before removing the tray after the resident said he was done eating. The Director of Hospitality stated the facility process was to honor resident food requests and that staff were responsible for calling the kitchen when food was missing. The facility policy stated residents are to be offered menu choices and provided meals based on food preferences, allergies, intolerances, and the plan of care.
Inaccurate Weight Documentation in EHR
Penalty
Summary
The facility failed to properly document the medical record for one resident by inaccurately recording a weight of 220 lbs. on 3/07/2026. The resident’s face sheet showed admission on 1/08/2026 with diagnoses including Alzheimer’s disease, hyperlipidemia, and dysphagia. The history and physical dated 1/08/2026 stated the resident had an inability to comprehend and follow simple commands. The MDS dated 5/29/2026 indicated the resident was dependent on all ADLs and required substantial to maximal assistance with transfers and repositioning. The care plan for nutrition/hydration included monthly weights and assistance with food and fluids during and between meals. During interview and record review, CNA 1 stated CNAs weigh residents as ordered and either document the weight in the electronic chart or report it to the nurse, and that questionable weight changes must be rechecked and reported. LVN 1 reviewed the chart and stated the 220 lb. entry was an error because surrounding weights were 127.2 lbs. on 2/11/2026, 222.0 lbs. on 3/07/3036, 124.6 lbs. on 3/10/2026, and 122.4 lbs. on 4/01/2026, and there was no documentation that the entry was charted in error or corrected. The RD also stated the 220 lb. documentation must be an error and that accurate weight documentation is important for assessing nutritional status. The CS stated the documentation error should have been corrected and that the policy was not being followed. The facility policy on Documentation, Nursing Weekly Summary required an accurate and concise summary of the resident’s health status and completion of all areas in the EHR.
Failure to Remove Gloves and Perform Hand Hygiene After Resident Care
Penalty
Summary
The facility failed to maintain its infection prevention and control program when CNA 6 did not remove disposable gloves and perform hand hygiene before exiting Resident 37’s room after using lift equipment to place the resident in bed. During observation, CNA 6 was seen leaving the room wearing blue disposable gloves and pushing the lift equipment down the hall. The CNA then placed the lift equipment at the side of the hallway, walked away from it, and removed the gloves only after leaving the resident’s room area. Resident 37’s H&P dated 1/7/2026 indicated diagnoses of HF, osteoporosis, and HTN. The MDS dated 7/7/2026 indicated the resident was able to understand others and make herself understood, and was dependent on staff for eating, oral and personal hygiene, toileting, bathing, and mobility. During interview, CNA 6 stated she used the lift equipment to place Resident 37 in bed and acknowledged she did not remove the gloves and perform hand hygiene after providing care and before exiting the room. RN 1 stated gloves are considered dirty after resident care and should be immediately removed with hand hygiene performed prior to exiting the room for standard precautions. RN 1 also stated disposable gloves should never be worn in the facility hallways after exiting a resident’s room. The Clinical Supervisor reviewed the facility’s hand hygiene, infection precaution techniques, and standard precautions policies, which stated hand hygiene should be performed after glove removal and before leaving the room, and that gloves should be removed promptly after use before touching noncontaminated items and environmental surfaces.
Failure to Inventory and Document Home Medications on Admission
Penalty
Summary
The facility failed to inventory a resident’s home medications upon admission, resulting in mismanagement of those medications. The resident, who had dementia and was prescribed Norco and Klonopin, was admitted with personal belongings and home medications from an assisted living facility. The Resident Belongings/Valuables admission inventory form dated 12/11/2025 did not list any home medications, was unsigned, and noted that the resident was unable or refused to sign. Interviews with the Chief Nursing Officer and Director of Risk Management confirmed that the resident’s home medications were brought in at admission, reviewed by the admitting Nurse Practitioner, and then sent to the pharmacy, but no inventory or documentation of these medications was completed by nursing, pharmacy, or on the belongings form. The Chief Nursing Officer stated that the pharmacy evaluated the home medications to determine if any were needed temporarily and then kept them until they were returned to the resident’s daughter a few days later. The Director of Risk Management reported that the usual practice was for home medications to go to nursing and pharmacy for review and then be returned to the family, and that the facility did not keep home medications or document them on the Resident Belongings and Valuables form. The Director also confirmed there was no separate process in place to track, inventory, or document patient home medications. These practices were inconsistent with the facility’s policies, which required that medications brought in at admission be verified, counted, and documented in a log when transferred to pharmacy, and that all personal effects, including items that may affect health and safety, be recorded on the Resident Belongings and Valuables form or in the EHR. The deficient practice resulted in mismanagement of the resident’s home medications and created a high risk of lost belongings, medication omissions, and discrepancies in treatment.
Resident Rights Violated Due to Rough Handling by Staff
Penalty
Summary
A deficiency occurred when a staff member failed to uphold a resident's rights to a dignified existence and safe care environment. According to interviews and record reviews, a certified nurse assistant (CNA) was observed by another CNA forcefully assisting a resident with dementia, chronic kidney disease, multiple venous thromboembolisms, fibromyalgia, and spinal stenosis to the commode. The witness described the staff member as becoming frustrated and manhandling the resident by her armpits, then slamming her onto the commode with aggressive and excessive force. This incident resulted in physical harm to the resident. The facility's Director of Risk Management and Regulatory Affairs confirmed that the staff member's behavior was considered misconduct due to the rough handling. Review of the resident's admission agreement and the facility's resident rights documentation indicated that residents are to be free from mental and physical abuse and treated with respect. The actions of the staff member violated these documented rights, as the resident was not provided care in a manner that ensured her dignity and safety.
Failure to Enforce Abuse Prevention Policy Resulting in Resident Exposure to Alleged Perpetrator
Penalty
Summary
The facility failed to enforce its own abuse prevention and reporting policies for a resident with dementia and multiple chronic medical conditions, including VTE, CKD, fibromyalgia, and spinal stenosis. On one occasion, a CNA was witnessed by another CNA forcefully and aggressively handling the resident while assisting her to the commode, including manhandling her by the armpits and slamming her onto the commode. The incident was observed to be an act of misconduct due to rough handling, as confirmed by the Director of Risk Management and Regulatory Affairs. Despite the facility's policy requiring immediate suspension of employees suspected of abuse to protect residents, the CNA involved continued to work several shifts after the incident. The DON acknowledged that the CNA should have been suspended the same day as the incident, and that the delay left the resident exposed to potential further abuse. The facility's Code of Conduct and abuse prevention policies, which require residents to be treated with care and respect and mandate suspension of suspected employees, were not followed in this case.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an alleged abuse incident involving a resident in accordance with its own policy and regulatory requirements. A certified nurse assistant (CNA) witnessed another CNA forcefully and aggressively assist a resident with dementia, chronic kidney disease, venous thromboembolism, fibromyalgia, and spinal stenosis to the commode, using excessive force and manhandling the resident. The incident occurred late at night and was not reported to the appropriate authorities within the required 24-hour timeframe. The facility's Director of Nursing acknowledged that the incident was reported late to the licensing agency, local law enforcement, and ombudsman, as the report was sent by fax several days after the event. Facility policy required a telephone report to law enforcement and written reports to the ombudsman and licensing agency within 24 hours of the incident. The delay in reporting resulted in a delayed investigation by the state agency and law enforcement. Medical assessment of the resident after the incident did not reveal any injuries or discoloration.
Failure to Obtain Informed Consent for Psychoactive Medications
Penalty
Summary
The facility failed to ensure that residents and/or their responsible parties were fully informed and provided with written informed consent prior to the administration of psychoactive medications. For two sampled residents, the required documentation of informed consent was not found for several prescribed psychotropic medications, including lorazepam, mirtazapine, escitalopram, and gabapentin. This omission was identified through interviews and record reviews, where staff confirmed the absence of signed consents in the residents' medical records. One resident, who had a history of depression, insomnia, and atrial fibrillation, was admitted with moderate cognitive impairment and was prescribed multiple psychoactive medications for anxiety, depression, and insomnia. Despite the facility's policy requiring written informed consent for such medications, no documentation of consent was present for any of the prescribed drugs. Staff interviews confirmed that the process of obtaining and documenting informed consent, including discussion of risks and benefits, had not been completed as required. A second resident, also with moderate cognitive impairment and diagnoses of anxiety disorder, depression, and diabetes mellitus, was prescribed escitalopram for depression and anxiety. Again, review of the medical record and interviews with nursing staff revealed that no written informed consent was obtained or documented for the use of this psychotropic medication. The facility's policy, which mandates informed consent and regular renewal every six months, was not followed in these cases, resulting in a violation of the residents' rights to make informed decisions regarding their care.
Failure to Develop and Implement Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for multiple residents, resulting in disorganized documentation and the omission of critical interventions. For two residents with multiple medical conditions and cognitive impairments, the care plans listed all medical problems together without grouping them by specific issues, and the associated goals and interventions were not tailored to individual problems. Instead, interventions were mixed together, making it difficult for staff to identify which actions corresponded to which medical issues. Both nursing and administrative staff acknowledged that this disorganization could lead to delays in care and miscommunication among healthcare providers. In another instance, a resident who expressed a desire to smoke was assessed by the interdisciplinary team and determined to require the use of a smoking apron for safety. However, the resident's care plan did not include the intervention of wearing the apron, despite this being identified as necessary in the assessment. Staff interviews confirmed that the omission was an oversight, and that the care plan is the primary tool used to communicate required interventions to all staff. The absence of this intervention in the care plan created the potential for staff to allow the resident to smoke without the required safety equipment. The facility's own policies and procedures require that care plans be comprehensive, coordinated, and based on individual assessments, including specific goals, interventions, and review dates. In each of the cases reviewed, the care plans did not meet these requirements, as they failed to clearly communicate individualized problems and interventions, and in one case, omitted a critical safety intervention altogether.
Failure to Follow Professional Standards in Medication Administration
Penalty
Summary
The facility failed to provide care in accordance with professional standards of practice in several areas related to medication administration. For two residents, scheduled medications were not administered as ordered at the scheduled times. In both cases, a licensed nurse administered medications earlier than the scheduled time without proper documentation or provider authorization, and the electronic medication administration record (MAR) did not allow for accurate recording of the actual administration time. The nurse reported giving medications early based on resident preference and convenience, but did not consistently document the reason or obtain a revised order, as required by facility policy and professional standards. For another resident with a gastrostomy tube (g-tube), the nurse failed to check the tube's placement and patency before administering medications, and did not flush the tube with water between each medication as required by facility policy. The nurse stated that she only checked for patency once per shift and did not flush between medications because there was no specific physician order to do so. However, facility policy and interviews with supervisory staff confirmed that placement and patency should be checked before every medication administration and that flushing between medications is necessary to prevent mixing and ensure proper delivery. Additionally, for a resident receiving subcutaneous insulin, the facility did not rotate injection sites as required by professional standards and the manufacturer's guidelines. Review of administration records showed repeated use of the same injection sites over multiple days. Nursing staff and facility leadership acknowledged that injection sites should have been rotated to prevent adverse effects and ensure proper absorption, but this was not done according to the established protocols.
Failure to Provide Timely ROM Interventions and Assessments
Penalty
Summary
The facility failed to provide appropriate treatments and services to prevent a decline in joint range of motion (ROM) and mobility for four residents with limited ROM and mobility. For one resident with hemiplegia and contracture of the left hand, the Restorative Nursing Aide (RNA) program order for ambulation was not updated to reflect the Physical Therapy (PT) recommendation to use a platform walker for stability after PT discharge. Instead, the resident continued to ambulate with a front-wheeled walker, contrary to PT's recommendation. Additionally, this resident did not receive the required quarterly PT and Occupational Therapy (OT) joint mobility screens (JMS) as scheduled. Another resident with dementia and lower extremity ROM impairment did not receive timely RNA treatments for ambulation after PT recommended RNA upon discharge. There was a delay of about three months before the RNA order was implemented. This resident also missed a quarterly PT JMS, which was not completed as required. Interviews with staff confirmed that RNA programs should be initiated immediately after PT or OT discharge and that quarterly JMS are necessary to monitor for changes in ROM and function. Two additional residents, one with multiple sclerosis and functional quadriplegia and another with congestive heart failure and polyarthritis, did not receive their scheduled quarterly PT and OT JMS. Staff interviews revealed that these screenings are intended to monitor joint mobility and identify any changes or declines. The facility lacked a policy and procedure for PT and OT joint mobility screening or monitoring ROM, contributing to the missed assessments.
Failure to Prevent Accident Hazards and Ensure Resident Supervision
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards for multiple residents, as evidenced by several observed deficiencies. One resident on swallow precautions, with a history of stroke and recurrent pneumonia, was left unsupervised while eating breakfast and was not positioned at the required 90-degree angle. The assigned staff member admitted to leaving the resident alone during meals, despite clear orders and posted signage requiring supervision and specific positioning to prevent aspiration or choking. Another resident with cognitive deficits and a diabetic foot ulcer had a bottle of Daikin's solution, a strong antiseptic, left at the bedside mixed with food items. Facility staff acknowledged that medications should not be left at the bedside due to the risk of accidental ingestion. Additionally, a resident with severe cognitive impairment and high fall risk was found to have a call light cord with exposed/frayed wires and fall mats with furniture and equipment placed on top, compromising both electrical safety and the effectiveness of the fall mats. Similar issues were observed with another resident, where overbed tables were placed on top of bilateral floor mats, increasing the risk of injury and reducing the protective function of the mats. A further deficiency was noted when a resident with dementia and impaired safety judgment had an unattended medication cup containing ointment left at the bedside, accessible for self-administration. Multiple staff members entered the room without removing the ointment, and it remained on the nightstand for an extended period. Staff interviews confirmed that medications should not be left unattended in resident rooms, especially in units where residents have dementia and impaired safety awareness. Facility policies and procedures reviewed during the survey supported the need for a hazard-free environment and proper medication administration practices, which were not followed in these instances.
Medication Administration and Pharmaceutical Service Deficiencies
Penalty
Summary
Surveyors identified multiple deficiencies in the administration of pharmaceutical services and medication management for several residents. One incident involved a nurse administering mupirocin ointment to a resident with a stage two sacral pressure injury without a current physician's order. The nurse had continued to apply the discontinued medication, which remained in the treatment cart, for several days, believing there was still an active order. Both the nurse and other staff acknowledged that the medication should have been removed from the cart after discontinuation, and that medication administration should always be based on an active physician's order, as per facility policy. In another instance, two residents did not receive their scheduled medications at the prescribed times. A nurse administered medications earlier than the scheduled time, outside the one-hour window allowed by facility policy, due to the residents' preferences and convenience. The nurse did not document the reason for the early administration or obtain a revised order from the provider to reflect the change in timing. The facility's electronic medication administration record (eMAR) system also did not allow documentation of the actual time of administration outside the scheduled window, leading to further deviation from policy. Additionally, a nurse failed to follow proper procedures for administering medications via a gastrostomy tube for another resident. The nurse did not check the tube's placement and patency before administering medications and did not flush the tube with water between medications. These actions were not in accordance with the facility's medication administration policies and procedures, which require verification of tube placement and flushing to ensure safe and effective medication delivery.
Failure to Monitor for Adverse Effects of High-Risk Medications
Penalty
Summary
The facility failed to ensure that residents' drug regimens were free from unnecessary drugs by not providing appropriate monitoring for adverse effects associated with certain high-risk medications. For two residents receiving antibiotics, there was no documented monitoring for adverse effects. One resident was prescribed azithromycin for pneumonia prophylaxis without an order or documentation for monitoring potential side effects, despite the medication's known risks, especially in elderly patients. Interviews with nursing and pharmacy staff confirmed the absence of such monitoring and emphasized its importance for timely intervention and prevention of complications, including antibiotic resistance. Another resident was prescribed amoxicillin as a PRN order for dental procedure prophylaxis, but the order lacked instructions for monitoring adverse effects. The medication was only administered once, but staff and a nurse practitioner noted that the PRN order increased the risk of medication errors and that monitoring for adverse effects was not in place. Facility leadership acknowledged that the order should have been written as a one-time dose and that monitoring for adverse effects was necessary to ensure safe use of the antibiotic. A third resident was prescribed both aspirin and clopidogrel for stroke prophylaxis, but there was no order or documentation for monitoring adverse effects such as bleeding. Nursing staff and facility leadership confirmed the lack of monitoring and highlighted the importance of such oversight to prevent and address potential adverse reactions. Product information for these medications, provided by the facility, listed significant risks such as hemorrhage and other side effects, underscoring the need for monitoring that was not implemented.
Medication Error Rate Exceeds Acceptable Threshold Due to Improper Administration Practices
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required, with seven medication errors identified out of 28 opportunities, resulting in a 25% error rate. For two residents, a licensed vocational nurse (LVN) administered scheduled 9 a.m. medications earlier than the prescribed time without proper documentation or provider authorization. The LVN stated that the residents preferred to receive their medications earlier, and although the nurse practitioner or physician was reportedly notified, there was no documented order to change the scheduled administration time. Facility policy and interviews with the Director of Pharmacy and Director of Long-Term Care confirmed that medications should be administered within one hour before or after the scheduled time, and any deviations require provider approval and documentation. In another instance, the same LVN failed to follow facility policy for administering medications via gastrostomy tube (g-tube) for a resident with epilepsy, muscle spasm, neuralgia, and neuritis. The LVN did not flush the g-tube with water between administering different medications, contrary to the facility's policy, which requires flushing with 15-30 ml of water between each medication to prevent mixing and ensure tube patency. The LVN stated she followed the physician's order to flush before and after medication administration but did not flush between medications due to the absence of a specific order. Interviews with facility leadership confirmed that the standard of practice and facility policy require flushing between medications, and the LVN acknowledged not following this procedure. Additionally, the LVN did not check the g-tube for placement and patency at every scheduled medication administration, as required by facility policy. Instead, she checked for patency only once per shift, based on instructions she believed were provided by her supervisor. However, facility leadership clarified that the policy is to check placement, patency, and residual before every medication administration. The failure to adhere to these procedures was confirmed through interviews, record reviews, and direct observation, and was not in accordance with the facility's written policies and procedures for safe medication administration.
Medication Administration Errors and Failure to Follow Protocols
Penalty
Summary
Surveyors identified multiple deficiencies related to medication administration for several residents. One resident receiving insulin (liraglutide/Victoza) did not have injection sites rotated as required by standards of practice and the manufacturer's guidelines. Documentation showed repeated use of the same injection sites over several months, and nursing staff confirmed that site rotation was not performed. This failure was acknowledged by both nursing staff and facility leadership, who stated that not rotating sites can affect medication absorption and is not in accordance with accepted practice. Two other residents were found to have received scheduled oral medications outside of the prescribed administration window. Nursing staff administered medications earlier than the scheduled time, citing resident preference and convenience, but did not document provider approval or the reason for the deviation. Facility policy and interviews with pharmacy and nursing leadership confirmed that medications should be given within a one-hour window before or after the scheduled time, and any deviations should be communicated to and approved by the provider, with documentation in the medical record. The electronic medication administration record (eMAR) system did not allow documentation of the actual administration time outside the allowed window, and staff reported giving medications early on multiple occasions without proper documentation or provider notification. Additionally, a resident receiving medications via gastrostomy tube (g-tube) did not have water flushes administered between medications, contrary to facility policy and standard practice. The nurse administered all medications consecutively, flushing only before and after the medication pass, and stated that she followed the physician's order, which did not specify flushing between medications. Facility policy, as well as statements from nursing and pharmacy leadership, required flushing with water between each medication to prevent mixing and ensure tube patency. The nurse also did not consistently check tube placement and patency as required by policy.
Deficient Food Storage and Preparation Practices
Penalty
Summary
Surveyors observed multiple failures in food storage and preparation practices within the facility's kitchen. A disposable cup of coffee belonging to a kitchen staff member was found on top of a metal cart outside the dry food storage area, despite facility policy prohibiting personal or staff food items in the kitchen to prevent cross contamination. Several food items in the dry storage area, including boxes of dried noodles, a bottle of instant coffee, and a box of wonton chips, were found open and not labeled with an open date. Additionally, the wonton chips were stored in an unsealed plastic bag. A container labeled as containing black-eyed peas was found to actually contain brown short grain, which appeared to be brown rice, and red potatoes were observed stored in a wet bin rather than a dry container as required by policy. Interviews with the Director of Hospitality Services and the Director of Long-Term Care confirmed that these practices were not in accordance with facility policy or professional standards. Both directors acknowledged that all opened food items should be labeled with an open date, containers should be labeled accurately, and produce should be stored in dry containers to prevent contamination. The facility's policy and the Food Code 2022 were reviewed, both of which require proper labeling, sealing, and storage of food items to maintain safety and prevent contamination.
Failure to Complete Timely Therapy Discharge Summaries
Penalty
Summary
The facility failed to maintain timely and accurate medical records for two residents by not completing required discharge summaries for physical therapy (PT) and occupational therapy (OT) services. For one resident with diagnoses including congestive heart failure and polyarthritis, the last PT and OT treatment notes were completed in early January, but no discharge summaries were documented after therapy services ended. Interviews with the therapy manager confirmed that discharge summaries should have been completed at the time of discharge, as they provide essential information on the resident's progress, current level of function, and recommendations for ongoing care. Another resident, admitted with conditions such as anoxic brain damage, hemiplegia, and monoplegia, also did not have a PT discharge summary completed after the last PT treatment. The physical therapist confirmed that the resident was discharged from PT, but the required summary was not documented. The absence of these summaries meant that other staff were not formally informed of the residents' therapy discharge status or the recommendations for their continued care. Facility policy required all documentation to be completed within 48 hours of service provided or attempted. The failure to complete these discharge summaries for both residents was identified through record review and staff interviews, demonstrating a lack of adherence to the facility's documentation standards and professional requirements for maintaining accurate and timely medical records.
Failure to Adhere to Infection Control Protocols and Proper Linen Storage
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple staff not adhering to required personal protective equipment (PPE) protocols and improper linen storage. In one instance, an Activities Assistant entered the room of a resident on droplet precautions without donning a mask or any PPE, despite clear signage at the door indicating the need for a surgical-grade mask. The staff member admitted to not reading the sign before entering and was unaware of the specific requirements, even after reviewing the sign post-incident. The resident in question had respiratory symptoms and was under physician-ordered droplet precautions. In two other cases, Certified Nursing Assistants and another staff member failed to wear isolation gowns and gloves while performing high-contact activities, such as transferring, oral hygiene, and other ADL care, for residents on Enhanced Barrier Precautions (EBP) due to the presence of wounds or indwelling devices like a g-tube. Despite signage and facility policy requiring gowns and gloves for these activities, staff either forgot or neglected to follow the protocol. Interviews confirmed that staff were aware of the requirements but did not comply during the observed care activities. Additionally, the facility was observed to be using linen cart covers made of loosely woven, permeable material, which staff and supervisors acknowledged would not adequately protect clean linens from environmental contaminants. The facility's own policy required clean linen to be transported in covered carts to prevent contamination, but the covers in use allowed air and liquids to pass through, potentially exposing linens to bacteria and viruses.
Failure to Notify Provider and Responsible Party After Resident's Hypoxia Episode
Penalty
Summary
A deficiency occurred when the facility failed to notify both the physician and the resident's responsible party (RP) after a resident experienced an episode of hypoxia. The resident, who had diagnoses including dementia, major depressive disorder, and Parkinson's disease, was admitted with severely impaired cognition and required substantial to total assistance with activities of daily living. The resident had an existing physician's order for oxygen via nasal cannula as needed for hypoxia. On the date of the incident, nursing staff assessed the resident for hypoxia, noting an oxygen saturation of 83-85% on room air and a respiratory rate of 30 per minute. Oxygen was applied and titrated to 1 L/min, resulting in an improved oxygen saturation of 93%. However, the nursing documentation did not indicate that the medical provider or the resident's RP were notified of this change in condition. Interviews with the registered nurse and the Director of Long-Term Care confirmed that neither the provider nor the RP were notified, and there was no documentation of such notification in the resident's records. Both staff members acknowledged that facility policy requires notification of the provider and RP for any change in condition, and that this was not followed in this instance. The facility's policy specifically states that the provider and responsible party must be notified of significant changes in a resident's status, and documentation of the notification must be maintained.
Failure to Accurately Assess and Document Pressure Injury
Penalty
Summary
The facility failed to ensure that a resident received care consistent with professional standards of practice to prevent and manage a pressure injury (PI). Specifically, the nursing staff did not perform an accurate assessment of the resident's pressure injury on the right buttock. The wound was initially documented as a stage 2 PI, later as an unstageable PI, and then incorrectly reclassified as a stage 2 PI, which constitutes reverse staging—a practice not permitted by professional standards. Multiple registered nurses and the Director of Long-Term Care confirmed during interviews that the wound should have been documented as a healing unstageable PI rather than being restaged to a lower classification. The resident involved had a history of dementia, major depressive disorder, and mobility abnormalities, and required significant assistance with activities of daily living, including total assistance with toileting, hygiene, bathing, and transfers. The resident's clinical records indicated severe cognitive impairment but retained the ability to communicate needs. The wound care assessments were completed weekly by registered nurses and documented in the facility's electronic health record, but the documentation failed to accurately reflect the wound's progression and stage. Facility policy required accurate and complete documentation of pressure injuries, including proper staging and ongoing evaluation. The failure to accurately assess and document the pressure injury as healing unstageable, rather than incorrectly restaging it as stage 2, meant that the resident was at risk for inappropriate treatment and potential worsening of the wound. This deficiency was confirmed through record review and staff interviews, which acknowledged the error and the importance of proper wound assessment and documentation.
Failure to Anchor Suprapubic Catheter to Statlock
Penalty
Summary
A deficiency was identified when a resident with a suprapubic urinary catheter was observed to have the catheter tubing not anchored to the statlock device on their right thigh. The statlock, which is intended to secure the catheter and prevent movement or accidental dislodgement, was present but not utilized as required. This observation was confirmed by both a Licensed Vocational Nurse and the Director of Long Term Care, who stated that all urinary catheters should be anchored to prevent movement and potential complications. The resident involved had a history of unspecified dementia, hypertension, and the presence of a suprapubic catheter, and required varying levels of assistance with activities of daily living. Physician orders and facility policy both specified that indwelling catheters should be properly secured after insertion to minimize movement. Despite these directives, the catheter was not anchored, as observed during the survey, and this was acknowledged by facility staff during interviews.
Discontinued Medication Not Removed, Resulting in Continued Administration
Penalty
Summary
A deficiency occurred when a discontinued medication, mupirocin ointment, was not removed from a treatment cart after the physician's order to discontinue it. Despite the order being discontinued, the ointment remained accessible in the cart, and a Licensed Vocational Nurse (LVN) continued to administer it to a resident during wound care. The LVN stated that she routinely applied the mupirocin to the resident's pressure injury, unaware that the order had been discontinued, as the medication was still present in the cart. The resident involved had a history of neurocognitive disorder with Lewy bodies and a stage two pressure injury on the sacral region. The resident was dependent on staff for all activities of daily living and was rarely able to communicate or understand others. The care plan for the resident included specific wound care instructions, and the physician's orders had clearly discontinued the use of mupirocin prior to the observed administrations. Interviews with nursing staff and the Director of Long Term Care confirmed that facility policy required discontinued medications to be removed from nursing stations immediately to prevent inadvertent administration. However, the discontinued mupirocin was not removed, resulting in its continued use on the resident. The failure to remove the medication from the cart and the subsequent administration of a discontinued drug constituted a breach of accepted medication storage and administration practices.
Failure to Clarify Prolonged Azithromycin Use for Pneumonia Prophylaxis
Penalty
Summary
The facility failed to reduce the risk of adverse events and the development of antibiotic-resistant organisms by not clarifying the appropriate indication for the use of azithromycin as a prophylaxis for pneumonia in a resident with chronic recurrent pneumonia. The resident was admitted with multiple medical conditions, including dyslipidemia, chronic recurrent pneumonia, and atrial fibrillation, and had an active order for azithromycin 250 mg twice weekly for pneumonia prophylaxis without an end date. The order was continued per the primary medical doctor, and the plan of care reflected this ongoing use, but there was no documented clarification of the clinical guideline supporting this prolonged prophylactic use. Interviews and record reviews revealed that the nursing and pharmacy staff were aware of the order but did not question the appropriateness of azithromycin for pneumonia prophylaxis or the lack of a stop date. The registered nurse confirmed the order and its indication, stating that education had been provided regarding the need for stop dates and appropriate indications for antibiotics. The nurse practitioner noted that such use of azithromycin was atypical and was unable to identify a clinical practice guideline supporting it. The director of pharmacy acknowledged receiving the order but did not discuss it with the prescriber or the infection preventionist, and the issue was not brought to the Pharmacy and Therapeutics committee for peer review. The infection preventionist stated that the antibiotic stewardship program relies on communication from the pharmacist when new antibiotics are prescribed, but she was not notified when antibiotics were used for prophylaxis. She indicated that, had she been notified, she would have sought clarification from the prescriber, as azithromycin is generally used for prophylaxis in cases of bronchitis or COPD, not pneumonia. The facility's policy required the pharmacist to communicate new antibiotic orders to the infection control nurse, including the diagnosis and duration, but this process was not followed in this case, resulting in a failure to ensure the appropriateness of the antibiotic order.
Failure to Implement Policies for Side Rails and Restraints
Penalty
Summary
The facility failed to establish and implement policies and procedures regarding the use of side rails (SR) and physical restraints. During an interview and record review, the Director of Nursing (DON) admitted that the facility did not have a policy for SRs or restraints, as they considered themselves a restraint-free facility. The DON emphasized the importance of having policies to guide the facility based on the standard of care. The Administrator (ADM) also acknowledged the lack of a specific policy for restraints and stated that it was her responsibility to ensure such policies were in place. The ADM mentioned that the SR policy should include an assessment for SR usage and informed consent for any SRs used in the facility. The facility's existing policy and procedure for policy review and approval, last reviewed in April 2023, outlined a standardized process for developing, reviewing, revising, approving, implementing, and maintaining facility policies. However, this process was not followed for SRs and restraints. The lack of these policies had the potential to result in psychosocial harm, decline in physical functioning, physical harm from entrapment, and death of residents, affecting all 87 residents residing in the facility.
Failure to Keep Call Lights Within Reach
Penalty
Summary
The facility failed to keep the call light within reach of four out of five sampled residents, which had the potential for delaying care and services requested by the residents and placing them at risk for falls and injuries. Resident 77, who was admitted with diagnoses including nontraumatic subdural hemorrhage, seizures, and dementia, was observed with the call light on top of the bed while sitting on a chair away from the bed. The CNA confirmed that the call light was not within reach, which could prevent the resident from calling for help and increase the risk of falls. The resident's care plan specifically indicated the need for the call light to be within reach due to high fall risk, but this intervention was not followed during the observation. Resident 56, diagnosed with Alzheimer's disease, dementia, and glaucoma, was also found with the call light on top of the bed while sitting on a chair away from the bed. The CNA acknowledged that the call light was not within reach and should be accessible to prevent falls. The resident's care plan included an intervention to keep the call light within reach due to high fall risk, but this was not adhered to during the observation. Similarly, Resident 70, with diagnoses including Alzheimer's disease and dementia, was observed with the call light clipped on a folded blanket at the foot of the bed, out of reach. The CNA confirmed that the resident would not be able to reach the call light, which could result in the resident not being able to call for help and increase the risk of falls. Resident 12, who had hemiplegia and hemiparesis following a stroke, was found with the call light tied to the left upper side rail and dangling toward the floor, making it inaccessible. The resident stated she could not use her left arm and could not reach the call light. The CNA confirmed that the call light should have been placed on the resident's right side, where it would be accessible. The DON also acknowledged that the call light should have been within reach and that the facility's policy was not followed. The facility's policies and procedures indicated the importance of keeping the call light within reach to ensure patient safety and the ability to call for help when needed, but these were not followed in the observed cases.
Failure to Ensure Residents' Freedom from Physical Restraints
Penalty
Summary
The facility failed to ensure residents were treated with respect and dignity, specifically regarding the use of physical restraints. For four sampled residents, the facility did not assess the need for side rails, assess the risk for entrapment, obtain informed consent, or secure a physician's order before using side rails and positioning beds against walls. This was observed in Residents 8, 77, 56, and 70. For instance, Resident 8, who had advanced dementia and a history of falls, was found with side rails raised and the bed pushed against a dresser without proper assessments or consent. The Director of Nursing (DON) confirmed that no assessments or consents were documented for these actions, which restricted the resident's movement and posed risks of entrapment and injury. Additionally, the facility used chair alarms for Residents 77 and 56 without assessing the need, obtaining a physician's order, or securing informed consent. Resident 77's bed was pushed against the wall with both upper side rails up, and a chair alarm was in place, all without proper documentation or consent. Similarly, Resident 56's bed was pushed against the wall, and a chair alarm was used without the necessary assessments or consents. The DON and other staff members acknowledged that these interventions were considered nursing interventions and did not require a physician's order, which was incorrect. The facility's lack of a specific policy for restraints and the misunderstanding of what constitutes a restraint led to these deficiencies. The DON and Administrator admitted that they were unaware of the regulations regarding side rail use and the need for assessments and consents. The facility's policy indicated that residents have the right to be free from restraints, but this was not adhered to in practice. The DON acknowledged the risks associated with the improper use of side rails and bed positioning, including restriction of movement, entrapment, and potential physical harm.
Failure to Follow Manufacturer's Guidelines for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to provide care consistent with professional standards of practice to prevent pressure ulcers for two residents. For Resident 58, the facility did not set the low air loss mattress (LALM) according to the resident's weight and failed to apply Heel Protectors (HP 1) on both lower extremities as ordered. During an observation, it was noted that the HP 1 was only applied to the right lower extremity, and the LALM was set based on resident comfort rather than the manufacturer's guidelines. The Central Supply Staff (CSS) admitted to not following the manufacturer's guidelines and did not inform the Administrator about the issues with the company's responsiveness. The Director of Nursing (DON) confirmed the lack of a policy on the use of LALM and emphasized the importance of following the manufacturer's guidelines to prevent skin breakdown effectively. For Resident 45, the facility did not set the alternating pressure mattress (APP) according to the user manual. The APP mattress was observed to be set at the firmest setting, which the resident found uncomfortable and reported mild low back pain. The Certified Nursing Assistant (CNA) and Licensed Vocational Nurse (LVN) confirmed that the mattress settings were based on resident comfort rather than the manufacturer's guidelines. The DON reiterated the importance of following the manufacturer's guidelines, especially since the facility lacked a policy on the use of specialty mattresses. The facility's policies and procedures on pressure injury monitoring and the use of specialty beds were reviewed. The policies indicated the need for a comprehensive evaluation and treatment for residents with pressure injuries and the implementation of specialty beds as ordered. However, the facility did not have specific policies for the use of LALM and APP mattresses, leading to inconsistent practices and potential risks for the residents involved.
Failure to Provide ROM Services and Baseline Assessments
Penalty
Summary
The facility failed to provide services and treatments to monitor and maintain joint range of motion (ROM) for four of five sampled residents. Specifically, the facility did not provide Restorative Nursing Aide (RNA) program treatments as ordered for two residents and did not conduct baseline upper extremity ROM assessments for two other residents upon admission. These deficiencies had the potential to cause a decline in ROM, mobility, and overall quality of life for the affected residents. Resident 2, who had diagnoses including Alzheimer's disease and abnormalities of gait and mobility, had orders for RNA for ambulation with a two-wheeled walker three to five days a week. However, the resident missed several RNA treatments over a three-month period. Similarly, Resident 12, who had hemiplegia and hemiparesis following a cerebral infarction, also missed multiple RNA treatments despite having orders for passive and active ROM exercises and the use of a knee splint. Additionally, the facility failed to provide baseline upper extremity ROM assessments for Residents 45 and 63 upon admission. Both residents had significant medical conditions that warranted such assessments, but due to the unavailability of an Occupational Therapist (OT), these evaluations were not completed. This lack of baseline assessment made it difficult for the facility to monitor and compare any changes in the residents' ROM over time.
Failure to Ensure Safe and Appropriate Use of Side Rails
Penalty
Summary
The facility failed to ensure the safe and appropriate use of side rails for three residents, leading to potential risks of entrapment and injury. For Resident 8, the facility did not conduct an assessment for the risk of entrapment or obtain informed consent before using side rails. The resident, who had advanced dementia and a history of falls, was observed with bilateral side rails raised and the bed positioned against a wall, restricting mobility and increasing the risk of entrapment. Interviews with staff and family confirmed that no assessment or informed consent was documented, and the facility lacked a policy on side rail use. Similarly, Resident 77, who had dementia and was at high risk for falls, was found with the bed pushed against the wall and both upper side rails raised. There was no physician's order for the use of side rails, and the staff confirmed that the side rails were used to prevent falls without conducting a risk assessment or obtaining informed consent. The DON acknowledged the need for assessments and consents for side rail use and the requirement for a physician's order. Resident 70, diagnosed with Alzheimer's disease and dementia, was also found with the bed pushed against the wall and both upper side rails raised. The resident's care plan indicated a high risk for falls, but there was no physician's order for side rail use. Staff confirmed that the side rails were used to prevent falls without conducting a risk assessment or obtaining informed consent. The DON reiterated the importance of assessing the risk of injury from entrapment and obtaining consent for side rail use.
Inadequate RNA Staffing
Penalty
Summary
The facility failed to provide adequate and sufficient nursing staff to deliver care for residents requiring Restorative Nursing Aide (RNA) services. This deficiency had the potential to affect 70 residents with physician's orders for RNA services, which included treatments such as range of motion (ROM) exercises, application of splints or braces, ambulation, strengthening exercises, and transfers. The review of the facility's nurse staffing hours from January to April 2024 revealed inconsistent RNA staffing, with some days having no RNAs available, thereby failing to meet the residents' needs as ordered by their physicians. Interviews with staff, including RNAs, Nursing Supervisors, and the Director of Nursing (DON), confirmed the short-staffing issue. The DON acknowledged that the facility was aware of the insufficient RNA staffing and that residents were not receiving their RNA treatments 3 to 5 times a week as ordered. The DON also mentioned that RNAs were sometimes reassigned to work as CNAs due to CNA staffing shortages, further impacting the delivery of RNA treatments. The RNA supervisor and other staff members echoed these concerns, stating that the current RNA staff was not enough to meet the residents' needs, leading to missed treatments and potential declines in residents' mobility and overall well-being. The facility's policy on the Restorative Nursing Program, dated June 2023, indicated that RNA activities should be performed 3 to 5 times a week as ordered. However, the facility's staffing records and staff interviews revealed that this standard was not being met. The Performance Improvement Plan required a Registered Nurse to review the ROM exercises with the RNAs monthly to ensure appropriateness and delivery, but the staffing shortages hindered the consistent implementation of this plan. Consequently, the residents with RNA orders were at risk of deconditioning and worsening contractures due to the lack of adequate RNA services.
Deficiencies in Food Storage, Preparation, and Distribution
Penalty
Summary
The facility staff failed to ensure proper storage, preparation, and distribution of food in accordance with professional standards for food service safety. In one instance, a sandwich labeled with a use-by date was found in a resident's room two days past the expiration date. The Assistant Activities Coordinator removed the sandwich, and the Licensed Vocational Nurse acknowledged that the expired sandwich should not have been in the resident's room as it could have led to food poisoning. The Director of Nursing confirmed that the facility's policy on food storage was not followed, posing a potential risk to the resident's health. Another deficiency was observed in the serving temperature of food. Two residents reported that their food was rarely delivered warm, which was confirmed by the Trayline Manager who measured the temperature of a bowl of soup at 128 degrees Fahrenheit, below the required 135 degrees. The Registered Dietician and the Director of Nursing acknowledged that serving food at low temperatures could lead to bacterial growth and decreased palatability, potentially causing malnutrition and foodborne illness. Additionally, a box of moldy lemons was found in the walk-in refrigerator, which should have been discarded to prevent the spread of mold. The Director of Hospitality and the Registered Dietician confirmed that moldy foods should not be stored or served. Furthermore, the kitchen ice machine's drainpipe was found touching the drain grate, lacking the required air gap to prevent backflow and cross-contamination. The Director of Hospitality and the Registered Dietician confirmed that this setup could lead to contamination of the ice, posing a risk of foodborne illness to residents.
Failure to Provide Adequate Rehabilitative Therapy Services
Penalty
Summary
The facility failed to provide necessary rehabilitative therapy services, including occupational therapy (OT) and physical therapy (PT), to two of five sampled residents. The facility did not provide OT services to any residents from October 7, 2023, to the present. Additionally, the facility did not conduct OT evaluations for Residents 45 and 63 upon their admission, which is part of the facility's standard of care. This failure prevented the establishment of a baseline for residents' range of motion (ROM) and their ability to perform activities of daily living (ADLs). The absence of OT services was confirmed by multiple staff members, including the Physical Therapist (PT 1), the Administrator (ADM), and the Nurse Practitioner (NP 1), who all acknowledged that there had been no OT available since October 2023. Resident 45, who was admitted with diagnoses including hemiplegia and hemiparesis following a cerebral infarction, did not receive an OT evaluation or services. The resident required substantial assistance with various ADLs and had no functional limitations in ROM according to the Minimum Data Set (MDS). Despite the need for OT services to address these issues, the resident did not receive any OT evaluation or treatment. Similarly, Resident 63, who was admitted with diagnoses including morbid obesity and chronic obstructive pulmonary disease, also did not receive an OT evaluation or services. The resident required substantial assistance with lower body dressing, toileting, and chair transfers, but no OT evaluation was conducted to establish a baseline for ROM and ADLs. The facility also failed to provide adequate PT services to meet the care plans and goals for Residents 45 and 63. Resident 45's PT sessions were limited to 15 minutes once a week, which was insufficient to meet the resident's rehabilitation goals. The PT 1 confirmed that he was only available for two hours a day, four days a week, and had to divide his time among multiple units, leaving insufficient time for SNF residents. Resident 63 also received minimal PT services, with sessions lasting less than 30 minutes and occurring only once or twice a week. Both residents expressed dissatisfaction with the limited PT services, stating that they were not making progress toward their rehabilitation goals. The ADM and Nurse Supervisors acknowledged the performance issues with the contracted PT services, confirming that the residents needed more PT than was being provided.
Infection Control Deficiencies During Medication Administration and Respiratory Care
Penalty
Summary
The facility failed to maintain an infection prevention and control program, leading to potential cross-contamination during medication administration and respiratory care. Licensed Vocational Nurse 3 (LVN 3) did not perform hand hygiene before preparing medications for Resident 2, who had multiple diagnoses including Alzheimer's disease, COPD, and type 2 diabetes mellitus. LVN 3 admitted to not performing hand hygiene, acknowledging the risk of cross-contamination and potential illness for the resident. Similarly, LVN 4 did not perform hand hygiene before donning gloves and administering eye drops to Resident 87, who had severe cognitive impairment and diagnoses including Parkinson's disease and mild intermittent asthma. LVN 4 also failed to doff gloves before leaving the resident's room to retrieve a tissue box, further increasing the risk of cross-contamination. LVN 4 admitted to the oversight and recognized the potential for bacterial introduction to the resident. Additionally, the facility did not ensure that Resident 38's nasal cannula was labeled and dated within the last seven days. Resident 38, who had diagnoses including diastolic heart failure and COPD, reported that the oxygen tubing was not changed as frequently as desired. Observations confirmed that the nasal cannula was not labeled, and staff admitted that the tubing should be changed weekly to prevent bacterial growth and potential respiratory infections. The Director of Nursing confirmed that the facility's policy was not followed, acknowledging the risk of respiratory infection due to the oversight.
Failure to Maintain Resident Dignity by Not Covering Urinary Catheter Drainage Bag
Penalty
Summary
The facility failed to provide care in a manner that maintained or enhanced a resident's dignity and respect by not ensuring that a urinary catheter drainage bag was covered with a privacy bag. This deficiency was observed during a random observation of a resident who had been admitted with diagnoses including neuromuscular dysfunction of the bladder, spinal stenosis, and benign prostatic hyperplasia. The resident had severely impaired cognition and required varying levels of assistance with activities of daily living. The urinary catheter drainage bag was visible from the doorway and did not have a privacy cover, which was against the facility's policy and procedure for catheter care. During the observation, a Licensed Vocational Nurse confirmed that the drainage bag should have had a privacy cover to preserve the resident's dignity and self-worth. The Director of Nursing also stated that urinary catheter drainage bags should have privacy covers, especially when facing the door. The facility's policy, last reviewed in February 2023, indicated that all Foley catheter drainage bags must have a dignity bag to ensure privacy for the patient.
Failure to Provide Information on Advance Directives
Penalty
Summary
The facility failed to provide Resident 83 and their representative with information regarding the formulation of an advance directive. Resident 83, who was admitted on 6/28/2023, had severe cognitive impairment and was dependent on staff for activities of daily living. The resident's medical record did not contain documentation indicating whether the resident or their representative had been asked about an advance directive or provided with information on creating one. The Director of Social Services (DSS) confirmed this omission during a review of the resident's medical record on 4/4/2024. The DSS stated that it is standard procedure to ask residents or their responsible persons about advance directives upon admission and to provide educational materials if needed. However, this procedure was not followed in the case of Resident 83, who was non-verbal and had their husband as the responsible person. The facility's policy and procedure on advance directives, last reviewed on 10/18/2023, mandates that each adult patient or their responsible party should receive a pamphlet on medical treatment decisions and be asked about existing advance directives upon admission. The policy also requires documentation of any advance directive in the resident's medical record. The DSS acknowledged that failing to provide this information could result in the facility not knowing how to honor the resident's wishes during end-of-life care. This deficiency had the potential to impact the resident's end-of-life care decisions, as neither the resident nor their representative were informed about their rights to formulate an advance directive.
Failure to Develop Comprehensive Care Plans for Restraint Use
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for four residents, specifically regarding the use of side rails and restraints. Resident 8, who had Alzheimer's disease and a history of falls, was observed with bilateral side rails raised and the bed placed against a built-in dresser wall cabinet, restricting the resident's ability to exit the bed. The facility did not have a care plan addressing these restraints, and the Director of Nursing (DON) confirmed that the bed placement and side rails constituted a restraint. The Minimum Data Set Coordinator (MDSC) also confirmed the absence of care plans for these restraints. Resident 77, who had dementia and a history of seizures, was observed with the bed pushed against the wall, both upper side rails up, and a chair alarm in place. The Certified Nursing Assistant/Restorative Nursing Aide (CNA/RNA) stated these measures were for fall prevention, but there was no care plan addressing the use of these restraints. Similarly, Resident 56, who had Alzheimer's and required substantial assistance for mobility, was observed with the bed against the wall and a chair alarm, but no care plan was in place for these restraints. The Nursing Supervisor (NS) confirmed the absence of care plans, considering these measures as nursing interventions rather than restraints. Resident 70, who had Alzheimer's and moderately impaired vision, was observed with the bed pushed against the wall, both upper side rails up, and an overbed table placed on the right lower side of the bed. The Certified Nursing Assistant (CNA) stated these measures were to prevent falls, but there was no care plan addressing the use of these restraints. The Nurse Informaticist (NI) and the DON confirmed the absence of care plans for these restraints, emphasizing the importance of individualized care plans to address resident problems and implement appropriate interventions. The facility's policy required comprehensive care plans based on resident assessments and individual needs, but this was not followed for the use of restraints in these cases.
Failure to Apply TED Hose as Ordered
Penalty
Summary
The facility failed to ensure residents received treatment and care in accordance with professional standards of practice by not following the physician's order to apply thromboembolic deterrent (TED) hose for two residents. Resident 77, who was admitted with diagnoses including acute embolism and thrombosis, had a physician's order for TED hose to be applied every twelve hours. However, during an observation, the resident was found not wearing the TED hose, and the Certified Nursing Assistant (CNA) was unaware of the order. The Nursing Supervisor confirmed the order but did not know why the TED hose was not applied. Similarly, Resident 56, admitted with a history of venous thrombosis and embolism, had a physician's order for TED hose to be applied twice a day. During an observation, the resident was found wearing regular socks instead of the TED hose, and the CNA did not know if the resident ever wore the TED hose. The Director of Nursing (DON) confirmed that staff should apply the TED hose as ordered by the physician and acknowledged the lack of a policy for the use of TED hoses.
Failure to Ensure Safe Transfers and Medication Administration
Penalty
Summary
The facility failed to provide an environment free from accidents and hazards by not ensuring that a Certified Nursing Assistant (CNA) did not transfer a resident from bed to wheelchair using a Hoyer lift without another staff member's assistance. The resident, who had moderately impaired cognition and required substantial assistance with activities of daily living, was transferred by CNA 5 alone, which was against the facility's policy requiring two-person assistance for mechanical lift transfers. This action placed the resident at risk for falls and serious injuries. The CNA admitted to performing the transfer alone because other staff were busy, and the Director of Nursing confirmed that the transfer should have been done with two staff members for safety reasons. Additionally, the facility failed to ensure that residents did not have access to medications at their bedside. A resident with a history of cognitive decline and dependency on staff for daily activities was found with a bottle of lidocaine 4% roll-on at their bedside. The medication was not supposed to be left unattended with the resident, as per the facility's policy. The Licensed Vocational Nurse responsible for the resident's medication administration did not know how long the lidocaine bottle had been in the room or when it was last administered. The Director of Nursing confirmed that the medication should not have been left at the bedside due to safety concerns. These deficiencies highlight lapses in adherence to the facility's policies on safe transfers and medication administration, which are critical for preventing accidents and ensuring resident safety. The failure to follow these protocols placed residents at risk for falls, injuries, and potential medication misuse.
Failure to Label Medication with Expiration Date
Penalty
Summary
The facility failed to label a bottle of valproic acid solution with an expiration date, which was observed in one of the medication carts. This deficiency was identified during an observation and interview with a Licensed Vocational Nurse (LVN), who acknowledged the importance of labeling medications with expiration dates to ensure proper usage and disposal. The Director of Nursing (DON) also confirmed that the medication should have been labeled with an expiration date according to the facility's policy and procedure. The affected resident, identified as Resident 70, had a history of dementia, Alzheimer's disease, and major depressive disorder. The resident's physician had prescribed valproic acid to manage dementia-related behaviors, including physical aggression. The failure to label the medication with an expiration date increased the risk of administering ineffective or potentially harmful medication to the resident. The facility's policy indicated that all drugs should be labeled in accordance with state and federal requirements, and containers with missing labels should be returned to the pharmacy for proper disposition.
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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 Woodland Hills
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| West Valley Post Acute | 3.3 mi | ★★★★★ | 6 | 0 |
| Canyon Oaks Nursing And Rehabilitation Center | 3.9 mi | ★★★★★ | 22 | 0 |
| West Hills Health And Rehabilitation Center | 4.2 mi | ★★★★★ | 13 | 0 |
| Topanga Terrace | 4.6 mi | ★★★★★ | 17 | 0 |
| Woodland Care Center | 5.4 mi | ★★★★★ | 37 | 0 |
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