Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Northridge Care Center during CMS and state inspections, most recent first.
Pest control was not effective in one resident room when staff and a family member observed live roaches in the room, including on the wall, ceiling, and floor. The resident had left total hip replacement, OA, and DM, and records showed the facility had already identified American roach activity in drains, with the pest control vendor noting that roach movement into the building could occur after treatment.
A resident with CHF, HTN, and DM had a documented fall after reaching for a roach while in bed, but the Fall Risk Evaluation completed afterward incorrectly marked no falls in the past 3 months and did not identify the resident as high fall risk. The DON stated the fall should have been included in the assessment history and that the omission occurred because she was confused when completing that section.
Delayed Stat X-Ray After Resident Fall: A resident with dementia, epilepsy, a history of falls, and severe cognitive impairment slid from bed and later developed left foot pain and swelling after landing on the foot with full body weight. The physician ordered a stat x-ray, but the imaging was not completed until the next morning, and the DON stated the delay exceeded the usual 4-hour timeframe and that the physician was not notified of the delay.
A CNA observed a roach in a resident’s room, killed it, and did not report it to supervisory or maintenance staff. The resident had left hip replacement, OA, and DM, and the resident’s family member had also previously seen a roach in the room and notified staff. The MS confirmed no report was received, while the DON and ICP stated roach sightings should be reported promptly as part of the infection control program.
Failure to notify the resident representative after a resident was found on a floor mat next to the bed with a skin tear. The resident had DM, muscle weakness, dysphagia, UTI, a history of falls, and depression, and later documentation showed severely impaired cognition and dependence for several ADLs. The RP said the facility did not call after the fall and only learned about it when calling later that morning; the DON confirmed staff should have notified the RP when the incident occurred.
Delayed Communication of Lab Results: A resident with DM, UTI, dysphagia, and impaired cognition had CBC and BMP results received by the facility in the evening, but the RN did not review and send them to the physician until the next morning. The DON confirmed the results should have been communicated promptly, and the facility policy required the attending physician to be notified as soon as test results were received.
Incomplete documentation of physician response to change in condition. A resident with type 2 DM, dysphagia, UTI history, weakness, and impaired cognition developed chills, fever, and general weakness, and was given acetaminophen while the MD was notified. The LVN and RNS confirmed the physician told staff to continue monitoring, but that response was not documented on the COC form, and the DON confirmed the response should have been recorded for continuity of care.
A resident admitted with chronic pain and multiple medical conditions had errors in controlled substance handling and medication reconciliation. The controlled drug count record had missing nurse signatures across several shift changes, the morphine liquid count did not match the bottle on hand, and the morphine administration time was charted inconsistently between the controlled drug log and eMAR. Staff also did not verify the last hospital dose or the timing of the next scheduled dose after admission, and the DON confirmed there was no documentation showing that reconciliation was completed.
Baseline Care Plan for Pain Not Implemented: A resident admitted with chronic back pain, dysphagia, and HTN had a baseline care plan that included daily pain monitoring and opioid-related interventions, but staff did not document daily pain assessments after admission. The resident reported pain on arrival and later received hydrocodone-acetaminophen and scheduled morphine, while the DON confirmed the care plan interventions were not implemented because pain monitoring documentation was missing.
Pain assessment and medication documentation were not completed for a resident with severe back pain. A resident with ankylosing spondylitis reported pain on admission, but the pain level and notes were left blank, and the first documented pain medication was not given until the next day. The eMAR lacked documentation for Norco and morphine, and the DON stated there was no documentation of pre- and post-medication pain assessments, daily pain monitoring, or nonpharmacological or PRN pain interventions.
Physician Did Not Complete Required Initial Visit Within 72 Hours: A resident admitted with ankylosing spondylitis, dysphagia, and HTN did not receive the required initial physician visit within 72 hours of admission. RN notified the physician of the admission by text, and the physician responded with medication instructions, but the DON confirmed no visit by the attending physician or medical director was documented during the first several days after admission.
A resident with ankylosing spondylitis, dysphagia, and HTN had an incomplete CAR and missing admission notes. The CAR showed the resident arrived by ambulance with a family member and reported pain, but the pain fields were blank and 40 of 43 sections were left incomplete, including mental status, skin, mood/behavior, and mobility. The DON stated only three sections were completed by the RN and that required admission details such as the resident’s condition, admitting dx, and medication/order timing were not documented.
Missed and undocumented medication administration for two residents. One resident with stroke history, HTN, glaucoma, and stomach cancer did not have a scheduled Methadone dose documented as given for pain, and another resident with hemiplegia, narcolepsy, atrial fibrillation, dementia, and HTN had blank MAR entries for scheduled Apixaban, Famotidine, Losartan, and Modafinil doses. The ADM confirmed the doses were left blank and not signed off as administered.
A resident with CHF, chronic pulmonary edema, and orthostatic hypotension was admitted with a physician order for fluid restriction of 750 ml per day and no bedside water pitcher. Staff documented intake and output only for an initial period and then stopped monitoring and recording I/O, despite the ongoing restriction order. During interviews, an LVN and an RN acknowledged that licensed nurses had not continued I/O monitoring as required, even though facility policies mandate daily I/O documentation for residents on fluid restrictions for at least 30 days and ongoing monitoring when hydration concerns exist.
Surveyors found that staff failed to complete fall risk evaluations accurately for two residents. One resident with CHF, pulmonary edema, and orthostatic hypotension had a fall risk tool marked as having no SBP drop between lying and standing even though the resident could not stand, and the gait/balance and medication sections were left blank, resulting in a low fall score. For another resident with CHF and HTN, the MDS nurse documented no SBP drop between lying and standing without actually obtaining lying and standing BPs, relying instead on prior BP summaries that lacked standing readings, which also produced a non–high-risk fall score. These omissions and inaccurate entries meant the fall risk tools did not reflect the residents’ true fall risk status as required by facility procedures.
A resident with CHF and chronic pulmonary edema was readmitted with a hospital report and a physician telephone order indicating a 750 ml/day fluid restriction, but the order was not properly documented or incorporated into the active physician orders. The RN who received the hospital report acknowledged missing the entry of the fluid restriction, and the telephone order form lacked the signature and title of the person who transcribed it, making it impossible to identify who took the order or confirm that the person was licensed. The ADON and Medical Records Director were unable to locate the signed copy of the telephone order or any history of the fluid restriction in current or discontinued physician orders, contrary to facility P&P requiring licensed staff to document telephone orders with signature and title and for the physician to countersign them.
A facility failed to notify residents where to find the most recent survey results and failed to post the CMS-2567 in the survey binder. During a resident council meeting, several residents said they did not know the survey results existed or where they were located. The AD said residents were only told to ask the business office, and the DON confirmed the binder was incomplete. The residents involved were cognitively intact or mildly/moderately impaired and required setup assistance with ADLs.
Failure to protect PHI on meal tickets: A Dietary Aide was observed throwing meal tickets into the trash instead of placing them in the shred bin, and the Dietary Supervisor confirmed that meal tickets contained residents’ diet information, names, room numbers, and pictures. The RD stated all meal tickets should be shredded for HIPAA purposes, while the facility policy required PHI to be protected from unauthorized release or disclosure.
Failure to Provide Scheduled Bathing: A resident with hemiplegia/hemiparesis and dependence for bathing did not receive showers as scheduled, with the resident stating he was not getting showers as often as expected and preferred to feel clean and fresh. CNA reported the resident was scheduled for showers twice weekly and required full assistance, while the ADL record showed multiple missed bathing entries. An LVN acknowledged the resident did not get showered as often as he should have, despite the care plan directing scheduled bathing and facility policy emphasizing cleanliness, dignity, and infection prevention.
A facility failed to manage IV therapy for three residents by leaving an IV saline lock in place after IV antibiotics were completed for one resident, failing to date a midline dressing for another resident, and not changing a PICC dressing every 7 days for a third resident. RN and DON interviews, along with record review, showed the IV orders, dressing-change requirements, and facility policy were not followed.
Failure to Provide Ordered Oxygen Therapy: Two residents with respiratory-related diagnoses were involved in oxygen care deficiencies. One resident had been receiving oxygen for asthma, but the chart lacked a valid physician order for continuous oxygen for an extended period, and staff stated oxygen requires an order. Another resident had an order for continuous oxygen at 2 L/min via NC, but was observed without the NC in place while the tubing remained connected to the concentrator; an LVN and the DON confirmed he should have been wearing it.
Kitchen staff were not routinely trained and evaluated for competency in thawing food and checking sanitizer concentration. A cook thawed fish and meat together in a prep sink with running water, did not monitor water temperature or thaw time, and could not explain required time/temperature controls. A Dietary Aide also could not properly demonstrate chlorine test strip use and initially agitated the strip instead of following the manufacturer’s directions, resulting in an inaccurate ppm reading.
Food was not prepared and served to preserve palatability and temperature when trayline items were found out of range: milk was 42 F, juice was 61 F, and triple fruit crisp was 98 F. A beef roast was also observed to be dry, and the DS stated the cold foods were not placed in an ice bath and the dry meat could lead to poor intake. A resident on a soft bite-sized diet with thin liquids said the meat was very chewy and he could not swallow it.
Unsafe kitchen storage, preparation, and sanitation practices were observed throughout the dietary area. A rack was rusted and cracked, food debris was on the dry storage floor, multiple bins, carts, racks, vents, a coffee spout, and condiment containers had residue or dirt buildup, dented cans were mixed with intact cans, and meal trays had cracks and lost glaze. Staff also stacked pans wet, thawed fish and chicken together in the same sink, thawed fish without a sealed container, used chlorine test strips incorrectly, and left food items in a resident refrigerator unlabeled and undated.
A resident with DM2, AKI, and HTN brought unpasteurized whole eggs into the facility and cooked them in the microwave without staff knowledge. Staff found the egg in the activity room refrigerator, and the resident said he brought whole eggs in one or two times a week and did not need to tell nurses. The DON stated residents were not allowed to bring raw food or cook, and the facility policy allowed only cooked or packaged items to be stored, with no raw food in resident refrigerators.
A resident receiving IV antibiotics had PICC dressing changes documented in the MAR even though the dressing was not actually changed as ordered, and the dressing was observed to have been last changed earlier than charted. In a separate event, IV Zosyn was documented under an RN’s login for another resident at times when that RN was not working, and the EHR was found left open with another user still logged in, creating inaccurate medication records and unauthorized charting.
Infection control standards were not maintained when an LVN brought a medication tube into a resident’s room, applied diclofenac gel to both knees, and returned the tube to the med cart without disinfecting it. In a separate observation, a resident’s O2 NC was found touching the floor beside the bed while connected to the O2 concentrator. The DON stated items taken into a resident’s room should be disinfected before returning to the cart, and the NC should not be on the floor.
Failure to maintain resident dignity and privacy for two residents: one resident who preferred her own clothes was repeatedly observed in a hospital gown despite personal clothing being in her closet, and another resident was observed in bed in public view wearing only an incontinent brief. The residents had care plans addressing privacy and choice of clothing, and staff including the ADON, LVN, and DON acknowledged that residents should be dressed appropriately and protected from exposure.
A resident’s call light was found with the button cover broken off, leaving a hard tube that was uncomfortable and harder to push. The resident said the issue had been reported before but the cover had not been replaced, and a CNA confirmed the call light could cause pain to the resident’s thumb. The ADON stated call lights must function properly so residents can call staff for assistance, and the facility policy called for a safe, clean, comfortable, and homelike environment.
PASARR Not Updated After Bipolar Diagnosis: A resident admitted for PT after a total knee arthroplasty had bipolar disorder documented in the H&P, MDS, and psych note, but the facility did not submit a new Level 1 PASARR to reflect the diagnosis. The existing PASARR screening stated the resident did not have a diagnosed mental disorder, and the ADON acknowledged the mismatch with the facility’s PASARR policy.
A resident with cognitive impairment and PRN hydrocodone-acetaminophen had a care plan that did not include the drug’s black box warnings, and the DON stated the risks of addiction, abuse, overdose, and death were omitted. Another resident on a CCHO, NAS, soft and bite-sized, thin diet was observed with an unpasteurized egg in the refrigerator, stated he regularly brought whole eggs from outside and microwaved them, and the DON confirmed the care plan did not address outside raw food being brought into the room.
Failure to Update Fall Care Plan After Incident: A resident with a hx of falls, HTN, and need for assistance with toileting and dressing had a nighttime fall after going to the bathroom unassisted. The resident reported her feet caught in the wheelchair footrests, while the ADON stated the wheelchair was unlocked and in the way, causing the resident to lose balance and hit her head. The resident’s fall-related care plan was not updated to address the contributing factors.
Incomplete Zosyn Antibiotic Treatment Plan: A resident receiving IV Zosyn for PNA lost IV access, and nursing notes documented that two scheduled doses could not be given while staff awaited a midline. The RN said the missed midnight and 6 a.m. doses were not administered, and the DON found the resident received only 18 of 20 ordered doses with no documentation that the MD was contacted to clarify whether the antibiotic course should be extended to complete the regimen.
Unsafe Environment and Inadequate Accident Prevention: A resident with seizures and MS had care plans calling for a safe environment and padded side rails, but only one rail was padded while the other remained unpadded metal. Another resident with a history of falls was involved in a fall after her feet caught in an unlocked wheelchair’s footrests while she tried to go to the bathroom unassisted, and staff identified the wheelchair as a contributing factor.
Improper Foley Catheter Positioning and Urine Backflow: A resident with an indwelling urinary catheter had tubing with a u-shaped dependent loop, causing urine to pool and back up toward the resident. The resident had diagnoses including UTI and MS, and the care plan directed staff to maintain proper catheter alignment for drainage. An LVN and the DON both stated the tubing/bag positioning was incorrect and could allow urine to back up, contrary to the facility's catheter care policy requiring unobstructed urine flow.
A resident with HTN received Metoprolol 25 mg even though the SBP was below the ordered hold parameter of 110 mmHg. The eMAR showed the medication was administered when the BP was 108/56, and the ADON stated it should have been held per the MD order to avoid hypotension. Facility policy defined medication errors as administration outside the ordered parameters.
Unlabeled tablets were found loose in the bottom of Medication Cart 1 during survey observation. An LVN stated the medications should not have been stored that way, and the DON stated medications should be kept in their packaging because unlabeled items could not be identified or linked to a resident. The facility policy also stated medications should remain in the containers dispensed by the pharmacy.
Fruit Fly Observed in Dry Food Storage: A fruit fly was observed in the residents' dry food storage during an observation with the DS. The DS stated the kitchen should be fly-free because flies could cause cross-contamination and residents could get sick from contaminated food. The facility's Pest Control Policy states it maintains an ongoing pest control program to keep the building free of insects and rodents.
Insufficient Bedroom Space Per Resident: Surveyors found that multiple resident bedrooms did not meet the required square footage per resident, including several double-occupancy rooms and two 4-bed rooms with less than the minimum space required. The facility had submitted a waiver request for the affected rooms, and both resident council input and staff interviews reported no concerns about room size. The facility policy states double rooms must provide at least 80 sq. ft. per resident.
A resident with a history of falls, impaired cognition, and significant physical limitations was not provided with a properly functioning bed pad alarm as ordered by the physician. Staff confirmed the alarm was not working during inspection, and the responsible manager had not checked the alarm that day, contrary to facility policy requiring daily checks.
A resident with paraplegia, anxiety, and depression, who reported trauma from a gunshot injury, did not receive a complete trauma care evaluation or a care plan addressing past trauma and triggers. Despite the resident expressing that loud noises were a trigger, the trauma assessment was left incomplete and no individualized care plan was developed, contrary to facility policy. Both the SSD and DON acknowledged these omissions.
A facility failed to provide privacy during medication administration for four residents, violating their right to dignity and respect. An LVN was observed checking blood sugar levels and administering insulin without closing privacy curtains, despite the facility's policy on treating residents with respect and dignity.
The facility failed to revise care plans for two residents' activity needs and one resident's nutritional needs. Two residents with significant dependencies did not have their activity care plans evaluated or renewed quarterly, as required. Another resident with multiple health issues had a care plan that did not account for dialysis-related weight fluctuations, despite being at risk for malnutrition. These deficiencies were identified through interviews and record reviews, indicating non-compliance with facility policies.
The facility failed to properly label and store medications, including an Aplisol vial without an open date, an insulin pen not refrigerated, and Artificial Tears labeled with room numbers instead of resident names. Additionally, medications for a discharged resident were not removed from the cart, risking administration errors.
A facility failed to follow infection control guidelines when an RN did not remove an isolation gown and gloves after administering medication to a resident on enhanced barrier precautions. The resident, who was moderately cognitively impaired and dependent on staff, was receiving treatment for discitis and a urinary tract infection. The RN's actions were against the facility's policy, which requires removing PPE before exiting a resident's room to prevent infection spread.
A facility failed to complete a resident's Quarterly MDS assessment within the required timeframe, potentially affecting care provision. The resident, with asthma and Parkinson's, had an ARD of 11/29/2024, but the assessment was completed on 12/26/2024, beyond the 14-day requirement. This delay was confirmed by the MDS Nurse during interviews and record reviews.
A facility failed to develop a comprehensive care plan for a resident using bed rails, as required by their policy. The resident, who had intact cognitive skills but was dependent on staff for daily activities, did not have a safety assessment for the bed rails attached to their bed. This oversight was confirmed by the DON, who acknowledged the potential risk of injury due to entrapment. The facility's policy requires care plans to include medical, nursing, and psychosocial needs, but this was not followed in this case.
A resident with paraplegia, anxiety, and depression was not provided with consistent access to Bible studies, an activity of choice, due to a possible COVID-19 outbreak at the religious institution. The Activity Director could not provide participant lists or contact information, and the Director of Nursing acknowledged the importance of offering activities of choice to prevent increased anxiety and depression.
A resident in an LTC facility was found storing multiple bottles of supplements and vitamins at their bedside, accessible to other residents. Despite having intact cognition, the resident's medication storage posed a risk, as confirmed by staff interviews. Facility policies indicated that such storage is only allowed when it does not present a risk to other residents, which was not adhered to in this case.
A resident with multiple health conditions, including cerebral infarction and gastrostomy malfunction, was at risk of infection due to the facility's failure to cap the enteral feeding tube after disconnection. The oversight was confirmed by an LVN, IP, and DON, who acknowledged the increased risk of healthcare-acquired infections due to this deficiency.
Pest Control Program Not Effective in Resident Room
Penalty
Summary
The facility failed to maintain a pest-free environment by not ensuring effective pest control in one sampled resident room. Resident 3 was admitted with diagnoses including left total hip replacement, osteoarthritis, and diabetes mellitus, and was documented as having the capacity to make decisions and communicate needs. During the survey, a CNA reported seeing a roach crawling on the wall in Resident 3's room and stated she captured and killed it on the floor while a family member was present. Resident 3 and the family member also reported that a couple of days earlier they had seen a roach on the ceiling and notified staff, after which staff entered the room and killed it. Record review showed the facility's pest control service report noted concerns about American roaches and found live roach activity in drains, with a recommendation that drains be kept clean. The technician stated that increased roach activity, including possible movement into the building through drains, cracks, or gaps, could occur after treatment. The Infection Control Preventionist stated that any observed live or dead roaches should be reported to supervisory or maintenance staff for communication with pest control services, and the facility policy stated that the facility shall maintain an effective pest control program to keep the building free of insects and rodents.
Inaccurate Fall Risk Evaluation After Documented Fall
Penalty
Summary
Licensed nurses failed to accurately complete a Fall Risk Evaluation for a resident who had been admitted originally on 10/10/2020 and readmitted with diagnoses including CHF, hypertension, and DM. The resident’s MDS dated 3/23/2026 indicated cognition was intact and that the resident required setup or clean-up assistance for all ADLs. A Change of Condition Assessment Form dated 5/2/2026 documented that at 10:30 p.m. RN 1 found the resident sitting on the floor after the resident reported seeing a roach on the floor while lying in bed, reaching for it, falling out of bed, and breaking the footboard. A Fall Risk Evaluation dated 5/4/2026 was completed by the DON and marked the resident as having no falls in the past three months, despite the documented fall on 5/2/2026. The assessment totalled seven points and did not identify the resident as high risk for falls. During interview and record review on 5/20/2026, the DON stated the fall should have been included in the history of falls section and said the omission occurred because she was confused when completing that portion of the assessment. The facility policy on assessing falls and their causes stated that when a resident falls, a falls risk assessment and appropriate interventions to prevent future falls should be recorded.
Delayed Stat X-Ray After Resident Fall
Penalty
Summary
The facility failed to provide radiology services in accordance with a physician’s stat order for one resident after a fall. The resident was admitted with diagnoses including a right arm fracture, epilepsy, dementia, and a history of falling, and had severely impaired cognition with dependence on staff for multiple activities of daily living. After staff found the resident sitting on a landing pad beside the bed, the resident later reported left foot pain rated 4 out of 10, and swelling was noted to the left dorsal foot during skin assessment. The resident’s physician was notified and a stat x-ray of the left foot was ordered at 4:21 p.m. The radiology study was not completed until the next morning at 9:49 a.m. The DON stated that stat x-rays should typically be completed within four hours and that if not completed in that timeframe, nursing staff should notify the physician; however, that notification was not completed for this resident. The facility’s policy stated that diagnostic services are to be promptly carried out as ordered and that emergency requests must be labeled stat to assure prompt action.
Failure to Report Roach Sightings in Resident Room
Penalty
Summary
The facility failed to implement and maintain an effective infection prevention and control program when CNA 1 did not report a roach observed in Resident 3’s room. Resident 3 was admitted with diagnoses including left total hip replacement, osteoarthritis, and DM, and the H&P indicated the resident had the capacity to make decisions and communicate needs. During interview, CNA 1 stated she saw a roach crawling on the wall in the resident’s room, captured it while wearing gloves, and killed it on the floor while a family member was present at the bedside. Resident 3’s family member stated that a couple of days earlier they had observed a roach on the ceiling and notified staff, and staff entered the room and killed the roach. CNA 1 later stated she intended to report the incident to the MS but forgot and left the facility without notifying anyone. The MS stated no verbal or written reports, including maintenance logs, had been received regarding roach activity from staff, including CNA 1. The facility’s pest control report documented American roach activity in exterior drains and noted that increased pest activity, including potential activity within the facility, could be expected for several days following treatment. The DON stated the incident should have been reported immediately to supervisory and maintenance personnel for follow-up. The ICP stated that any sighting of live or dead roaches should be reported promptly to supervisory staff or maintenance personnel for communication with pest control services, and that failure to report such sightings is inconsistent with the facility’s infection prevention and control program.
Failure to Notify Resident Representative After Fall With Injury
Penalty
Summary
Facility staff failed to notify the resident representative after a resident was found on the floor mat next to the bed with an injury. Resident 1 was admitted and later readmitted with diagnoses including DM, muscle weakness, need for assistance with personal care, dysphagia, UTI, history of falling, and depression. The resident’s H&P stated the resident had the capacity to understand and make decisions, while a later MDS indicated severely impaired cognition and dependence or need for assistance with multiple activities of daily living. On 4/29/2026 at about 1:15 a.m., Resident 1 was found on the floor mat next to the bed after yelling for help and stated that she slid from the bed because she wanted to go to the restroom. The resident had a 3 cm skin tear on the right upper arm near the elbow and treatment was rendered. The change of condition form documented the event, and the resident was listed as self-responsible. During interview, the responsible party stated the facility did not inform them of the fall and they learned about it only after calling later that morning. The DON confirmed staff should have notified the responsible party when the resident was found next to the bed. The facility policy stated the resident, attending physician, and resident representative are to be promptly notified of changes in condition and that the nurse will notify the resident’s representative when the resident is involved in an accident or incident resulting in injury.
Delayed Communication of Lab Results
Penalty
Summary
The facility failed to ensure that laboratory results for one sampled resident were communicated to the physician in a timely manner. Resident 1 was admitted and later readmitted to the facility with diagnoses including type 2 DM, muscle weakness, need for assistance with personal care, dysphagia, UTI, history of falling, and depression. The resident’s H&P stated the resident had the capacity to understand and make decisions, while the MDS later indicated severely impaired cognition and dependence or assistance with several activities of daily living. A CBC and BMP were completed for Resident 1 and the laboratory report showed the results were sent to the facility at 9:41 p.m. RN 3 reviewed the results the next morning at 6:59 a.m. and confirmed during interview that he then sent the results to the resident’s physician. RN 3 stated he worked the 7 a.m. to 3 p.m. shift. The DON reviewed the same laboratory results and confirmed they were received by the facility on the evening they were sent, and stated the results should have been sent to the physician as soon as possible and should not have waited until the next day. The facility policy stated that when test results are provided to the facility, the attending physician shall be promptly notified and that the charge nurse receiving the results is responsible for notifying the physician.
Incomplete Documentation of Physician Response to Change in Condition
Penalty
Summary
The facility failed to ensure that one sampled resident had complete documentation on the change of condition form. Resident 1 was admitted on 9/15/2025 and readmitted on 9/27/2025 with diagnoses including type 2 DM, muscle weakness, dysphagia, UTI, history of falling, and depression. The resident’s H&P dated 9/16/2025 indicated the resident had the capacity to understand and make decisions, while the MDS dated 3/23/2026 indicated severely impaired cognition and dependence or assistance with multiple activities of daily living. On 4/28/2026, the COC form documented that Resident 1 was unable to sit up, had chills and fever, denied pain or discomfort, had general weakness, and received acetaminophen 325 mg, 2 tablets, with the MD being informed. During interview and record review, the LVN confirmed completing the form and stated the RNS was informed and then notified the physician, but the physician’s response was not documented. The RNS stated the physician instructed staff to continue to monitor the resident, and the DON confirmed the nursing staff should have documented the physician’s response on the COC form to ensure continuity of care.
Controlled Substance Counts, Morphine Documentation, and Medication Reconciliation Errors
Penalty
Summary
Pharmaceutical services were not accurately and safely provided for a resident admitted with ankylosing spondylitis, dysphagia, and heart failure, and who was unable to make medical decisions. The resident’s hospital discharge medication list included multiple scheduled and as-needed medications, including morphine sulfate oral solution 10 mg/5 mL, 5 mL by mouth four times daily for chronic back pain. On admission, the physician instructed nursing staff by text to follow the hospital discharge medication list exactly. During review of the controlled drug documentation and medication administration records, the facility failed to ensure controlled substances were properly accounted for and documented. The Controlled Drugs Count Record for the month reviewed had blank nurse-on and nurse-off signature or initial lines for multiple shift changes. The facility’s Controlled Drug Record for Liquid Only documented morphine sulfate doses and remaining amounts, but the amount recorded did not match the bottle observed at the medication cart. The record showed 65 mL remaining, while the bottle contained 77 mL. The LVN stated this created a 12 mL discrepancy. The same record also showed morphine sulfate documented as given at 11:45 a.m., while the eMAR showed administration at 1:00 p.m.; the LVN stated the medication was actually given at 1:45 p.m. but was incorrectly charted as 11:45 a.m. The facility also did not verify the last dose of medications administered at the acute care hospital or determine the proper timing of the next scheduled dose after admission. The DON stated staff should have clarified the last hospital dose to know whether another dose was due or whether it was safe to administer the next dose. The DON was unable to provide documentation showing staff verified the last dose or when the next dose was due, and confirmed the resident did not receive any medications on the day of admission based on the eMAR. Facility policy stated controlled medications are counted at the end of each shift with both nurses signing the count record, and medications are to be administered safely, timely, and within one hour of the prescribed time unless otherwise specified.
Baseline Care Plan for Pain Not Implemented
Penalty
Summary
The facility failed to implement the baseline care plan for one resident after admission. The resident was admitted with diagnoses including ankylosing spondylitis, dysphagia, and HTN, and the H&P stated the resident was able to make needs known but was unable to make medical decisions. The baseline care plan identified alteration in comfort/pain related to chronic lower back pain and opioid use, with interventions to administer pain medication as ordered or needed, notify the physician if pain medications were ineffective, monitor and assess for pain daily, and monitor for adverse reactions and side effects. The resident’s clinical admission record showed the resident arrived by ambulance with a family member and verbally reported pain while demonstrating protective body movements, but the pain level and pain notes sections were left blank. The Controlled Drug Record showed the resident received the first dose of hydrocodone-acetaminophen on 5/9/2026 at 12:00 p.m. The Controlled Drug Record for liquid morphine showed multiple administrations beginning on 5/9/2026 and continuing through 5/11/2026. During interview and record review, the DON stated the baseline care plan interventions for alteration in comfort related to chronic lower back pain and opioid use were not implemented because there was no documentation that staff monitored or assessed the resident’s pain daily from admission through the night shift on 5/11/2026. The DON stated the potential outcome of not monitoring or assessing pain is that staff would not know whether the resident is experiencing pain, which may prevent staff from providing the necessary care, and that not implementing the care plan interventions may result in ineffective pain management.
Pain assessment and medication documentation were not completed for a resident with severe back pain
Penalty
Summary
The facility failed to complete a pain assessment when a resident verbalized pain on admission. The resident was admitted with diagnoses including ankylosing spondylitis, dysphagia, and hypertension, and the history and physical noted the resident could make needs known but could not make medical decisions. On the clinical admission record, the resident arrived by ambulance with a family member and verbally reported pain while also demonstrating protective body movements, but the pain level and pain notes were left blank. The resident’s discharge medication list from the hospital included acetaminophen as needed for mild pain, hydrocodone-acetaminophen (Norco) as needed for moderate to severe pain, and morphine sulfate oral solution four times daily for chronic back pain. Text messages showed the RN notified the physician of the admission and the physician instructed staff to follow the hospital discharge medication list exactly. Despite this, the resident did not receive the first documented dose of hydrocodone-acetaminophen until the next day at noon, and the family member stated the resident had severe lower back pain and did not receive pain medication for about 18 hours after admission. Record review showed the controlled drug records documented administration of hydrocodone-acetaminophen and morphine sulfate, but the eMAR did not document administration of Norco or morphine sulfate during the reviewed period. The eMAR and nurses’ notes also lacked documentation of daily pain assessments, including pain level, location, intensity, and whether medication was effective. The DON stated there was no documentation of pre-administration and post-administration pain assessments for the first dose of hydrocodone-acetaminophen, and no documentation that licensed nurses provided nonpharmacological interventions or pain medications available from house stock or the emergency medication kit during the period after the resident reported pain.
Physician Did Not Complete Required Initial Visit Within 72 Hours
Penalty
Summary
The facility failed to implement its policy titled Physician's Untimely Visit for one sampled resident who was admitted with ankylosing spondylitis, dysphagia, and hypertension. The resident's face sheet showed admission to the facility on 5/08/2026, and the clinical admission record documented arrival by ambulance with a family member. A text message from RN 1 to Physician 1 on the day of admission notified the physician that the resident had been admitted, and the physician replied with instructions to follow the hospital discharge medication list exactly. During interview and record review on 5/12/2026, the DON stated that the resident's physician had not conducted a visit from the admission date through 5/12/2026, which was more than 72 hours after admission. The DON also stated she was unable to provide documentation showing that either the attending physician or the medical director had visited the resident during that period. The facility policy reviewed during the investigation stated that physician visits are to be completed within 72 hours of admission and that the administrator shall notify physicians to comply with facility policy and state and federal regulations.
Incomplete Admission Documentation and Medical Record Entries
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one sampled resident by leaving the Clinical Admission Record incomplete and by not completing admission notes. The resident’s face sheet showed admission to the facility with diagnoses including ankylosing spondylitis, dysphagia, and hypertension. The History and Physical dated 5/11/2025 stated the resident was able to make needs known but was unable to make medical decisions. In the Clinical Admission Record dated 5/08/2026 and timed 5:24 p.m., the resident was documented as arriving by ambulance with a family member and verbally reporting pain with protective body movements, but the pain level and pain notes sections were left blank. The same Clinical Admission Record had 40 of 43 sections left blank, including mental status, skin assessment, mood and behavior, and mobility. During interview and record review, the DON stated the record contained 43 sections and only three were completed by RN 1, and that all sections should have been completed as soon as possible after admission. The DON also stated she could not provide documentation that licensed nurses completed admission notes accurately and completely, including the date and time of admission, admitting diagnosis, general condition on admission, time medications were ordered from the pharmacy, and time physician orders were received and reviewed. The facility policy required the admitting nurse to document preliminary resident information upon admission and to keep the original admission note on the resident’s chart, and the DON stated RN 1 did not follow the policy.
Missed and Undocumented Medication Administration
Penalty
Summary
The facility failed to ensure that Resident 1 received Methadone Hydrochloride 5 mg every 8 hours as ordered for right knee aching pain. Resident 1 was admitted with diagnoses including cerebral infarction, hypertension, glaucoma, and malignant neoplasm of the stomach. The record showed Resident 1 had a physician order for Methadone and that the April 2026 MAR was left blank for the scheduled 5:00 a.m. dose on 4/27/2026, with no nursing signature documenting administration. Resident 1’s records also showed that he was able to make decisions regarding ADLs in the H&P, while the MDS indicated moderately impaired cognition and need for moderate assistance with eating and maximum assistance with oral hygiene, toileting, and personal hygiene. During interview, Resident 1 stated that nursing staff were occasionally late administering pain medication during the night shift. During the concurrent interview and record review, the Administrator confirmed the Methadone dose scheduled for 4/27/2026 was left blank and had not been signed off, and stated the medication should have been received as ordered. The facility also failed to ensure Resident 2 received scheduled medications as ordered, including Apixaban 2.5 mg twice daily for CVA prophylaxis, Famotidine 20 mg twice daily for GERD, Losartan Potassium 25 mg twice daily for hypertension, and Modafinil 100 mg each morning for narcolepsy. Resident 2’s diagnoses included right-sided hemiplegia, narcolepsy, atrial fibrillation, dementia, and hypertension, and the H&P stated Resident 2 did not have the capacity to understand and make decisions. The April 2026 MAR showed blank entries for these morning doses on 4/22/2026 and 4/27/2026, and the Administrator confirmed the doses were not signed off as administered and that nursing staff are required to document on the MAR immediately following administration.
Failure to Monitor and Document I/O for Resident on Fluid Restriction
Penalty
Summary
The deficiency involves the facility’s failure to monitor and document intake and output (I/O) for a resident on physician-ordered fluid restriction, in accordance with professional standards and facility policy. The resident was originally admitted with diagnoses including acute on chronic diastolic CHF, chronic pulmonary edema, and orthostatic hypotension, and was dependent on staff for ADLs but cognitively intact. On readmission, the RN hospital-to-facility admission report and physician’s telephone orders specified a fluid restriction of 750 ml per day due to chronic pulmonary edema, and a subsequent physician’s order directed that no water pitcher be left at the bedside. The facility’s I/O record for this resident showed monitoring and documentation from 12/30/2025 to 1/7/2026 only. During interviews and concurrent record reviews, an LVN confirmed that licensed nurses did not monitor or document the resident’s I/O after 1/7/2026 despite the ongoing fluid restriction order. An RN similarly stated that, given the 750 ml per day fluid restriction and the order for no bedside water pitcher, licensed nurses should have continued to monitor I/O closely, particularly in light of the resident’s heart problems and history of edema. Review of facility policies titled “Fluid Intake and Output” and “Resident Hydration and Prevention of Dehydration” showed that intake and output must be recorded for residents with restricted fluids as ordered by the physician, with daily I/O documented for a minimum of 30 days, and that nursing will monitor and document fluid intake when inadequate intake or dehydration concerns are present. The facility did not follow these policies for this resident after 1/7/2026.
Inaccurate Fall Risk Evaluations for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to accurately complete fall risk evaluations for two residents, contrary to its policy for promoting safety and reducing falls. For the first resident, who had diagnoses including acute on chronic diastolic CHF, chronic pulmonary edema, and orthostatic hypotension, the admission record showed readmission on 12/30/2025 and an MDS indicating intact cognition and dependence on staff for ADLs. The Fall Risk Evaluation dated 12/30/2025 documented that there was “no noted drop between lying and standing” for systolic blood pressure, even though the resident was not able to stand. The gait/balance section was left entirely unmarked, including the option for “not able to perform function,” and the medications section was also left blank, including the option indicating no relevant medications. The resulting fall score was four, which did not place the resident in the high-risk category. During interview and concurrent record review, the RN who completed this evaluation stated that the resident was not able to stand at the time of the assessment. The RN acknowledged marking “no noted drop between lying and standing” for systolic blood pressure because there was no “non-applicable” option, and admitted not completing the gait/balance and medication sections. The RN further stated that the total score of four, indicating no risk of fall, was not correct and confirmed that assessments are used to establish the plan of care to reduce fall risks. These statements confirmed that the fall risk evaluation for this resident was not completed thoroughly or accurately as required by the facility’s process. For the second resident, who had combined systolic and diastolic CHF and hypertension, the admission record showed readmission on 12/29/2020 and an MDS indicating intact cognition, with moderate assistance needed for oral/personal hygiene and supervision or touching assistance for toileting hygiene, dressing, and toilet transfer. The Fall Risk Evaluation dated 12/22/2025 recorded the resident as ambulatory and continent and again indicated “no noted drop between lying and standing” for systolic blood pressure, resulting in a fall score of eight, which did not meet the facility’s threshold for high fall risk. In an interview, the resident reported sometimes going to the bathroom alone and being able to self-clean. During a concurrent interview and record review, the MDS nurse who completed the evaluation stated she did not measure the resident’s systolic blood pressure in both lying and standing positions and instead relied on blood pressure summaries from other nurses, which did not include standing readings. She acknowledged that, as a result, the fall risk evaluation was not done correctly to assess the resident’s fall risks. The facility’s policy on promoting safety and reducing falls emphasized the need for caregivers to understand key fall risk factors, including gait and balance disturbances and the importance of residents rising slowly from lying or sitting positions, underscoring the expectation for accurate assessment of these parameters.
Failure to Properly Document and Countersign Physician Telephone Order for Fluid Restriction
Penalty
Summary
The facility failed to ensure that a physician telephone order for a fluid restriction was properly documented, signed, and incorporated into the resident’s active physician orders. A resident with diagnoses including acute on chronic diastolic CHF, chronic pulmonary edema, and orthostatic hypotension was originally admitted and later readmitted with a hospital report indicating a fluid restriction of 750 ml per day. The resident’s MDS showed intact cognition and dependence on staff for ADLs. On readmission, the RN Hospital to RN Facility admission report documented the 750 ml/day fluid restriction, and a Physician’s Telephone Order form dated the same day also indicated a fluid restriction of 750 ml/day due to chronic pulmonary edema. However, the fluid restriction was not entered into the physician’s orders or reflected in the physician order recap covering the admission period. During interviews and record reviews, RN 1 stated he became aware of the fluid restriction from the hospital report but missed inputting the restriction into the physician’s orders. When reviewing the Physician’s Telephone Orders, RN 1 stated he did not transcribe the order and could not identify who did because there was no name or signature on the form. The ADON similarly could not determine who transcribed the telephone order, whether that person was a licensed nurse, or whether the order had been entered into the charting system, and confirmed the fluid restriction was not present in the physician order summary. The Medical Records Director reported that the white copy of the Physician’s Telephone Orders, which should have been returned within five days after the physician’s signature, could not be located, and there was no history of the fluid restriction order in the current or discontinued physician orders. The facility’s P&P required that telephone orders be received only by licensed personnel, reduced to writing with date, time, signature and title of the person transcribing, and countersigned by the physician at the next visit or electronically, which was not followed in this case.
Survey Results Not Posted or Communicated to Residents
Penalty
Summary
The facility failed to notify residents of the location of the most recent survey results and failed to post the results of the most recent standard survey. During the resident council meeting, four residents stated they did not know there were written survey results from the Department of Public Health or where the results were located. A review of the front desk area found a binder near the receptionist window, but the 2025 recertification survey results Form CMS-2567 were not in the binder. The AD stated she had told residents in the past to ask at the business office if they wanted to see survey results, but not that there was a specific area or book where they were kept. The DON reviewed the binder and confirmed last year's recertification survey results were not included, and stated the binder should be complete with last year's survey results and residents should be notified of their location. The residents involved in the council meeting included one resident admitted in 2018 and readmitted later with hypertension, who was cognitively intact and required setup assistance with oral hygiene; another resident with hypertension who was cognitively intact and required setup assistance with eating and oral hygiene; a third resident with hypertension who was moderately impaired in cognition and required setup assistance with eating; and a fourth resident with hypertension who was cognitively intact and required setup assistance with eating and oral hygiene. The facility policy titled, Survey Results, Examination of, stated that a copy of the most recent standard survey, including follow-up revisit reports and state-approved plans of correction, is maintained in a 3-ring binder located in an area frequented by most residents, such as the main lobby or resident activity room.
Failure to Protect PHI on Meal Tickets
Penalty
Summary
The facility failed to keep residents’ personal and medical records private and confidential when meal tickets containing protected health information were not consistently shredded before being discarded. During an observation on 1/28/2026 at 9:02 a.m., a Dietary Aide was observed throwing diet tickets into the trash. During an interview, the Dietary Supervisor stated the dishwashing process included sorting paper, waste, trash, and leftover food into the trash, and that meal tickets were supposed to be placed in a bin on the counter for shredding by the evening shift dishwasher. The Dietary Supervisor stated meal tickets found in the trash should not be there and acknowledged that the trash goes to the big dumpster. During a concurrent observation and interview on 1/29/2026 at 8:51 a.m., the Dietary Aide was again observed throwing meal tickets into the trash while sorting dishes. The Dietary Aide stated she threw the wet meal tickets in the trash but placed dry meal tickets in the bin for shredding. The Registered Dietitian stated all meal tickets should be placed in the bin for shredding for HIPAA purposes. The meal tickets contained residents’ diet information, names, room numbers, and pictures, and the facility policy stated PHI must be protected from unauthorized release or disclosure.
Failure to Provide Scheduled Bathing
Penalty
Summary
The facility failed to ensure that a dependent resident received scheduled bathing services. Resident 32 was admitted with diagnoses including fracture of the neck of the left femur, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, and need for assistance with personal care. The resident’s H&P stated he had the capacity to understand and make decisions, and the MDS indicated he could make himself understood and understand others. The MDS also showed he was dependent on staff for showering/bathing, toileting hygiene, lower body dressing, and bed mobility, and that choosing between bathing options was very important to him. During interview, Resident 32 stated he was not receiving showers as frequently as expected and said he was supposed to get showers twice a week because he likes feeling clean and fresh. CNA 1 stated the resident’s scheduled shower days were Wednesday and Saturday and that he required full assistance with bathing. Review of the Task ADL record showed showers documented on 1/7/2026, 1/14/2026, 1/17/2026, 1/21/2026, and 1/28/2026, with no check marks for shower, bed bath, refusal, or not available on multiple other dates during the review period. LVN 1 stated the check marks on the Task ADL indicated what occurred on the specified date and said the resident should have had showers twice a week and a bed bath on non-shower days unless he refused. LVN 1 acknowledged the resident did not get showered as often as he was supposed to. The care plan directed staff to provide showering/bathing as scheduled and assist as needed. Facility policies stated bathing promotes cleanliness, comfort, skin observation, dignity, and infection prevention, and the DON stated residents are scheduled for showers twice a week with additional showers as requested and a bed bath offered if a shower is declined.
IV Therapy and Line Dressing Care Deficiencies
Penalty
Summary
The facility failed to provide safe, appropriate administration of IV fluids and IV antibiotic therapy for three residents. The report identified deficiencies involving a retained IV saline lock after antibiotic therapy was completed for one resident, an unlabeled IV dressing for another resident with a midline catheter, and failure to change a PICC line dressing and bio patch every seven days for a third resident. The report states these practices were found during observation, interview, and record review. One resident was admitted with bacteremia and pneumonia and had an order for IV ceftriaxone through 1/19/2026, with documentation showing the medication was last given on 1/18/2026. During observation on 1/26/2026, the resident still had an IV in the left hand dated 1-6 and stated he was not sure why it remained in place since no medication was being given through it. RN 1 confirmed the last IV medication had been given on 1/18/2026 and stated the IV should not remain in place for an extended period unless specifically ordered by the physician. The DON reviewed the facility policy and stated the IV should have been discontinued when the ordered doses were completed. Another resident was admitted with pneumonia and had orders for IV Zosyn and insertion of a midline catheter for ongoing IV antibiotic therapy. During observation, RN 1 found the midline dressing had no date on it and stated there should be a date from the insertion or the last dressing change. RN 1 also stated IV and central line dressings are to be changed every 7 days. Review of the insertion record showed the midline was started on 1/15/2026, and RN 1 stated he did not know if or when the dressing had been changed. The DON stated the site should have been labeled with a date so licensed nurses would know when the dressing needed to be changed. A third resident was admitted with osteomyelitis of the vertebra, spinal fusion, and sepsis and had a PICC line for IV antibiotic treatment. The physician ordered PICC line site care and transparent dressing changes every seven days. During observation, the PICC dressing was labeled 1/10/26, and the resident stated it had been several weeks since the dressing was last changed. RN 1 stated the dressing should have been changed every seven days and that the resident could develop pain or infection from the dressing not being changed as ordered. The DON stated PICC line dressings should be changed every seven days with sterile technique and that nurses must follow the physician's orders.
Failure to Provide Ordered Oxygen Therapy
Penalty
Summary
Resident 5 was admitted with diagnoses including asthma, seizures, and dementia, and her care plan indicated she was receiving oxygen due to asthma with interventions to check the oxygen flow rate per shift, change tubing weekly, and administer oxygen as ordered. During observation, she was lying in bed with an oxygen cannula on and set at 2 L/min, and she stated she had been using oxygen continuously since before she arrived at the facility and needed it because of asthma. However, review of her physician orders showed an order for oxygen on 1/26/2026 and a prior oxygen order that had been discontinued on 3/13/2024, with no oxygen order in place between those dates. During interview and record review, the ADON stated she called the physician and obtained an order for continuous oxygen therapy because Resident 5 required continuous oxygen and there was not an order for nurses to give it. The ADON stated oxygen therapy is considered a medication and requires a physician's order with instructions on how much and how to give it. The ADON also reviewed past orders and stated the last oxygen order had been discontinued on the same date it was written, and she was unsure why it was discontinued. Resident 77 was admitted with diagnoses including respiratory failure, syncope and collapse, and type 2 diabetes mellitus. His records showed he had capacity to understand and make decisions, and his care plans identified him as at risk for respiratory distress and cardiac distress, with directions to apply oxygen as needed or ordered and provide oxygen inhalation as ordered. Although his order summary showed an order for oxygen at 2 L/min via NC, during observation he was found without his oxygen NC, which was on the floor next to his bed and connected to the oxygen concentrator. The LVN stated Resident 77 was on continuous oxygen therapy and should have the NC on, and the DON stated he would not receive the prescribed oxygen when he was not wearing the NC.
Kitchen Staff Competency Deficiencies in Thawing and Sanitizer Testing
Penalty
Summary
The facility failed to ensure kitchen staff were routinely trained and evaluated for competency in food and nutrition services. During observation, unsealed fish and meat were thawed at the same time in the same meat preparation sink with running water. When interviewed, the cook stated she placed the meat in the sink with cold running water, did not know the water temperature during thawing, waited 20 to 25 minutes, and checked whether the meat felt defrosted before cooking it. She stated she discarded the chicken because it thawed in the same sink at the same time but cooked the fish, and she did not log or monitor the water temperature, meat temperature, or total thawing time. The Dietary Supervisor stated the facility had three thawing methods, including thawing in the sink with running water, and said staff should use cold running water so thawing meats were not in the danger zone. The supervisor also stated thawing in the sink should not be 2 hours because that was safest, but acknowledged the facility did not log or monitor the temperature of thawed meats and that cooks knew it. The facility policy on thawing food required potable running water at 70 degrees F or lower, sufficient velocity to agitate and float off loose food particles, and leak-proof containers or pans to prevent cross-contamination. The Food Code cited in the report required thawing under running water at 70 degrees F or below and limited the time food could remain above 41 degrees F. The report also found staff could not verbalize and demonstrate how to check chlorine concentration according to the test strip manufacturer's directions. During observation of dishwashing, a Dietary Aide placed chlorine test strips on the tray surface and agitated them four times before comparing the color chart and stating the solution was 50 ppm. The Dietary Supervisor stated staff were supposed to dip the test strips in the solution according to the manufacturer's guidelines. When asked to demonstrate, the aide was unable to do so until coached by the supervisor, and the test then read about 10 ppm. The manufacturer's instructions required dipping the strip into the solution without agitation, blotting dry, and comparing immediately to the color chart. The supervisor stated the aide did not follow the manufacturer's guidelines and that an inaccurate reading could leave bacteria not killed by the sanitizer.
Food Served at Improper Temperatures and Dry Meat
Penalty
Summary
Food and drink were not prepared in a manner that conserved appearance, flavor, and temperature when trayline items were served at improper temperatures and the beef roast was dry. During observation of the trayline, staff were seen placing milk, desserts, juice, and fruit on trays. On concurrent temperature checks, milk measured 42 F, another carton measured 41.2 F and 39 F, juice measured 61 F, and triple fruit crisp measured 98 F. The Dietary Supervisor stated the cold foods were not at a palatable temperature because staff forgot to place the cold food in an ice bath during trayline service, and stated residents would not eat the food and could have dissatisfaction and weight loss over time. The herb crusted beef roast listed on the menu for regular and therapeutic diets was observed to be dry on the pan. The Dietary Supervisor stated the beef looked dry without gravy and remained dry even with sauce, and that residents would not eat dry meat, leading to poor intake and weight loss as a potential outcome. Resident 13, who was admitted with HTN, anemia, and a sacral pressure ulcer, was assessed as understanding others and making self-understood, needing set-up and clean-up assistance with eating, and being on a regular soft bite-sized diet with thin liquids. Resident 13 stated the meat was very chewy and should be tender, liked the flavor, but could not swallow it. The RD stated that exceeding time and temperature with cooking meats could result in dry meat and loss of protein, iron, and B vitamins, and that residents would not get the nutrients from the dry beef.
Unsafe Kitchen Storage, Preparation, and Sanitation Practices
Penalty
Summary
The facility failed to maintain safe and sanitary kitchen conditions in multiple areas of food storage, preparation, and warewashing. During observations in the dry storage area, one of three racks was cracked and corroded with rust, and food particles were observed on the floor. The Dietary Supervisor stated the rack was breaking apart and that the dry storage area should be free from food particles. The facility’s policies and the Food Code excerpts reviewed in the report required clean, dry storage areas and equipment that were in good working condition and easy to clean. Kitchen equipment and utensils were observed with accumulated soil and residue. Thirteen food storage bins had old sticker residue, nine carts had old tape residue, drying racks were dusty, vents by the dishwashing area had dust buildup, the coffee spout had dirt buildup, and condiment containers had sugar, salt, pepper, and sweetener debris. The Dietary Supervisor stated these items should be free from debris and that the residue and dust could contribute to cross-contamination. The report also noted that seven dented cans were stored with non-dented cans, and 57 meal trays had cracks and had lost some of their glaze. The Dietary Supervisor stated the trays were not a cleanable surface and that dented cans should have been separated for food safety. Additional observations showed pans stacked wet instead of being air-dried, and frozen foods were thawed improperly in the sink. Fish and chicken were thawed at the same time in the same sink, and fish was observed thawing without being in a sealed container. Staff interviews indicated they did not monitor thawing time and temperature and that this had been their practice. During dishwashing, a dietary aide used chlorine test strips incorrectly by agitating them on the tray surface instead of following the manufacturer’s directions to dip them into the solution without agitation. In the resident refrigerator, red salsa and cheddar cheese snacks were found without names or dates. The report states these failures had the potential to result in harmful bacterial growth and cross contamination in residents who received food and ice from the kitchen.
Failure to Control Outside Food Storage and Raw Egg Use
Penalty
Summary
The facility failed to enforce its policy for food brought in by family and visitors when Resident 95 brought unpasteurized whole eggs into the facility and cooked them in the microwave without staff knowledge. Resident 95 was admitted and readmitted with diagnoses including type 2 diabetes, acute kidney failure, and essential hypertension. The resident’s MDS indicated he understood others and could make himself understood, but he needed supervision and touching assistance when eating. His diet order was consistent carbohydrate, no added salt, soft and bite-sized texture, with thin liquids. During observation, an unpasteurized whole egg labeled with Resident 95’s room number was found in the refrigerator in the activities room. The Dietary Supervisor stated the egg had just been brought in that day. Resident 95 stated he brought whole eggs to the facility one or two times a week and heated them in the microwave, and said he did not need to inform nurses when he brought food from outside. The Administrator stated staff were supposed to monitor the refrigerator by checking that food was in good condition and labeled with the resident’s name, date brought in, and expiration date. The DON stated residents were supposed to check in at the front office, nurses were to check outside food against the resident’s diet, and residents were not allowed to bring raw food or cook because of safety. The Assistant Activities Director stated she checked the resident refrigerator once a day for expiration dates, labeling, dating, and smell, but she was not aware Resident 95 had brought raw whole eggs. The DON stated the resident did not check in with nurses about the raw eggs and said the facility uses pasteurized eggs because unpasteurized eggs could cause salmonella poisoning. The Registered Dietitian stated Resident 95 was not compliant with the diet order and brought food from outside, and noted he cooked the eggs in the microwave. The facility policy stated only cooked or packaged items were allowed to be stored and no raw food was allowed in the resident refrigerator or freezer.
Inaccurate PICC Care Documentation and Unauthorized Medication Charting
Penalty
Summary
The facility failed to maintain accurate medical records for a resident receiving IV antibiotic therapy through a PICC line. The resident was admitted with diagnoses including osteomyelitis of the vertebra, spinal fusion, and sepsis, and the history and physical indicated the resident had capacity to understand and make decisions and was admitted for IV antibiotic treatment. The MDS indicated the resident made herself understood and understood others, was dependent on staff for several activities of daily living, took a high-risk antibiotic drug, and had a PICC line. The resident’s care plan and physician’s orders required PICC line dressing care every seven days. During observation, the resident had a PICC line in the left upper arm, and the dressing was labeled as last changed on 1/10/2026. The resident stated it had been several weeks since the dressing was changed and that it was slightly uncomfortable. The RN observed the dressing and stated it should have been changed every seven days. The RN later reviewed the January MAR and stated he worked on 1/13/2026 and 1/20/2026, but he had forgotten to change the actual PICC dressing on both dates and had mistakenly documented that he did so. The DON stated PICC dressings should be changed every seven days with sterile technique and that nurses must chart accurately. The facility also failed to safeguard medical record information when IV medication administration was documented under a nurse’s login ID while that nurse was not working in the facility. For another resident ordered Zosyn IV for pneumonia, the medication audit report showed the RN documented doses at times when his timecard showed he was not on duty. Nursing progress notes documented that the resident’s IV access was no longer present and that the scheduled IV antibiotic could not be administered. The RN stated he was not in the facility at the times the medication was charted and could not explain why his signature appeared. The IP observed the electronic record system left open with another user logged in, and stated nurses should sign out when finished documenting to protect patient information and prevent medication errors under another nurse’s login.
Infection Control Lapses With Medication Tube and Oxygen Cannula
Penalty
Summary
Infection prevention and control standards were not maintained when a medication tube was brought into a resident’s room, used to apply diclofenac sodium 3% external gel to both knees, and then returned to the medication cart without being cleaned. The resident had been admitted with diagnoses including osteomyelitis of the vertebrae, sepsis, and a UTI. The resident’s MDS showed moderately impaired cognition and dependence for oral hygiene, toileting, dressing, footwear, and personal hygiene, with substantial assistance needed for eating. During a concurrent observation and interview, an LVN brought the tube into the room, placed it on a table inside the room, applied the gel to the resident’s knees, and then returned the tube to the medication cart drawer. The LVN stated the medication tube should be cleaned before returning it to the medication cart because it had been touched and had been on the resident’s table. The DON later stated the medication tube should have been disinfected before returning it to the medication cart and that anything taken into the resident’s room should be disinfected before returning to the cart to prevent the spread of infection or bacteria. In a separate observation, a resident’s O2 nasal cannula was found touching the floor next to the bed while connected to the O2 concentrator and set at 2 liters per minute. The LVN stated the cannula should not be touching the floor because the floor is dirty and the cannula had been contaminated, and that it should always be kept clean and off the floor for infection control. The DON stated infection control practices should always be followed and that the cannula found on the bedside floor placed the resident at risk for infection.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to ensure resident dignity and respect for two residents when one resident who preferred to wear her own clothing was repeatedly observed dressed in a hospital gown. Resident 9 was admitted with diagnoses including Parkinson’s disease, hypertension, and chronic kidney disease. Her H&P indicated she could make needs known but could not make medical decisions, and her MDS showed she could usually make herself understood and usually understand others. The MDS also indicated she was dependent for showering and toileting hygiene and required substantial to maximal assistance with dressing, oral hygiene, and personal hygiene. Her care plan included interventions to allow her to be active in decision-making and to encourage choices of clothes as capable. Resident 9 was observed on multiple occasions in her room, the activity room, and the lobby wearing a hospital gown. During an interview, she stated she would like to be wearing her own clothes. When a CNA checked her closet, a pair of purple pants and a black shirt were found inside, and the CNA stated the resident did not have personal clothing and would be changed into her own clothing. The ADON stated that hospital gowns are typically worn in a hospital setting and that the facility is the residents’ home, where residents have the right to dress as they would in their own homes. The facility also failed to protect the dignity and privacy of Resident 77, who was observed lying in bed sleeping in public view wearing only an incontinent brief and no clothing. Resident 77 was admitted with diagnoses including respiratory failure, syncope and collapse, and type 2 diabetes mellitus. Her H&P indicated she had the capacity to understand and make decisions, and her MDS showed dependence for bathing and toileting and substantial to maximal assistance with lower body dressing. Her care plan included interventions to maintain privacy and respect rights. An LVN stated the resident should be dressed in clothing and the curtain drawn when unclothed to maintain privacy and dignity, and the DON stated the resident should not have been in public view without clothing and wearing only an incontinent brief.
Broken Call Light Button Left Resident Uncomfortable
Penalty
Summary
The facility failed to provide a comfortable environment for one sampled resident by not ensuring the resident’s call light button was intact. Resident 44 was admitted with diagnoses including bipolar disorder, aftercare following joint replacement surgery, and osteoarthritis of the right knee. The resident’s H&P indicated he had the capacity to understand and make decisions and was admitted for physical therapy after a total right knee arthroplasty. The MDS showed he made himself understood and understood others, and he required assistance with toileting, showering, lower body dressing, and footwear. His care plan directed staff to assist with ADLs as needed and keep the call light within reach so needs could be attended to promptly. During observation and interview, Resident 44 stated the call light was uncomfortable and hard to push because the button cover was broken off, and he reported that the red smooth cover that normally fit over the clear plastic tube at the end had not yet been replaced. A CNA observed the call light and confirmed it was missing the red smooth cover, leaving only a hard straw-like tube that was harder to push and could cause pain to the resident’s thumb. The CNA stated equipment issues were required to be reported to the charge nurse or maintenance staff. The ADON stated equipment issues must be reported and fixed promptly and that call lights must function properly so residents can call staff for assistance. The facility policy stated residents are to be provided with a safe, clean, comfortable, and homelike environment.
PASARR Not Updated After Bipolar Diagnosis
Penalty
Summary
The facility failed to submit a new Level 1 PASARR when a resident was diagnosed with bipolar disorder after admission. Resident 44 was admitted on 11/7/2025 with diagnoses that included bipolar disorder, aftercare following joint replacement surgery, and osteoarthritis of the right knee. The resident’s H&P dated 11/10/2025 stated the resident had the capacity to understand and make decisions and was admitted for physical therapy after a total right knee arthroplasty. The MDS dated 11/14/2025 indicated the resident made himself understood and understood others, required assistance with toileting, showering, lower body dressing, and footwear, and also identified bipolar disorder. A psychology progress note dated 12/2/2025 stated the resident has bipolar disorder and that a diagnosis of bipolar appears warranted at this time. The existing PASARR Level 1 screening completed by GACH on 11/7/2025 stated in the serious mental illness screen that the resident did not have a diagnosed mental disorder such as depression, bipolar disorder, schizoaffective disorder, or mood disorder. During interview and record review, the ADON stated the facility should have resubmitted a new Level 1 PASARR to reflect the bipolar diagnosis, and the facility policy stated a new Level 1 PASARR must be submitted when there is a significant change in mental or physical condition, when the MDS does not match the Level 1 screening, or when there are errors or discrepancies in the previous PASARR screening.
Incomplete Care Planning for Opioid Use and Outside Raw Food
Penalty
Summary
Resident 2 had diagnoses including fracture of the right lower leg and COPD, and the MDS dated 10/27/2025 indicated moderate cognitive impairment and dependence with all ADLs. The resident had an active order for hydrocodone-acetaminophen 5-325 mg every four hours as needed for severe pain. During a concurrent interview and record review, the DON stated the resident’s care plan did not include the black box warnings for hydrocodone-acetaminophen, including the risks of addiction, abuse, overdose, and death, and acknowledged that this information should have been included in the care plan to support resident safety. Resident 95 had diagnoses including type 2 DM, acute kidney failure, and essential HTN. The MDS dated 12/9/2025 indicated the resident understood others, could make himself understood, and needed supervision and touching assistance when eating. The order summary dated 11/20/2025 showed a CCHO, NAS, soft and bite-sized, thin consistency diet. During observation, an unpasteurized whole egg labeled with Resident 95’s room number was found in the residents’ refrigerator in the activities room, and the DS stated the egg had been brought in that day. During interview, Resident 95 stated he brought whole eggs to the facility at least one or two times a week and heated them in the microwave, and that he labeled outside food and placed it in the refrigerator without notifying nurses. The DON reviewed the resident’s care plan and stated it did not address the resident bringing raw food into the facility, despite an IDT meeting having occurred after staff were informed the resident had brought raw meat into the facility. The DON stated the resident could not cook in the room for safety, that a care plan should have been in place, and that interventions could include resident education and increased monitoring of the resident’s refrigerator.
Failure to Update Fall Care Plan After Incident
Penalty
Summary
The facility failed to develop a resident-centered care plan after a fall incident for Resident 66. Resident 66 was originally admitted on 5/14/2025 and readmitted on 11/17/2025 with diagnoses including hypertension and history of falling. The resident’s MDS dated 12/08/2025 indicated she could usually make herself understood and usually understand others, required substantial/maximal assistance with toileting hygiene, lower body dressing, and putting on and taking off footwear, and was dependent on staff for showering. During a concurrent observation and interview on 1/28/2026, Resident 66 was observed in a wheelchair with the bed in low position and a landing mat on the floor. The resident stated she had a nighttime fall that she could not fully recall, needed assistance to go to the bathroom, did not call for help, and went unassisted; she said her feet got caught in the wheelchair footrests, causing her to fall and hit her head with a bump. The ADON reviewed the resident’s fall-related care plan, change of condition, and post-fall evaluation and stated the resident fell while trying to walk to the bathroom, with the wheelchair in her way causing her to lose balance and hit her head on a trash can. The ADON stated the wheelchair was unlocked and the footrests were in the way, and that the care plan should have been updated after the fall to address contributing factors and prevent recurrence. The facility’s policy stated care planning is revised quarterly or as needed when the resident’s condition or needs change, and that a comprehensive person-centered care plan is developed and implemented for each resident.
Incomplete Zosyn Antibiotic Treatment Plan
Penalty
Summary
The facility failed to ensure there was a clear antibiotic treatment plan for one resident receiving Zosyn for pneumonia. The resident was admitted and later re-admitted with pneumonia, and the MDS indicated the resident was cognitively intact and required partial to moderate assistance with some activities of daily living. Physician orders included Zosyn 3.375 grams IV every six hours for five days and an order to insert a midline catheter for ongoing IV antibiotic therapy. The resident’s IV access was lost, and nursing progress notes documented that the scheduled IV antibiotic could not be administered because IV access was no longer present. The notes also documented that the physician was notified, a midline catheter was ordered, and staff were awaiting further orders regarding continuation or temporary alternative therapy. A midline was later inserted, and pharmacy delivery records showed Zosyn was delivered to the facility in quantities consistent with the ordered regimen. During interview, the RN stated the resident’s IV was dislodged and that the midnight and 6 a.m. doses were not given. The DON reviewed the MAR and progress notes and found the resident received only 18 of the 20 prescribed doses of Zosyn, but there was no documentation showing staff contacted the physician to clarify whether the resident should receive the two missed doses to complete the antibiotic regimen. The DON stated it was important to document the physician’s decision when medication doses are interrupted, and the IP stated that if there are interruptions in dosing, the licensed nurse is to notify the physician to determine whether antibiotic therapy should be continued.
Unsafe Environment and Inadequate Accident Prevention
Penalty
Summary
The facility failed to provide an environment free from accident hazards for two residents. For a resident with diagnoses including metabolic encephalopathy, seizures, and multiple sclerosis, the care plan directed staff to provide a safe environment, keep the environment free of safety hazards, and use padded side rails if indicated. The resident’s record also showed moderate cognitive impairment, total dependence or substantial assistance with most ADLs, and no capacity to understand and make decisions. During observation, the resident was in bed with both side rails up, but only the right rail had partial foam padding while the left rail had no padding. Staff stated the resident had only one padded rail because that was the side she could move, but later acknowledged both rails should have been padded because the rails were metal and could cause injury during a seizure. For another resident with diagnoses including hypertension and a history of falling, the record showed substantial to maximal assistance was needed for toileting hygiene, lower body dressing, and footwear, and dependence for showering. During observation, the resident was in a wheelchair with the bed in low position and a landing mat on the floor. The resident stated she needed help going to the bathroom, did not call for help, and went unassisted at the time of the incident. She reported that her feet got caught in the wheelchair footrests, causing her to fall and hit her head, resulting in a bump. Record review and staff interview confirmed the fall event. The ADON reviewed the care plan, change of condition, and post-fall evaluation and stated that on the night of the incident the resident fell while trying to walk to the bathroom, with the wheelchair in her way causing her to lose balance and hit her head on a trash can. The ADON identified the wheelchair as a contributing factor because it was unlocked and the footrests were in the way. The facility policy stated that the environment should be as free from accident hazards as possible and that resident safety, supervision, and assistance to prevent accidents were facility-wide priorities.
Improper Foley Catheter Positioning and Urine Backflow
Penalty
Summary
Appropriate care was not provided to prevent a UTI for one sampled resident with an indwelling urinary catheter. Resident 3 was originally admitted on 9/15/2004 and readmitted with diagnoses including metabolic encephalopathy, UTI, and multiple sclerosis. The resident's H&P indicated the resident did not have the capacity to understand and make decisions, and the MDS showed moderate cognitive impairment and total dependence or substantial assistance with most ADLs. The care plan for alteration in urinary elimination and risk for UTI related to Foley catheter use directed staff to maintain proper alignment of the indwelling urinary catheter to promote proper drainage. During observation, Resident 3's catheter tubing had a u-shaped dependent loop with urine pooled and backing up the tubing toward the resident. The LVN stated the urine collection bag should be lower so urine can flow into the bag and that urine backing up could cause a UTI. The DON stated the catheter tubing should be positioned above the urine collection bag so urine does not back up the tubing, otherwise the resident would be at risk for getting a UTI. The facility policy on catheter care stated to maintain unobstructed urine flow, prevent urine from flowing back into the bladder, and check drainage tubing and bag to ensure the catheter is draining properly.
Medication Given Despite Hold Parameter for Low SBP
Penalty
Summary
The facility failed to ensure a blood pressure medication was held for a resident when the resident’s systolic blood pressure was below the ordered parameter. Resident 4 was admitted with diagnoses including muscle weakness and hypertension, and the history and physical stated the resident could make needs known but could not make medical decisions. The physician’s order for Metoprolol Tartrate 25 mg by mouth twice daily with meals directed staff to hold the medication if systolic blood pressure was less than 110 mmHg and pulse was less than 60 beats per minute. Review of the physician’s orders and eMAR showed that on 11/22/2025 at 7:30 a.m., the resident’s blood pressure was 108/56 mmHg, yet Metoprolol 25 mg was administered. During interview, the ADON stated the medication should have been held because the order included a parameter that should have been followed to avoid the resident becoming hypotensive. The facility policy on administering medications stated medications are to be given safely and as prescribed, and the policy on adverse consequences and medication errors defined a medication error as administration outside the parameter set in the order.
Unlabeled Tablets Found Loose in Medication Cart
Penalty
Summary
The facility failed to ensure medications were properly stored when one of two inspected medication carts, Medication Cart 1, contained unlabeled, unpackaged tablets in the bottom of a drawer. During a concurrent observation and interview with LVN 3, surveyors found one orange oval tablet, one round white tablet, one white oval tablet, one half piece of a round yellow tablet, and two quarter pieces of a round white tablet stored loose and without labels. LVN 3 stated the medications should not have been stored that way. The DON later stated that all medications should be safely stored in the medication cart in their packaging and, if not, they need to be disposed, and that because the medications were not labeled, staff were unable to identify what they were or which residents they belonged to. The facility policy stated medications should be kept in the containers dispensed by the provider pharmacy and that outdated, contaminated, deteriorated, or unsecured medications are to be removed and disposed.
Fruit Fly Observed in Dry Food Storage
Penalty
Summary
The facility failed to maintain sanitary conditions in the food services department when a fruit fly was observed in the residents' dry food storage during a concurrent observation and interview with the Dietary Supervisor. The Dietary Supervisor stated that the area had a fruit fly in the dry storage room. During a later interview, the Dietary Supervisor stated the kitchen should be fly-free because flies could cause cross-contamination and residents could get sick from contaminated food. A review of the facility's Pest Control Policy stated that the facility shall maintain an effective pest control program and maintain an ongoing pest control program to keep the building free of insects and rodents.
Insufficient Bedroom Space Per Resident
Penalty
Summary
The facility failed to provide at least 80 square feet per resident in multiple resident bedrooms, affecting 27 of 42 rooms reviewed. The rooms identified included multiple double-occupancy rooms and two 4-bed rooms, with measured space per resident ranging from 75.6 to 79.3 square feet in the double rooms and 77.4 square feet in the 4-bed rooms. The report states that the minimum square footage should be 160 square feet for a 2-bed room and 320 square feet for a 4-bed room, and that the facility had submitted a Request for Room Size Waiver letter dated 1/6/2026 for the 27 rooms because they did not meet the federal requirement. During the Resident Council meeting on 1/27/2026, no residents raised concerns about room size. On 1/28/2026 and 1/29/2026, surveyors observed that residents had ample space to move freely in the rooms and that there was sufficient space for beds, side tables, and resident care equipment. Staff interviewed on 1/28/2026 reported no concerns regarding the size of the affected rooms. The facility policy titled "Bedrooms," last reviewed on 11/20/2025, states that bedrooms must measure at least 80 square feet of space per resident in double rooms.
Failure to Ensure Proper Functioning Bed Pad Alarm for Resident at Fall Risk
Penalty
Summary
A deficiency occurred when a resident with a history of falls, right femur fracture, hemiplegia, morbid obesity, dementia, and moderately impaired cognition was not provided with a properly functioning bed pad alarm as ordered by the physician. The resident required significant assistance with daily activities and was dependent on staff for toileting, showering, and dressing. The physician had ordered a bed pad alarm to decrease the potential for injury, and facility policy required daily checks of such alarms for proper functioning. During an observation, a CNA attempted to demonstrate the bed pad alarm but no alert was heard, and both the CNA and DON confirmed the alarm was not working. The Central Supply Manager stated that position change alarms are typically checked daily, but on this day, the resident's alarm had not been checked. The DON acknowledged that the alarm should be operational at all times and confirmed it was not working at the time of inspection, which was inconsistent with facility policy and physician orders.
Failure to Complete Trauma Evaluation and Care Plan for Resident with Trauma History
Penalty
Summary
The facility failed to complete a thorough trauma care evaluation and develop a comprehensive, person-centered care plan addressing past trauma and triggers for one resident. The resident, who had diagnoses including complete paraplegia, anxiety disorder, and depression, reported a history of being shot in the back, which resulted in paralysis and ongoing depression. During the psychiatric intake, the resident disclosed this trauma, and during an interview, stated that loud noises, such as staff slamming doors, triggered memories of the gunshot event. Despite this, the trauma care evaluation was incomplete, with only the first question marked as declined and the remaining questions left blank. The facility's policy required further information gathering from family or medical records if the resident declined to participate, but this was not done. Additionally, a review of the resident's care plans revealed that there was no care plan addressing the resident's past trauma or potential triggers, despite staff being aware of the trauma history. The Social Services Director acknowledged that more information should have been gathered and documented, and the DON confirmed that a care plan should have been created to address the trauma and triggers. The facility's policy required individualized care plans to minimize triggers and re-traumatization, but this was not implemented for the resident in question.
Failure to Ensure Privacy During Medication Administration
Penalty
Summary
The facility failed to provide privacy to four residents during medication administration, which violated their right to dignity and respect. The incidents involved Licensed Vocational Nurse 1 (LVN1) who was observed checking the blood sugar levels of the residents and administering insulin without closing the privacy curtains in their rooms. This lack of privacy occurred despite the facility's policy that emphasizes treating residents with respect and dignity at all times. Resident 54, who was admitted with dysphagia and type 2 diabetes, had intact cognitive skills but was dependent on staff for personal care. During a medication administration observation, LVN1 checked the resident's blood sugar in the room with the privacy curtain open. Similarly, Resident 35, with impaired cognitive skills and requiring maximal assistance, had their blood sugar checked by LVN1 in bed without the privacy curtain being closed. Resident 58, with intact cognitive skills but dependent on staff for personal care, also had their blood sugar checked and insulin administered by LVN1 without privacy. Lastly, Resident 3, with severely impaired cognitive skills, experienced the same lack of privacy during their medication administration. LVN1 acknowledged the oversight and stated that residents should not be put in situations that could cause embarrassment, emphasizing the importance of providing privacy during such procedures.
Failure to Revise Care Plans for Activity and Nutritional Needs
Penalty
Summary
The facility failed to revise the comprehensive person-centered care plans for two residents, Resident 15 and Resident 69, regarding their activity needs. Resident 15, who was diagnosed with anxiety disorder and Parkinson's disease, had an intact cognitive ability for daily decision-making but was totally dependent on staff for various activities of daily living. The care plan for Resident 15's activity needs was not evaluated or renewed on the target date, which was supposed to be done quarterly. Similarly, Resident 69, diagnosed with quadriplegia and epilepsy, had severely impaired cognitive skills and was also totally dependent on staff. The care plan for Resident 69's activity needs was not evaluated or renewed on the target date. The Director of Nursing acknowledged that the care plans were not active and should have been reviewed quarterly to ensure ongoing activities were provided to address the residents' psychosocial needs. The facility also failed to revise the comprehensive person-centered care plan addressing the nutritional needs of Resident 25. Resident 25, with diagnoses including acute respiratory failure, type 2 diabetes, and end-stage renal disease, had moderately impaired cognitive skills and required moderate assistance from staff. The nutritional assessment indicated a risk for malnutrition, and the dietary note highlighted weight loss due to fluid shifts related to dialysis. However, the care plan did not reflect the resident's dialysis treatment, which could significantly contribute to weight fluctuation. The Director of Dietary Services and the Director of Nursing both noted that the care plan should have been person-centered and included all nutritional risk factors to meet the resident's needs. The facility's policies and procedures require that resident care plans be implemented on admission and reviewed at least quarterly. However, the care plans for the residents in question were not updated as required, potentially impacting the residents' care and services related to their activity and nutritional needs. The deficiencies were identified through interviews and record reviews, highlighting the facility's failure to adhere to its own policies and procedures regarding care plan evaluations and revisions.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications, leading to several deficiencies. In Medication Room A, a multi-dose vial of Aplisol was found without an open date, which is against the facility's policy and the manufacturer's instructions. The Director of Nursing (DON) confirmed that the vial should have been labeled with an open date and discarded after 28 or 30 days to prevent inaccurate test results for tuberculosis. This oversight increased the risk of residents receiving ineffective or potentially toxic medication. In another instance, an unopened insulin pen for a resident was improperly stored in Medication Cart 2 instead of being refrigerated. The Licensed Vocational Nurse (LVN) acknowledged that the insulin pen should have been refrigerated to maintain its efficacy. The DON confirmed that improper storage could lead to the insulin losing its effectiveness, potentially causing hyperglycemia in the resident. Additionally, the facility failed to label a box of Artificial Tears with a resident's name, using a room number instead. This practice was observed during an inspection of one of the medication carts. The DON confirmed that medications should be labeled with the resident's name to prevent administration errors. Furthermore, medications for a resident who was discharged to a hospital were not removed from the medication cart, increasing the risk of another resident receiving the wrong medication.
Infection Control Breach During Medication Pass
Penalty
Summary
The facility failed to adhere to infection control guidelines during a medication pass observation involving a resident on enhanced barrier precautions (EBP). Registered Nurse 1 (RN 1) was observed administering Cefazolin via a central line to a resident diagnosed with discitis, a urinary tract infection, and major depressive disorder. The resident was moderately impaired in cognition and dependent on staff for daily activities. After administering the medication, RN 1 exited the resident's room without removing the isolation gown and gloves, which is against the facility's policy for EBP. The incident was confirmed through interviews with the Infection Preventionist and the Director of Nursing, both of whom stated that RN 1 should have removed the gown and gloves before leaving the resident's room to prevent the spread of infection. The facility's policy on EBP, revised in March 2024, requires the use of personal protective equipment, including gloves and gowns, during high-contact resident care activities, especially for residents with indwelling medical devices. This oversight had the potential to increase the risk of spreading infection to other residents.
Delayed Completion of Quarterly MDS Assessment
Penalty
Summary
The facility failed to ensure that a resident's Quarterly Minimum Data Set (MDS) was completed in a timely manner, as required by federal guidelines. The deficiency involved a resident who was admitted to the facility with diagnoses of asthma and Parkinson's disease. The resident had intact cognition and was dependent on staff for most activities of daily living. The Quarterly MDS, which is a standardized assessment and care screening tool, was not completed within the required timeframe, potentially affecting the provision of necessary care and services for the resident. During the review, it was found that the assessment reference date (ARD) was set for 11/29/2024, and the assessment should have been completed by 12/12/2024. However, the assessment was not completed until 12/26/2024, which was more than 14 days after the ARD. This delay was confirmed during interviews and record reviews with the MDS Nurse, who acknowledged the oversight and confirmed that the assessment was not completed within the required period as per the guidelines set by the Centers for Medicare and Medicaid Services (CMS) and the Omnibus Budget Reconciliation Act of 1987 (OBRA).
Failure to Develop Comprehensive Care Plan for Resident Using Bed Rails
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident, identified as Resident 58, who was investigated under accidents. The deficiency was identified during a review of the resident's admission record and Minimum Data Set (MDS), which indicated that the resident had intact cognitive skills but was dependent on staff for various activities of daily living. Despite these needs, the facility did not conduct a safety assessment for the use of bed side rails, which were attached to the resident's bed. This oversight was confirmed during an interview with the Director of Nursing (DON), who acknowledged the absence of a safety assessment and the potential risk of injury due to entrapment in the bed rails. The facility's policy on resident care plans, which aims to provide individualized nursing care and promote continuity of care, was not adhered to in this case. The policy requires that care plans include identification of medical, nursing, and psychosocial needs, with goals stated in measurable terms. However, the care plan for Resident 58 did not address the use of bed rails, nor did it include a timeframe for evaluating the effectiveness of this intervention. This lack of a comprehensive care plan had the potential to result in the resident not receiving necessary care and services to prevent potential injury from the bed rails.
Inconsistent Activity Provision for Resident
Penalty
Summary
The facility failed to provide appropriate and consistent activities for a resident, identified as Resident 52, which had the potential to negatively affect the resident's physical, cognitive, sense of belonging, and emotional health. Resident 52, who has diagnoses including paraplegia, anxiety, and depression, was admitted to the facility with intact cognition and required assistance for most activities of daily living. The resident expressed a preference for participating in Bible studies on Sunday afternoons, an activity that was discontinued without explanation, despite being listed on the facility's activities calendar. The Activity Director (AD) acknowledged that Bible studies had not been provided for the past 3-4 weeks due to a possible COVID-19 outbreak at the religious institution that facilitated these services. The AD was unable to provide a list of participants or contact information for the religious organization. The Director of Nursing (DON) confirmed that the facility should provide activities of choice to residents, as failing to do so could increase anxiety and depression. The facility's policy on spiritual and religious activities indicated that a variety of such activities should be available and scheduled through local religious organizations, encouraging residents to attend those of their choice.
Resident's Bedside Medication Storage Poses Hazard
Penalty
Summary
The facility failed to maintain an environment free from accident hazards by allowing a resident to store medications at their bedside, which were readily accessible to other residents. This deficiency was identified during a review of a resident's care area for accidents. The resident, who had intact cognition and required supervision to moderate assistance for most activities of daily living, was observed with multiple bottles of supplements and vitamins stored in clear plastic drawers next to their bed. The resident confirmed that they self-administered these medications. Interviews with facility staff, including a Licensed Vocational Nurse and the Director of Nursing, revealed concerns about the risk posed by the resident's bedside medication storage. The staff acknowledged that the presence of medications at the bedside could lead to other residents, particularly those who are confused and may wander into the room, consuming the medications and potentially experiencing adverse side effects. The facility's policy on self-administration of medication and storage of medication indicated that bedside storage is only permitted when it does not present a risk to other residents, highlighting a failure to adhere to these guidelines.
Failure to Cap Enteral Feeding Tube Increases Infection Risk
Penalty
Summary
The facility failed to ensure proper care for a resident receiving enteral feeding, leading to a potential risk of infection. The deficiency was identified when the enteral feeding tube of a resident was observed to be disconnected and hanging on a pole without a cap covering the tip. This oversight was confirmed by a Licensed Vocational Nurse (LVN) and the Infection Preventionist (IP), both of whom acknowledged that the tubing should be capped to prevent contamination and reduce the risk of healthcare-acquired infections. The resident involved had multiple diagnoses, including cerebral infarction, acute respiratory failure with hypoxia, gastrostomy malfunction, and schizophrenia. The resident was totally dependent on staff for all activities of daily living and had moderately impaired cognition. The facility's policy on enteral feeding safety precautions, last reviewed in March 2024, was not adhered to, as it required the capping of the tubing to prevent microbial growth. Interviews with the LVN, IP, and Director of Nursing (DON) confirmed the failure to cap the tubing increased the risk of infection for the resident.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 3,508 citations issued within 25 miles in the last 12 months — including the 27 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Reseda
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Park View Nursing And Subacute | 0.9 mi | ★★★★★ | 7 | 0 |
| Grancell Village Of The Jewish Homes For The Aging | 1.1 mi | — | 5 | 0 |
| Joyce Eisenberg Keefer Medical Center D/p Snf | 1.1 mi | ★★★★★ | 28 | 0 |
| Woodland Care Center | 1.5 mi | ★★★★★ | 19 | 0 |
| Eisenberg Village | 1.8 mi | ★★★★★ | 22 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.