Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pacifica Hospital Of The Valley Dp Snf during CMS and state inspections, most recent first.
Failure to Maintain and Update Facility Assessment: The facility failed to review and update its facility assessment at least annually. During interview and record review, the DSD and DON could not provide the prior assessment or state when it was last completed or reviewed. The DSD said he was not sure whether a 2025 assessment had been completed, that a former staff member had handled it, and that the facility had no policy or procedure for when or how to conduct the assessment.
Failure to Submit PBJ Staffing Data: The facility failed to electronically submit required PBJ staffing data to CMS for one quarter after the initial file did not go through and the resubmission missed the deadline. The SC confirmed quarterly PBJ submission is required, and the DON stated there was no policy for PBJ staffing submission. The DSD stated the missing submission affected reporting of staffing hours and the facility’s CMS star rating.
Incomplete QAPI Documentation and Meeting Records: The facility failed to maintain documentation and evidence of an ongoing QAPI program. The DON stated only a few QAPI meetings were documented after she restarted the process, and the DSD stated earlier QAPI activity was not properly documented and consisted only of sign-in sheets. The facility policy required QAPI minutes to include meeting details, reports and findings, action plans, conclusions, recommendations, and adjournment time.
Infection control practices were not followed when an LVN wore soiled gloves while pressing a call light reset button and disposed of contaminated fluids into a shared sink during care of a dependent resident with trach and PEG. A resident with a trach was also observed keeping multiple disposable face masks on a wheelchair where they touched the wheels. The facility did not document infection outcomes in surveillance logs, did not complete surveillance analysis reports, did not follow its WMP testing process, and a bubble humidifier was documented as changed on the MAR but was not actually changed as ordered.
A facility failed to protect dignity and privacy for multiple residents. A resident with a Foley catheter had the drainage bag visible outside a dignity bag, an RNA entered another resident's room without knocking, and an LVN administered g-tube meds to a resident in a shared room without full privacy. In another case, a cognitively intact resident who requested a transfer closer to family was not kept informed about the status of the request or involved in ongoing care planning.
Failure to Implement Ordered Seizure Precautions: Three residents with seizure-related diagnoses were found without required padded side rails or with seizure precautions not supported by an order. One resident had an order for bilateral padded side rails but the bed rails were unpadded, another had an order for padded side rails and was observed with all 4 rails up and no padding, and a third had a seizure history with a care plan calling for padded rails but no corresponding order in the MAR/order summary. The DON and an LVN stated the missing padding could lead to injury during a seizure.
Improper Use of Side Rails Without Required Orders, Assessment, or Consent: The facility failed to use bed rails safely for multiple residents. A resident with trach and dysphagia was observed with all 4 rails up despite an order for bilateral rails, and staff found no consent or entrapment assessment. Other residents with severe neuro/respiratory conditions, including coma, seizure disorder, and cognitive impairment, were also observed with 4 rails up, sometimes without padding, even when orders called for bilateral padded rails. RN and LVN staff stated the rails were being used to prevent falls, but the record lacked documented entrapment risk assessments and informed consent.
Controlled substance access, destruction documentation, and reconciliation failures were observed in multiple medication areas. Staff could not open a locked refrigerated container holding CSs and an eKIT, preventing immediate access to midazolam and Ativan; four medication destruction forms lacked required nurse witness signatures; and two eKITs containing CSs were not reconciled at each shift. In addition, two nurses signed a narcotic count as accurate for a cart without verifying the refrigerated CS inventory.
An open Lantus SoloStar insulin pen for a resident was found stored at room temperature in a med cart without an open date, and an LPN stated it was unknown when the pen had been opened or when it would expire. The same bin also contained insulin pens together with an earwax softener drop and an eye drop, despite staff stating eye and ear medications should be stored separately to prevent wrong-route use and contamination. The DON confirmed the missing date and improper storage, and facility policy and manufacturer guidance required opened insulin pens to be dated and discarded after 28 days.
Unsafe Ice Storage and Handling in Kitchen: Three bags of purchased ice, still in their original packaging, were observed mixed with ice from the ice maker and used for 14 of 60 residents receiving food and drinks from the kitchen. The DM stated the ice maker sometimes does not work well and separate bags of ice are purchased, but the ice should have been removed from the bags to prevent cross contamination. The facility P&P stated ice that comes in contact with food and beverages must be from a sanitary source.
Call Light Not Accessible or Usable for Two Residents: A resident with severe respiratory and mobility dependence had a touch-activated call light placed out of reach above his head, and he stated he sometimes could not reach it and had to call out for help. Another resident with traumatic encephalopathy, a trach, seizures, impaired cognition, and bilateral wrist/finger contractures had a standard push button call light tied to the side rail near his shoulder, but he said he did not know where it was or how to use it, and an LVN confirmed he could not use it.
Failure to Assist Two Residents With Advance Directives: The facility did not follow its Advance Directives policy for two cognitively intact residents who indicated they wanted further discussion about advance directives. One resident had a spinal cord injury with chronic respiratory failure and ventilator dependence, and the other had chronic respiratory failure and a seizure disorder. The SW found no documentation that either resident was met with for follow-up, and neither had an advance directive on file.
A resident with a history of respiratory distress, MCA occlusion, and dysphagia received multiple meds via G-tube, but an LVN flushed the tube with 25 ml of water instead of the ordered 30 ml before and after medication administration. The LVN and DON both confirmed the ordered flush volume was not followed, despite the facility policy calling for a minimum of 30 ml.
Failure to Use Ordered SCD for DVT Prophylaxis: A resident with a history of DVT and PE had an order for SCD use at all times for DVT prophylaxis, but staff observed the device disconnected, turned off, and hanging on the bed instead of being worn. An RN confirmed the resident’s history and stated the care plan did not document SCD use, while the DON acknowledged the order was not being followed. The facility policy stated the SCD should remain in place except for skin checks or bathing.
Failure to Apply Ordered AFO Splints: A resident who was comatose and dependent for all ADLs was observed with bilateral wrist and ankle contractures and no AFOs applied. The chart showed an MD order for bilateral AFOs per splinting protocol, and RN staff confirmed the splints were not being worn as ordered despite the facility policy requiring splints to be applied on the physician-directed schedule.
Improper Indwelling Catheter Positioning: Two residents with indwelling urinary catheters were observed with tubing positioned in a way that did not maintain proper drainage. One resident had a dependent loop with urine collecting in the tubing and an unattached leg strap, while another resident’s suprapubic catheter tubing was placed above bladder level over a positioning wedge with urine backing up toward the body. Staff stated these conditions could interfere with urine flow and increase the risk for UTI/CAUTI.
Inaccurate documentation occurred when an RT charted that a resident's bubble humidifier had been changed on the MAR even though it had not been changed. The resident had chronic hypoxemic respiratory failure, CVA, and post PEG status, and the humidifier remained dated from an earlier change while the order required changes three times weekly. RT 2 stated he documented before performing the task, did not complete it because the resident was receiving care, and forgot to return; the DON stated charting should occur only after the intervention is performed.
Failure to Complete Antibiotic Time-Out: A resident with severe medical conditions, including cardiopulmonary arrest, respiratory failure, encephalopathy, HTN, and DM, was receiving IV Zosyn for elevated WBCs, but the IPN found no documentation of an antibiotic time-out within the required 48 to 96 hours after therapy started. The DON confirmed the facility expected antibiotic time-outs for residents on antibiotics, but the required review was not completed or documented.
Failure to provide required annual dementia training: A CNA who was also an RNA did not have documentation of dementia management in-service training within the past 12 months. The HRS confirmed the missing training record, and the DSD stated RNAs had not received dementia training during that period. Facility policy required annual in-service education for all sub-acute staff, including dementia management and resident abuse prevention.
A resident with a history of head trauma and a skin lesion had a dermatology appointment canceled due to staffing shortages, but the conservator was not consulted prior to the cancellation. Facility staff confirmed that the conservator, who holds exclusive authority for medical decisions, was only notified after the fact, violating the resident's rights to participate in care planning and informed consent.
A facility failed to inform a resident's family about the care plan and changes in condition, causing family anxiety due to lack of input in treatment. The resident, with a history of traumatic SDH and chronic respiratory failure, was unaware of treatment discussions. The CNO admitted to not communicating with the family, and the Social Worker confirmed the family's exclusion from IDT meetings. The facility's failure to maintain regular contact with the family and update them on significant changes led to this deficiency.
The facility failed to submit staffing information to CMS for two quarters in 2024 due to the absence of the responsible staff member and the departure of key personnel with access to the reporting portal. This resulted in incomplete staffing data for the 3rd and 4th quarters.
The facility failed to develop comprehensive care plans for three residents, leading to potential inadequate care. A resident with a stroke did not have a care plan for their RNA program, while two residents on antibiotic therapy lacked care plans to monitor adverse reactions. This failure to adhere to care planning policies could result in unaddressed complications.
The facility failed to involve residents or their representatives in IDT care conferences, affecting the development of resident-centered care plans. Additionally, a resident's care plan was not updated after the removal of an indwelling catheter, leading to inaccurate medical records and potential care issues.
The facility failed to implement necessary safety measures for three residents, leading to potential injury risks. Two residents with seizure disorders were found without required padded side rails, and a third resident had a broken wheelchair with a malfunctioning hand brake and footrest. Staff acknowledged the deficiencies, which were contrary to physician orders and care plan directives.
The facility failed to manage G-tube administration properly, leading to potential health risks. An LVN did not check a resident's stomach residual before administering medication, risking aspiration pneumonia. Another resident's feeding bottle lacked labeling, risking infection from spoiled formula. Additionally, a feeding syringe was not labeled, risking cross-contamination, and another resident's feeding formula was not labeled with the time and date, risking adverse reactions.
A facility failed to ensure physician orders were signed and dated for three residents, leading to potential delays in care. One resident with respiratory failure had unsigned orders for physical therapy and nursing assistance. Another resident with diabetes and anemia had undated medication and lab orders. A third resident had an undated lab order for iron levels. Interviews confirmed the orders were not properly documented, violating facility policy.
A resident admitted with complex medical conditions did not receive a social service assessment within the required 48 hours due to the social worker being overwhelmed with other assignments. The facility's policy mandates timely assessments to address psychosocial needs and assist with adjustment, which was not adhered to, placing the resident at risk.
The facility failed to ensure proper documentation of controlled drug administration and timely replacement of emergency kits. Two residents had discrepancies between the Controlled Drug Record and Medication Administration Records, while three residents experienced delays in e-Kit replacement after Ativan was used. Staff interviews revealed non-compliance with facility policies, potentially leading to medication errors and service delays.
The facility failed to properly label and store medications, risking the administration of expired or discontinued drugs. An open potassium chloride solution lacked an open date, and a discontinued chlorhexidine solution was stored without a physician's order. Additionally, a Vitamin A and D ointment was undated, violating facility policy on medication shelf life.
The facility failed to label food stored in its freezers with the date they were placed, as observed by a registered dietician. Unlabeled frozen pork chops and fish sticks were found, contrary to the facility's policy requiring labeling for easy identification. This practice potentially risked 17 out of 58 residents receiving food from the facility's kitchen.
The facility failed to maintain infection control practices, as observed in three separate incidents involving staff not wearing protective gowns when required. A housekeeper entered a contact isolation room without a gown and failed to perform hand hygiene. An LPN administered medication via a gastrostomy tube to a resident on enhanced barrier precautions without a gown, acknowledging the oversight. Another LPN administered enteral feeding and medication without a gown, unaware of the requirement. These lapses in PPE usage could lead to cross-contamination and infection spread.
A facility failed to keep a call light within reach of a resident who was totally dependent on staff for all ADLs and had intact cognition. The resident's care plan required the call light to be easily accessible, but it was observed out of reach. Staff confirmed the deficiency, acknowledging it could prevent the resident from requesting assistance, contrary to facility policy.
The facility failed to follow its advance directive policies for two residents. One resident was not provided with information about their right to create an advance directive upon admission, despite having intact cognitive skills. Another resident's advance directive was not maintained in their clinical record, despite severe cognitive impairment and total dependence on staff. These deficiencies were confirmed through staff interviews and record reviews.
A resident with complex medical needs was discharged from an LTC facility without a proper care plan or discharge planning assessment. The resident, who required significant assistance and had severe cognitive impairments, did not have a discharge plan developed or documented by the social worker, who was on medical leave. The Director of Nursing confirmed the discharge planning was incomplete, as no interdisciplinary team conference was held to address the resident's needs.
A facility failed to monitor a resident for orthostatic hypotension as per physician's orders on two occasions. The resident, with a history of dysphagia, bipolar disorder, and schizophrenia, was at high risk for falls. Despite the physician's order to monitor from 7:00 a.m. to 7:00 p.m. weekly, documentation was missing for specific weeks in October and November. A nurse confirmed the importance of this monitoring to prevent falls, aligning with the facility's policy to monitor residents on certain medications for adverse effects.
The facility failed to document pain management for two residents, as pain assessments were not conducted before and after administering Norco. The MAR lacked entries for medication administration, and interviews with staff confirmed that the process of signing the MAR was not followed, leading to potential unmanaged pain.
The facility failed to act on a pharmacist's recommendations for two residents, leading to deficiencies in medication management. One resident's need for FeroSul was not reassessed, and another resident did not receive recommended blood testing for levetiracetam levels. The facility lacked a specific policy for addressing the monthly Medication Regimen Review, contributing to these deficiencies.
A facility failed to monitor a resident for side effects of Cymbalta, prescribed for depression. Despite the care plan's directive, there was no documentation of monitoring, confirmed by a nurse. The resident had a history of Guillain-Barre syndrome, diabetes, and hypertension, and required maximal assistance with ADLs. The DSD acknowledged the need for monitoring to adjust medication dosage, as per facility policy.
The facility failed to maintain safe room temperatures for 51 residents in the Sub-Acute Unit due to malfunctioning chillers and inadequate monitoring by engineering staff. Despite installing rental chillers, temperatures ranged from 77 to 82 degrees Fahrenheit, exceeding the acceptable range. Staff interviews and observations confirmed the deficiency, highlighting a lack of adherence to facility policies for temperature monitoring.
Failure to Maintain and Update Facility Assessment
Penalty
Summary
The facility failed to review and update its facility assessment at least annually. During a concurrent interview and record review on 2/11/2026 at 8:25 a.m. with the DSD, the document titled Facility Assessment Tool, updated 2/9/2026, was reviewed, and the DSD stated it was used to create a facility assessment during the week of 2/9/2026. During a later concurrent interview and record review on 2/11/2026 at 3:34 p.m. with the DON and DSD, they were unable to provide the previous facility assessment document or the date it was completed or last reviewed. The DSD stated he was not sure if a facility assessment had been completed in 2025 and said a staff member who last worked in the facility in 2024 had been responsible for completing the facility assessment, with no one having access to the last version at that time. The DSD also stated the facility did not have a policy or procedure regarding how and when to conduct a facility assessment. The DON stated the facility assessment should be completed regularly and should involve input from residents and their families, and the DSD later stated the assessment should be updated yearly so new issues or concerns could be addressed and accommodated.
Failure to Submit PBJ Staffing Data
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to CMS based on payroll and other verifiable and auditable data for the third quarter of 2025. During a concurrent interview and record review, the 2025 PBJ Staffing Report showed that quarter 3 was triggered for failing to submit data for the quarter. The Staffing Coordinator stated that quarterly PBJ submission is required. The Director of Staff Development stated the initial PBJ data submission for quarter 3 did not go through because of an issue with the data file sent, and although the facility fixed the problem and resubmitted it, the submission missed the deadline. The Director of Staff Development also stated that PBJ data is used to report staffing hours caring for residents and that failure to submit affects the facility’s CMS star rating. The Director of Nursing stated the facility did not have a policy regarding submission of PBJ staffing.
Incomplete QAPI Documentation and Meeting Records
Penalty
Summary
The facility failed to maintain documentation and demonstrate evidence of an ongoing QAPI program. During a concurrent interview and record review with the DON and DSD, the facility's QAPI Minutes dated 11/25/2025, 12/16/2025, and 1/29/2026 were reviewed. The DON stated these were the only documented QAPI meetings from the past year and explained that she restarted QAPI after being hired in the fall of 2025. The DON also stated that a well-developed QAPI program is important for department leaders to discuss issues, identify potential gaps in care, and brainstorm ideas to improve resident care. The DSD stated that before the current DON started in the fall of 2025, the facility had a QAPI program, but it was not documented properly and there were only sign-in sheets showing who was present. The DSD stated QAPI meetings should be documented so prior discussions can be reviewed and action can continue from one meeting to the next. Review of the facility's policy titled Quality Assurance and Performance Improvement (QAPI) Committee 2025, last reviewed 1/29/2026, showed that the committee is to establish, maintain, and oversee organizational systems and processes to support quality of care and services, and that minutes must include the date and time of the meeting, members present and absent, summaries of reports and findings, action plans, conclusions and recommendations, and the adjournment time.
Infection Control and Surveillance Deficiencies
Penalty
Summary
The facility failed to ensure staff followed transmission-based precautions and infection control practices during care of a resident who was dependent for all activities of daily living and had diagnoses including chronic traumatic encephalopathy, seizure disorder, respiratory failure, tracheostomy, and gastrostomy. During morning care, an LVN was observed wearing soiled gloves, pressing the call light reset button without removing the gloves, and then continuing care. The same LVN was also observed pouring visibly contaminated fluids into a shared sink in the resident’s room. The DON stated the call light reset button was a high-touch surface and that pressing it with soiled gloves could contaminate the surface, and stated that disposing contaminated water into a resident’s sink could contaminate the sink basin and surrounding surfaces. The facility also failed to maintain appropriate handling of disposable face masks for a resident with chronic respiratory failure, tracheostomy, and hemiplegia who was cognitively intact and used a wheelchair. The resident was observed self-propelling with multiple disposable face masks hanging from the wheelchair brake handle and touching the wheelchair wheels. The resident stated the masks were kept on the wheelchair and were changed frequently because of excessive mucus related to the tracheotomy. RN 3 stated disposable masks should not be hung on the wheelchair brake handle or touch the wheelchair wheels because they could become contaminated. The facility’s infection surveillance process was also deficient. The Infection Preventionist stated the infection surveillance logs did not document outcomes for identified infections, and the Infection Preventionist was unfamiliar with the Infection Surveillance Analysis and Reports and was not aware that surveillance analysis needed to be completed. Record review showed no documented Infection Surveillance Analysis Reports. In addition, the facility did not follow its Water Management Program as written because chlorine residual levels were not tested, a schedule for water testing was not maintained, and logs for water testing and results were not available. The facility also failed to change a resident’s bubble humidifier as ordered; the humidifier was observed dated 2/4, the order required changes every Monday, Wednesday, and Friday, and the RT later stated he documented the task as completed on the MAR before going to the bedside but did not actually change it and forgot to return.
Failure to Preserve Resident Dignity and Communication Rights
Penalty
Summary
The facility failed to provide care in a manner that promoted dignity and respect for four sampled residents. For one resident with a Foley catheter, the urine collection bag was observed attached to the bed rail with urine visible inside, and the collection bag was placed outside of the dignity bag. An LVN stated the bag should have been inside the dignity bag because the purpose of the dignity bag is to hide the urine drainage from other people's view. The DON stated dignity bags are expected to be used for all residents with Foley catheters. For another resident who was completely dependent for all ADLs and had a tracheostomy with ventilator dependence and CVA, an RNA entered the room without knocking or asking permission. The resident was observed in bed at the time. The RNA stated she forgot to knock and acknowledged she should have done so because the resident's room is the resident's home and privacy should be respected. The DON stated anyone entering a resident's room must knock and ask permission before entering. A third resident, who was in a persistent vegetative state and dependent for all ADLs, received medications through a g-tube in a shared room without full privacy. The LVN closed only one side of the curtain, left the foot of the bed and the resident's right side exposed, then lifted the gown to expose the abdomen and g-tube while administering medications. The LVN stated the resident should have been provided privacy during medication administration. The DON and DSD also stated the resident should have been given privacy and that residents have the right to privacy during exposure. For a cognitively intact resident who requested transfer to a facility closer to family, the resident stated he had informed the social worker about the request approximately two months earlier but had not received updates about the status. The social worker reviewed notes showing no documentation that the resident was provided information about transfer referrals or updated on the transfer process, and stated the transfer process had not been communicated to the resident. The DON stated residents have the right to be informed, that staff were expected to discuss care plan updates and obtain resident input when changes occur, and that residents and families should be kept aware of progress of all aspects of care.
Failure to Implement Ordered Seizure Precautions
Penalty
Summary
The facility failed to provide an environment free from accident hazards for three residents with seizure-related precautions. Resident 44 had diagnoses including seizures and tracheostomy, was unable to make his own decisions, and was completely dependent on staff for all ADLs. A physician order dated 5/20/2025 directed bilateral padded side rails up at all times, but during observation on 2/9/2026 the upper bed rails were metal and not padded. RN 1 stated the padding was needed to protect the resident’s head and body during seizures, and the DON stated staff did not follow the physician’s instructions to apply padding. Resident 29 was admitted with diagnoses including chronic respiratory failure with hypoxia, seizure disorder, traumatic subdural hemorrhage, and dysphagia. The MDS indicated moderate cognitive impairment, dependence for all ADLs, and dependence for chair/bed-to-chair transfer. An order summary report dated 5/5/2024 directed bilateral padded side rails at all times every shift, but during a concurrent observation and interview on 2/10/2026 the resident’s bed was observed with all four side rails up and no padding. LVN 6 stated the resident was at risk for seizures and that lack of padding could result in head injury or trauma during a seizure. Resident 55 had diagnoses including chronic traumatic encephalopathy following head injury, history of seizure disorder, respiratory failure, tracheostomy, and gastrostomy. The MDS indicated the resident was comatose and dependent on staff for all ADLs and for rolling left and right. During a concurrent interview and record review on 2/10/2026, the care plan indicated bilateral padded side rails were to remain up at all times for seizure precautions, but the Physician Order Summary did not show an order for padded side rails. During observation in the resident’s room, the bed had four side rails up with no padding. LVN 6 stated the resident had a history of seizure disorder and that without an order and padding in place, the resident could be at increased risk for head injury or trauma during seizures.
Improper Use of Side Rails Without Required Orders, Assessment, or Consent
Penalty
Summary
The facility failed to safely use side rails for five sampled residents by not following physician orders and by not completing required assessments and consent processes before using the rails. The report states that the facility did not have a physician's order for Resident 55 and Resident 6's use of side rails as used, and that Resident 6 was observed with all four side rails up even though the order was for bilateral side rails up at all times. The report also states that Residents 6, 8, 24, 29, and 55 did not have documented entrapment risk assessments or informed consent for the use of bed rails prior to use. Resident 6 was admitted with tracheostomy and dysphagia and was described in the H&P as lacking capacity to make his own decisions, while the MDS indicated some cognitive decline but that he could make himself understood and understand others. During observation, Resident 6 was sitting up in bed with four side rails up. RN 1 later reviewed the record and stated there was only an order for bilateral side rails and that all four should not have been up. RN 1 also stated there was no consent for bed rail use and no entrapment assessment. Resident 8 was admitted with cardiopulmonary arrest, respiratory failure, encephalopathy, hypertension, and DM, and was comatose and totally unresponsive to verbal and painful stimuli. Resident 8's MDS showed dependence for all ADLs and rolling in bed. During observation, Resident 8 was lying in bed with four side rails up, while the order summary showed an order for bilateral side rails up at all times. LVN 6 stated the four side rails were up to prevent falls. Resident 24 was admitted with traumatic encephalopathy following head injury, history of respiratory failure, permanent tracheostomy, and seizure disorder, and was awake, responsive, and able to verbalize slightly. The MDS showed moderately impaired cognitive skills and dependence for all ADLs and rolling. Resident 24 was observed in bed with four side rails up, but the order summary called for bilateral padded side rails for seizure precautions. LVN 6 stated the four side rails were up to prevent falls and that lack of padding could result in head injury or trauma during a seizure episode. Resident 29 had chronic respiratory failure with hypoxia, seizure disorder, traumatic subdural hemorrhage, and dysphagia, with moderate cognitive impairment and dependence for all ADLs and transfers. Resident 29 was also observed with four side rails up and no padding, although the order summary called for bilateral padded side rails at all times. LVN 6 stated the rails were up to prevent falls and that lack of padding could result in head injury or trauma during a seizure. Resident 55 had chronic traumatic encephalopathy following head injury, history of seizure disorder, respiratory failure, tracheostomy, and gastrostomy, and was comatose and dependent for all ADLs and rolling. Resident 55 was observed with four side rails up and no padding. The care plan indicated bilateral padded side rails were to remain up at all times for seizure precautions, but the physician order summary did not document an order to maintain padded side rails up at all times. LVN 6 stated that without an order and padding in place, Resident 55 could be at increased risk for head injury or trauma in the event of seizures.
Controlled Substance Access, Destruction Documentation, and Reconciliation Failures
Penalty
Summary
The facility failed to provide immediate access to controlled substances and an emergency medication kit stored in a refrigerator in Medication Room Subacute 2. During observation, RN 4 could not open the double locks on a clear plastic container inside the refrigerator that held controlled substances for several residents and an eKIT. Several nurses were unable to open the container, and the pharmacy and engineering departments were called to assist. The Director of Pharmacy stated he did not have keys to the container, and Engineering stated it did not have keys either. Later, the container was opened and was found to contain midazolam vials for several residents and an eKIT labeled 24 containing Ativan for facility stock. The facility also failed to include verifying signatures of two licensed nurses on four Facility Medication Destruction Form records located in Medication Room Subacute 2. RN 4 reviewed the records and could not locate the signatures or names of the licensed nurses on the disposition logs. The records dated 1/2/2026 and 2/9/2026 showed the prepared by, checked by, and verified by sections were blank. The DON also reviewed the forms and stated the witness signatures could not be located and that licensed nurses failed to include signatures of witnesses when destroying medications. In addition, the facility failed to reconcile two medication eKITs containing controlled substances for February 2026 in Medication Room Subacute 2 and Medication Room Subacute 3. RN 4 and RN 2 each observed an eKIT in the refrigerator without an accountability log for shift-by-shift reconciliation. The DON stated the eKITs labeled 2 and 24 were not reconciled at every shift in February 2026. The facility also failed to complete an accurate controlled substance reconciliation at shift change for Medication Cart Subacute Cart 2. LVN 4 and LVN 5 signed the Floor Narcotic Release log at 7 a.m. without verifying the controlled substance inventory in the refrigerator because they could not open the locked container, yet the log indicated the count was accurate and there were no shortages or overages.
Unlabeled insulin pen and mixed storage of eye and ear drops
Penalty
Summary
One open and used Lantus SoloStar insulin pen for Resident 4 was observed stored at room temperature in Medication Cart Subacute 2 Cart 2 without a date showing when room-temperature storage or use began. During the observation, LVN 3 stated the insulin pen was open, used, stored at room temperature, and not labeled with the date it was opened, and stated it was a multi-dose medication that should be discarded after 28 days of use. LVN 3 also stated it was unknown when the pen had been opened or when it would expire. In the same medication cart bin, three insulin Lantus SoloStar pens were stored together with one earwax softener drop and one lubricant eye drop. LVN 3 stated internally administered medications and externally administered medications such as eye drops and ear drops should be stored separately in their own sections or bins to prevent wrong-route administration and possible infections or contamination. The DON later confirmed that the Lantus SoloStar pen was not labeled with the date it was first opened and used, and that several LVNs failed to label the date the pen was opened and used. The facility policy titled Storage of Medications stated that medications and biologicals shall be stored safely, securely, and properly according to manufacturer recommendations, that eye medications shall be kept separate from ear medications, and that opened insulin pens must have the open date written down and be discarded according to the storage table. The manufacturer guidance for Lantus SoloStar stated the pen should be used for up to 28 days after first use and then thrown away, even if insulin remains in the pen.
Unsafe Ice Storage and Handling in Kitchen
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when purchased bags of ice, still in their original packaging, were placed on top of ice made by the ice maker and used for 14 of the 60 residents who eat and drink food prepared by the kitchen. During a kitchen tour, three bags of purchased ice were observed mixed with ice made by the ice maker. During a concurrent interview, the Dietary Manager stated the ice maker sometimes does not work well and the facility has to purchase separate bags of ice, but the ice should have been removed from the bags to prevent cross contamination. The facility policy titled Ice Machine, last revised on 1/29/2026, stated that when ice comes in contact with food and beverages it shall be from a sanitary source.
Call Light Not Accessible or Usable for Two Residents
Penalty
Summary
The facility failed to reasonably accommodate resident needs and preferences by not ensuring call lights were within reach or usable for two residents. Resident 5 was admitted with chronic hypoxemic respiratory failure, dependence on respirator/ventilator status, and Guillain-Barre syndrome, and was described as bedbound. His MDS showed he was dependent for eating, oral hygiene, toileting hygiene, personal hygiene, showering, dressing, and rolling left and right. During observation, Resident 5 was lying in bed with a touch-activated call light placed on the left side above his head, out of reach, and he stated he taps the call light with his head when he needs help but sometimes cannot reach it because of where it is placed. During the same observation, the call light remained out of Resident 5's reach, and an LVN stated the touch-activated call light was what he used to let staff know he needed help and should always be within reach. The LVN also stated that without the call light, Resident 5 did not have a device to let staff know he needed help. The DON stated staff are expected to make sure call lights are always within residents' reach and responded to timely, and the facility's care plans for Resident 5 included interventions to ensure the call light was available, within reach, and placed within easy reach. Resident 24 was admitted with traumatic encephalopathy following head injury, history of respiratory failure, permanent tracheostomy, and seizure disorder. His H&P stated he was awake, responsive, and able to verbalize slightly, while the MDS indicated moderately impaired cognitive skills and dependence for all ADLs and rolling left and right. During observation, a standard push button call light was tied to the right upper side rail near Resident 24's shoulder, while his wrists and fingers were contracted bilaterally. Resident 24 stated he was yelling for a nurse because he did not know where the call light was or how to use it, and an LVN later confirmed he could not move his wrists and fingers well enough to use the standard call light.
Failure to Assist Two Residents With Advance Directives
Penalty
Summary
The facility failed to follow its Advance Directives policy by not providing assistance to two residents who indicated they wanted further discussion about advance directives. Resident 2 was admitted with diagnoses including a history of assault with spinal cord injury and chronic respiratory failure with ventilator dependence; the H&P noted impaired mental status, though the resident was able to make needs known and make some decisions, and the MDS later described the resident as cognitively intact and dependent for all ADLs. Resident 27 was admitted with diagnoses including chronic respiratory failure and a seizure disorder; the H&P described the resident as alert and oriented, and the MDS described the resident as cognitively intact and dependent for all ADLs except eating, which required moderate assistance. During a concurrent interview and record review, the Social Worker reviewed both residents’ Advance Health Care Directive Acknowledgments, which showed that neither resident had an advance directive but both had indicated they wanted to discuss advance directives further and that nursing should refer them for follow-up. The Social Worker stated there was no documentation that either resident had been met with to follow up on an advance directive and that neither had an advance directive on file. The facility policy stated that if a resident has not established an advance directive, the facility will offer assistance to establish one, the resident may accept or decline, and nursing staff will document the offer and the resident’s decision.
G-tube Flush Volume Not Given as Ordered
Penalty
Summary
The facility failed to provide G-tube care in accordance with professional standards for one resident who was receiving medications and water flushes through a gastrostomy tube. During an observation in the medication cart area, an LVN flushed the resident’s G-tube with 25 ml of water, then administered amiodarone, losartan, polyethylene glycol 3350, amlodipine, docusate, ferrous sulfate, metoprolol, and magnesium oxide through the tube, using 5 ml water flushes between each medication, and finished with another 25 ml flush. The LVN stated that flushing before and after medication administration was standard practice and acknowledged that the physician order required 30 ml of water before and after medication administration through the G-tube, but the LVN used 25 ml instead because it fell within a usual range of 20 to 30 ml. The resident’s record showed a history of respiratory distress, MCA occlusion, and dysphagia, and the care plan identified dependence on tube feeding and water flushes. The order summary and MAR both directed staff to flush the tube with 30 ml of water before and after medication administration. The facility’s medication administration policy stated to flush the tube with approximately 30 ml of water and with a minimum of 30 ml of water. The DON confirmed that the resident’s order required 30 ml flushes and stated the LVN failed to flush the G-tube with the ordered amount during medication administration.
Failure to Use Ordered SCD for DVT Prophylaxis
Penalty
Summary
The facility failed to provide preventative care according to physician orders for one resident with a history of DVT and pulmonary embolism. The resident’s record showed an order for SCD use for DVT prophylaxis at all times, but during observation the SCD was found hanging over the footboard of the bed, disconnected from the resident, and turned off. The resident was observed lying in bed with side rails up, and the device was not in use as ordered. During interview, an RN stated the resident had a history of DVT and confirmed that not using the SCD placed the resident at great risk for blood clots and serious health problems. The RN also stated the resident’s care plan did not include documentation for SCD use, and that this could lead to staff not using the device consistently. The DON stated that not applying the SCD as ordered for a resident with a history of DVT could increase the risk of blood clots and pulmonary embolism. The facility policy stated that, except when removed for skin checks or bathing, the SCD device and sleeves should remain in place.
Failure to Apply Ordered AFO Splints
Penalty
Summary
Facility staff failed to provide appropriate services, equipment, and assistance to maintain or improve the mobility of Resident 8 by not applying bilateral ankle-foot orthoses (AFOs) in accordance with the facility’s splinting protocol and the physician’s order. Resident 8 was originally admitted and later readmitted to the facility, and the history and physical documented diagnoses including cardiopulmonary arrest, respiratory failure, encephalopathy, hypertension, and diabetes mellitus. The resident was comatose and totally unresponsive to verbal and painful stimuli. The MDS dated 12/24/2025 indicated the resident was dependent for all ADLs and dependent with rolling left and right. During observation on 2/9/2026, Resident 8 was seen with bilateral wrist and ankle contractures and no splints applied. On 2/10/2026, RN 3 reviewed the medical record and stated the physician ordered continuation of the RNA/nursing program for application of bilateral AFOs per splinting protocol, which required splints to be applied per order and removed every 2 hours for skin integrity and circulation checks. During the same date’s observation, Resident 8 again was not wearing the ankle splints. RN 3 stated that not having the splints applied as ordered could place the resident at risk for worsening contractures and reduced mobility. The DON stated that not applying splints as ordered was not acceptable practice and could lead to worsening contractures, increased muscle spasms, and further loss of function. The facility policy stated splints are to be worn according to the schedule determined by written physician order.
Improper Indwelling Catheter Positioning
Penalty
Summary
The facility failed to ensure appropriate catheter care and prevention of urinary tract infections for two sampled residents with indwelling urinary catheters. Resident 1 was admitted with diagnoses including acute hypoxemic respiratory failure, diabetes mellitus, and a history of UTI. The resident’s MDS showed severe cognitive impairment and dependence for oral hygiene, toileting hygiene, personal hygiene, bathing, and dressing. The physician ordered a Foley catheter for wound management, and the care plan identified the resident as at risk for urine backflow and UTI, with instructions to apply a leg strap and maintain proper alignment of the catheter free of kinks. During observation, Resident 1 was found lying in bed with the urinary catheter bag hanging from the bed frame, urine present in the tubing near the urethral meatus, and a dependent loop in the tubing. The resident had an empty leg strap on the thigh without the catheter attached. The LVN stated the leg strap should secure the catheter to prevent dislodgement and maintain drainage, and that improper placement could allow urine to flow back and cause a UTI. The DON stated the catheter should be secured with a leg strap, the bag should hang below bladder level, and tubing should not be kinked or contain dependent loops because this may cause urine to flow back and potentially result in a UTI. Resident 8 was admitted and later readmitted with diagnoses including cardiopulmonary arrest, respiratory failure, encephalopathy, hypertension, and diabetes mellitus. The resident was comatose, totally unresponsive, and dependent on staff for all ADLs, including rolling left and right. During observation, Resident 8’s suprapubic indwelling urinary catheter was secured to the left thigh, and the drainage tubing was laid over a positioning wedge above the level of the bladder, with urine visibly backing up toward the resident’s body. RN 3 stated the tubing was above bladder level and that this positioning could increase the risk for UTIs and CAUTIs. The DON stated it was not acceptable for catheter tubing to be positioned above bladder level and that the tubing must remain below bladder level.
Inaccurate Documentation of Bubble Humidifier Change
Penalty
Summary
The facility failed to maintain accurate clinical records for one of four sampled residents when a respiratory therapist documented on the MAR that the resident's bubble humidifier had been changed even though it had not been changed. Resident 13 was admitted with chronic hypoxemic respiratory failure, CVA, and post PEG status, and the H&P indicated the resident was unable to make decisions. The MDS indicated the resident rarely or never could make self-understood or understand others and was dependent for multiple activities of daily living. During observation, a bubble humidifier dated 2/4 was seen connected to the resident's oxygen tubing. RT 1 stated the date on the humidifier indicated when it was last changed, and that it had not been changed as scheduled. The physician's order required the bubble humidifier to be changed every Monday, Wednesday, and Friday morning, but the MAR showed initials on 2/6 at 9:00 a.m. indicating the task was completed. RT 2 stated he documented the task before going to the bedside, did not actually change the humidifier because the resident was occupied receiving care from another staff member, and then forgot to return. The DON stated documentation should be done only after the intervention has been performed.
Failure to Complete Antibiotic Time-Out
Penalty
Summary
The facility failed to implement its Antibiotic Stewardship Program for one sampled resident by not completing an Antibiotic Time-Out within 48 to 96 hours of starting antibiotic therapy, as required by the facility's policies and procedures. Resident 8 was originally admitted to the facility and later readmitted, and the History and Physical dated 12/19/2025 documented diagnoses including cardiopulmonary arrest, respiratory failure, encephalopathy, hypertension, and diabetes mellitus. The resident was comatose, totally unresponsive to verbal and painful stimuli, and the MDS dated 12/24/2025 indicated the resident was dependent on staff for all ADLs and dependent with rolling left and right. During a concurrent interview and record review on 2/11/2026, the Infection Preventionist Nurse reviewed Resident 8's records and found an order for Zosyn solution 3-0.375 gm/50 ml, to be given intravenously every 8 hours for elevated WBC for 7 days. The IPN stated the facility's policy required an antibiotic time-off within 48 to 72 hours of antibiotic initiation to assess effectiveness, but there was no documentation of an antibiotic time-out assessment. During an interview on 2/12/2026, the DON stated the facility's policy was to perform and document an antibiotic time-out for residents on antibiotics, expected within two to four days of starting treatment. The facility's policy and procedure titled Antibiotic Stewardship Program, reviewed/revised in January 2026, stated the facility would utilize a process for completion of an Antibiotic Time-Out between 48 and 96 hours of therapy initiation.
Failure to Provide Required Annual Dementia Training
Penalty
Summary
The facility failed to ensure that one sampled CNA, who was also a Restorative Nursing Assistant, received the required annual in-service training in dementia management. During a concurrent interview and record review with the Human Resources Supervisor, the employee file for RNA 2 was reviewed, and the HRS stated there was no record of dementia training in the last 12 months. The deficiency involved the facility’s review of staff training records and showed that the required dementia-related education had not been documented for this CNA. During an interview with the Director of Staff Development, he stated he was responsible for ensuring required trainings were completed and acknowledged that dementia training had not been provided to RNAs in the last 12 months. He stated that dementia management training would be provided annually moving forward and explained that the training is intended to improve staff knowledge about dementia and resident care. The facility’s policy titled Sub-Acute Staff Training stated that all sub-acute staff must participate in annual in-service training, including dementia management and resident abuse prevention, and that training requirements are to be met prior to staff providing services, annually, and as necessary based on the facility assessment.
Failure to Involve Conservator in Medical Appointment Cancellation
Penalty
Summary
The facility failed to ensure that a resident's conservator was included in the decision to cancel a scheduled dermatology appointment. The resident, who was admitted for long-term care following head trauma resulting in cerebral swelling and a right temporal contusion, had a dermatology consult scheduled for a skin lesion related to dermatitis. The appointment was canceled due to a lack of available staff to accompany the resident, and the conservator was not consulted prior to this decision. Instead, the conservator was only notified after the cancellation and informed of the need to reschedule. Interviews with facility staff confirmed that there was no communication with the conservator before the appointment was canceled, despite the conservator's legal authority to make medical decisions for the resident. The facility's own admission agreement and resident rights documentation indicated that residents and their representatives have the right to participate in care planning and to be informed about medical appointments. The Director of Staff Development acknowledged that the lack of communication with the conservator before canceling the appointment was a violation of the resident's rights.
Failure to Inform Family of Resident's Care Plan and Condition
Penalty
Summary
The facility failed to inform the family of a resident's plan of care and change of condition, leading to anxiety for the family due to their lack of input into the resident's treatment. During an observation, the resident was seen with a tracheostomy and was able to speak in short sentences. The resident mentioned that his mother visits daily, but he was unaware of the outcome of discussions regarding his treatment. The Chief Nursing Officer admitted to not having direct conversations with the resident's mother, despite the resident being a candidate for transfer to a lower level of care. The facility's Social Worker acknowledged that there was a delay in obtaining a neurosurgery consultation due to insurance issues and confirmed that the family had not been included in previous Inter-Disciplinary Team (IDT) meetings. The resident's medical records indicated a history of traumatic subdural hemorrhage and chronic respiratory failure, with a plan for transfer to a facility providing a lower level of care. However, the resident's mother was unable to care for him at home, and there was no record of communication with her regarding the resident's current medical condition. The Social Worker's job description emphasized the importance of maintaining regular contact with residents' families and updating them on significant changes or concerns. Despite this, the facility failed to include the family in the resident's care planning process, as evidenced by the lack of documentation of communication with the family and their exclusion from IDT meetings. This deficiency highlights a breakdown in communication and collaboration between the facility and the resident's family, impacting the resident's care and the family's involvement in decision-making.
Failure to Submit Staffing Data for Two Quarters
Penalty
Summary
The facility failed to electronically submit staffing information based on payroll data to the Centers for Medicare and Medicaid Services (CMS) for two fiscal quarters in 2024. Specifically, the facility did not submit the required Payroll-Based Journal Staffing Data Report (PBJ-SDR) for the 3rd quarter (April 1 to June 30) and the 4th quarter (July 1 to September 30) of 2024. This deficiency was identified during an interview and record review with the Director of Staff Development (DSD), who revealed that the individual responsible for submitting the PBJ-SDR was on medical leave. Additionally, the previous facility Administrator and Director of Nursing (DON), who had access to the reporting portal, were no longer employed by the facility, which contributed to the failure to submit the data. The facility's policy, titled PBJ Data Submission Specifications, dated April 16, 2020, mandates that staffing and census information be reported electronically to CMS through the Payroll-Based Journal system in compliance with section 6106 of the Affordable Care Act. The policy specifies that staffing information should be collected daily and submitted for each fiscal quarter no later than 45 days after the end of the reporting quarter. The failure to adhere to this policy resulted in incomplete and inaccurate direct care staffing information being unavailable to the public for the specified quarters.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, leading to potential inadequate care. For Resident 46, who was admitted with diagnoses including stroke, tracheostomy, gastrostomy, and seizure disorder, the facility did not create a care plan addressing the Restorative Nursing Assistant (RNA) program. Despite a physician's order for passive and active assistive range of motion exercises, no person-centered interventions were developed, which could result in inadequate monitoring and care for the resident's condition. For Resident 57, who was admitted with chronic renal failure and type 2 diabetes mellitus, the facility did not develop a short-term care plan for antibiotic therapy after a change in condition due to pneumonia. The absence of a care plan meant that adverse reactions to the prescribed antibiotic, Zosyn, could go unmonitored, potentially leading to complications such as dehydration. The facility's policy required a care plan to ensure timely intervention and effective treatment evaluation, which was not followed. Similarly, Resident 55, who was in a persistent vegetative state and diagnosed with dysphagia and hypertension, did not have a care plan developed for antibiotic therapy after a change in condition due to urosepsis. The lack of a care plan for monitoring adverse reactions to Zosyn could result in unaddressed complications. The facility's failure to adhere to its care planning policy, which mandates updates upon changes in condition, contributed to these deficiencies.
Failure to Involve Residents in Care Planning and Update Care Plans
Penalty
Summary
The facility failed to ensure that the Interdisciplinary Team (IDT) invited residents or their representatives to participate in care conferences for three out of five sampled residents. This lack of involvement was observed in residents who were in a persistent vegetative state and totally dependent on staff for self-care. The facility's policy encourages the participation of residents or their representatives in IDT meetings to ensure the care plan is resident-centered. However, the facility did not extend invitations to the representatives of these residents during several IDT meetings, potentially leading to care plans that were not tailored to the residents' needs. Additionally, the facility failed to update and revise a resident's care plan after the removal of an indwelling catheter. The resident, who had a history of hemorrhagic stroke and recurrent urinary tract infections, had their catheter removed, but the care plan was not revised to reflect this change. The care plan continued to include interventions related to the catheter, which was no longer applicable. This oversight was acknowledged by the MDS Nurse and the Director of Nursing, who stated that care plans should be updated immediately after such changes to ensure accurate medical records and appropriate care. The facility's policy on care planning requires that a coordinated and comprehensive written plan be developed based on the resident assessment instrument and updated upon any change of condition. However, the failure to revise the care plan after the catheter removal indicates a lapse in adhering to this policy. The Director of Nursing emphasized the importance of having care plans that reflect the current condition of residents to provide appropriate care and services.
Failure to Implement Safety Measures for Residents
Penalty
Summary
The facility failed to implement necessary accident risk and hazard interventions for three residents, leading to potential injury risks. Resident 30, who has a seizure disorder, was observed without the required padding on the bed side rails, despite physician orders and care plan interventions specifying the need for such precautions. The Licensed Vocational Nurse confirmed the absence of padding and acknowledged the risk of injury during a seizure. Similarly, Resident 34, also diagnosed with a seizure disorder, was found without padded side rails, contrary to physician orders and care plan directives. The Director of Nursing confirmed that the staff did not implement the required seizure precautions, which could result in injuries during seizure activity. Resident 18 experienced issues with a broken wheelchair, which had a malfunctioning hand brake and footrest. Despite the resident's intact cognitive skills and ability to voice concerns, the wheelchair remained unrepaired for two weeks, with the resident resorting to using a rubber band to hold the hand brake in place. The Registered Nurse acknowledged awareness of the broken wheelchair components and admitted to not following up on the repair status. The Director of Nursing confirmed that staff failed to ensure the wheelchair was functioning properly, posing a risk of falls and injuries. The facility's policies and procedures for seizure precautions and safety precautions were not adhered to, as evidenced by the lack of padded side rails for Residents 30 and 34 and the unresolved issues with Resident 18's wheelchair. These deficiencies highlight the facility's failure to provide a safe environment and adequate supervision to prevent accidents, as required by their own guidelines.
Deficiencies in G-Tube Management and Labeling
Penalty
Summary
The facility failed to properly manage the administration of medications and feeding through gastrostomy tubes for several residents, leading to potential health risks. In one instance, a Licensed Vocational Nurse (LVN) did not check the residual volume in the stomach of a resident in a persistent vegetative state before administering Tramadol via a G-tube. This oversight could have increased the risk of aspiration pneumonia, as the medication might have been delivered into the lungs if the tube was improperly placed. Another deficiency was observed with a resident whose G-tube feeding bottle was not labeled with the date and time it was started. This lack of labeling made it impossible to determine if the feeding formula had been used for more than 24 hours, posing a risk of infection from spoiled formula. The facility's policy requires that feeding bottles be labeled to ensure they are changed within the safe time frame. Additionally, the facility did not label a feeding syringe with the resident's name and the date it was last changed, which could lead to cross-contamination and increased risk of healthcare-acquired infections. Furthermore, another resident's feeding formula was not labeled with the time, date, and initials of the nurse who initiated it, potentially allowing the formula to exceed its safe hang-time, which could cause adverse reactions. These deficiencies highlight lapses in following established protocols for enteral feeding management.
Physician Orders Not Properly Signed and Dated
Penalty
Summary
The facility failed to ensure that physicians signed and dated all orders in the physical or electronic records during visits for three residents. Resident 4, who was admitted with respiratory failure and had severe cognitive impairment, had several telephone orders related to physical therapy and nursing assistance that were not signed, dated, or timed by a physician. These orders included evaluations and exercises for maintaining the resident's functioning, as well as the application of supportive devices. Resident 13, who was cognitively intact and had diagnoses of diabetes mellitus and anemia, had multiple medication and laboratory orders that lacked dates and times. These orders included medications for weight loss and allergies, as well as laboratory tests and imaging studies. Similarly, Resident 51, who was severely cognitively impaired and dependent on staff for daily activities, had an order for laboratory tests related to iron levels that was not dated or timed. Interviews with the Director of Staff Development and the Director of Nurses confirmed that the orders were not properly signed, dated, or timed, which is against the facility's policy. The facility's policy requires that all medication orders be clear, complete, and signed by a licensed physician, with telephone orders countersigned within five days. The lack of proper documentation could lead to delays in the residents' care plans.
Failure to Conduct Timely Social Service Assessment
Penalty
Summary
The facility failed to implement its policy and procedure for conducting a social service assessment within 48 hours of admission for a resident. The resident, who was admitted with complex medical conditions including stroke, tracheostomy, gastrostomy, and seizure disorder, did not receive a timely social service assessment. Despite having intact cognitive skills and being dependent on staff for various daily activities, the resident reported not having seen a social worker since admission. The social worker confirmed that no assessment was conducted due to being overwhelmed with other assignments. The facility's policy requires social workers to meet with residents within 24 hours of admission and complete an initial assessment within 48 hours. This assessment is crucial for gathering psychosocial information pertinent to the resident's adjustment and well-being. The Director of Nursing acknowledged the lapse, emphasizing the importance of timely assessments to address psychosocial concerns and assist with the resident's adjustment to the facility. The failure to conduct the assessment as per policy placed the resident at risk of not receiving appropriate social services to meet their needs.
Medication Administration and e-Kit Replacement Deficiencies
Penalty
Summary
The facility failed to ensure that the Controlled Drug Record (CDR) coincided with the Medication Administration Records (MAR) for two residents, which could lead to medication errors or drug diversion. Resident 6, who was severely impaired in cognition and dependent on staff for daily activities, had discrepancies in the administration of Norco and lorazepam. The CDR indicated that these medications were removed on specific dates, but there were no corresponding entries in the MAR. Similarly, Resident 42, who was cognitively intact but required assistance with daily activities, had a discrepancy with the administration of Norco. The CDR showed that Norco was removed, but the MAR did not reflect this administration. The facility also failed to replace the refrigerator emergency kit (e-Kit) within 72 hours after medications were removed for three residents. Resident 4, who was severely impaired in cognition and had a diagnosis of seizures, received Ativan from the e-Kit, but the kit was not replaced in a timely manner. Resident 27, also severely impaired in cognition and with a seizure diagnosis, had a similar issue with the e-Kit not being replaced after Ativan was administered. Additionally, Resident 14, who had a seizure disorder and was totally dependent on staff, had an e-Kit opened for Ativan, but the replacement process was not followed, and the log for usage was missing. Interviews with staff, including the Director of Staff Development (DSD) and the Director of Nursing (DON), revealed that the process for documenting medication administration and replacing the e-Kit was not followed. The facility's policies and procedures required immediate documentation on the MAR after administering controlled drugs and prompt replacement of the e-Kit within 72 hours. However, these protocols were not adhered to, leading to potential delays in pharmaceutical services and inadequate documentation of medication administration.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications, leading to potential risks of administering expired or discontinued drugs. In one instance, an open potassium chloride solution used for a resident with severe cognitive impairment and total dependency on staff was found without an open date, making it difficult to determine its beyond use date. This oversight was confirmed by a registered nurse during an observation of the medication cart. Another deficiency involved the storage of an open and discontinued chlorhexidine solution in the medication cart for a resident who had no physician's order for this medication. The solution was not labeled with an open date, and the Director of Staff Development acknowledged that medications without orders should be removed promptly to prevent medication errors. The facility's policy mandates the removal of outdated or discontinued medications, which was not adhered to in this case. Additionally, a container of Vitamin A and D ointment was found in a medication cart without an open date. The Director of Staff Development confirmed that all opened medications should be dated to track their shelf life. The facility's policy requires that floor stock medications not be maintained beyond the manufacturer's expiration date or 180 days after opening, which was not followed in this instance.
Improper Food Storage Practices in Facility Freezers
Penalty
Summary
The facility failed to ensure proper food storage practices by not labeling food stored in the facility's freezers with the date they were placed in the freezer. This deficiency was observed during a survey when a registered dietician found an unlabeled plastic bag containing five individually sealed frozen pork chops in Freezer 1 and an unlabeled bag of frozen fish sticks in Freezer 2. Both the registered dietician and the dietary supervisor confirmed that all food items in the freezer are required to be labeled with the date they were placed in the freezer. The facility's policy and procedure for Food and Nutrition Services, last reviewed in March 2021, also indicated that frozen foods should be labeled with the name of the item and date of delivery for easy identification. This practice had the potential to place 17 out of 58 residents who receive food from the facility's kitchen at risk for foodborne illnesses.
Infection Control Lapses in PPE Usage
Penalty
Summary
The facility failed to maintain proper infection control practices in several instances, leading to potential cross-contamination and infection spread. In one case, a housekeeper entered a resident's room, which was under contact isolation due to Carbapenem-resistant Enterobacterales (CRE) and Extended-Spectrum Beta-Lactamases (ESBL) in the urine, without donning a gown. After collecting trash, the housekeeper exited the room, removed gloves, and failed to perform hand hygiene. This was observed by a Licensed Vocational Nurse (LVN), who confirmed that all staff entering such rooms are required to wear gloves and gowns and perform hand hygiene to prevent infection spread. In another instance, a Licensed Vocational Nurse (LVN) administered medication via a gastrostomy tube to a resident on enhanced barrier precautions without wearing a protective gown. The LVN acknowledged the oversight and recognized that wearing a gown is necessary to prevent cross-contamination, as staff clothing can become contaminated when caring for multiple residents. The facility's policy requires staff to don personal protective equipment, including gowns, during high-contact resident care activities. A third incident involved another LVN who administered enteral feeding and medication via a gastrostomy tube to a resident on enhanced barrier precautions without wearing a gown. The LVN was unaware of the requirement to wear a gown during such procedures. The Director of Staff Development and the Infection Preventionist confirmed that the facility's policies mandate the use of gowns and gloves during high-contact activities to prevent the spread of multidrug-resistant organisms. These deficiencies highlight lapses in adherence to infection control protocols, potentially compromising resident and staff safety.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light was within reach of Resident 11, who was totally dependent on staff for all activities of daily living and had intact cognition. Resident 11 was admitted with diagnoses including Guillain-Barre syndrome, diabetes mellitus type 2, and hypertension. The resident's care plan specifically indicated that the call light should be placed within easy reach at the bedside. However, during an observation, it was noted that the adaptive call light was positioned on the left side of the head of the bed, out of reach for the resident, who could only move his head. Interviews with Registered Nurse 3 and the Director of Staff Development confirmed that the call light was not within reach, which contradicted the facility's policy and procedure. The policy required that call cords be placed within the resident's reach at all times. The staff acknowledged that the deficient practice could prevent the resident from requesting assistance and potentially lead to falls. The facility's policy emphasized the importance of ensuring that call lights are always accessible to residents.
Failure to Follow Advance Directive Policies
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding advance directives for two residents, Resident 46 and Resident 35. For Resident 46, the facility did not provide written information about the right to refuse or accept medical or surgical treatments and to formulate an advance directive upon admission. This was confirmed during interviews with Registered Nurse 1 and Social Worker 1, who acknowledged that the Advance Directive Acknowledgment form was not completed for Resident 46 upon admission, which is a violation of the resident's right to be informed about advance directives. Resident 46 was admitted with several medical conditions, including a stroke, tracheostomy, gastrostomy, and seizure disorder. Despite having intact cognitive skills for daily decision-making, the facility did not ensure that Resident 46 was informed about the option to create an advance directive, as required by the facility's policy. The policy mandates that residents be provided with written information about their rights concerning medical treatment and advance directives upon admission. For Resident 35, the facility failed to maintain a current copy of the resident's advance directives in the clinical record. Although the Advance Directive acknowledgment form indicated that Resident 35 had an advance directive, it was not present in the resident's chart. This oversight was confirmed by Social Worker 1 and the Director of Staff Development, who both stated that a copy of the advance directive should have been kept in the resident's chart to ensure the resident's wishes would be carried out. Resident 35 had severe cognitive impairment and was totally dependent on staff for all activities of daily living, making it crucial for the facility to have the advance directive readily available to guide care decisions.
Failure in Discharge Planning for a Resident with Complex Needs
Penalty
Summary
The facility failed to adhere to its discharge planning policy and procedure for a resident, identified as Resident 60, who was discharged without a proper care plan or discharge planning assessment. The resident, who had significant medical needs including a tracheostomy, gastrostomy, and seizure disorder, was admitted to the facility with severely impaired cognitive skills and was dependent on staff for various daily activities. Despite these needs, the facility did not develop a care plan addressing the resident's discharge plan or initiate a discharge planning assessment prior to the resident's discharge. The review of the resident's records revealed that the interdisciplinary team (IDT) conference notes lacked documentation for psychosocial and discharge planning sections. The social worker, who was responsible for the discharge planning, was on medical leave during the last IDT conference and did not document any discharge planning notes or develop a care plan for the resident's discharge. The social worker acknowledged the oversight and stated that it was important to comply with the facility's discharge policy by documenting all necessary discharge information and conducting required assessments. The Director of Nursing confirmed that the discharge planning for Resident 60 was incomplete, as there was no care plan developed for the resident's discharge needs, and no IDT conference was held to discuss these needs. The facility's policy required the social worker to document the level of care required for discharge within seven days of admission and to update it as needed. However, this was not done, and the discharge planning assessment was not initiated, leading to a lack of provision of necessary discharge care and services for the resident.
Failure to Monitor Orthostatic Hypotension
Penalty
Summary
The facility failed to adhere to a physician's order by not monitoring a resident for orthostatic hypotension on two specific dates, 10/23/2024 and 11/27/2024. This oversight involved a resident who had been admitted to the facility on 8/17/2021 and had a history of dysphagia, bipolar disorder, and schizophrenia. The resident's Minimum Data Set (MDS) indicated intact cognitive skills for daily decision-making and a requirement for supervision in certain activities. The resident was also identified as high risk for falls according to a Fall Risk Assessment. The physician's order, dated 2/3/2023, required monitoring for orthostatic hypotension from 7:00 a.m. to 7:00 p.m. weekly, which was not documented in the Medication Administration Records (MAR) for the specified weeks in October and November 2024. During an interview, a registered nurse confirmed the importance of monitoring for orthostatic hypotension, especially for residents on medications like Zoloft, to prevent potential falls and injuries. The facility's policy emphasized monitoring residents on certain medications for adverse effects, but this was not followed in the case of the resident in question.
Failure to Document Pain Management for Two Residents
Penalty
Summary
The facility failed to ensure proper pain management for two residents, Resident 6 and Resident 42, by not assessing their pain before and after administering pain medication. Resident 6, who was severely impaired in cognition and dependent on staff for daily activities, had orders for Norco to be administered via G-Tube for severe pain. However, the Medication Administration Record (MAR) did not reflect the administration of Norco on several dates, and there was no documentation of pain assessment for those times. Similarly, Resident 42, who was cognitively intact and required assistance with daily activities, had orders for Norco to be administered orally for severe pain. The Controlled Drug Record (CDR) indicated that Norco was removed from the blister pack, but the MAR did not show any record of administration or pain assessment on the specified date. Interviews with the Director of Staff Development (DSD) and the Director of Nurses (DON) confirmed that the process of signing the MAR after administering medication was not followed, which is crucial for assessing the effectiveness of pain relief. The facility's policies and procedures for controlled drug management and medication administration were not adhered to, as the licensed nurses failed to document the administration of pain medication on the MAR. This lack of documentation meant that there was no assessment or reassessment of the residents' pain levels, potentially leaving their pain unmanaged. The DON stated that the absence of documentation on the MAR indicated that pain was not assessed, which could result in the residents' pain not being relieved.
Failure to Act on Pharmacist Recommendations for Medication Review
Penalty
Summary
The facility failed to act upon the consultant pharmacist's recommendations for two residents, leading to deficiencies in medication management. For Resident 17, who was admitted with respiratory failure and was cognitively intact, the facility did not reassess the need for the medication FeroSul, which had been prescribed since admission. Despite the consultant pharmacist's recommendation to reassess the necessity of this medication, there was no documentation indicating that the physician had been contacted to address this concern. Similarly, for Resident 35, who had severe cognitive impairment and was dependent on staff for all activities of daily living, the facility did not follow the consultant pharmacist's recommendation to order blood testing for levetiracetam, a medication used to treat seizures. The recommendation was made to ensure the medication levels were within a safe range, but no Keppra level test was conducted. This oversight was acknowledged by the nursing staff, who recognized the increased risk of medication side effects due to the lack of monitoring. The facility's policies and procedures for medication administration and pharmaceutical services were reviewed, highlighting the requirement for medications to be administered according to physician orders and for any concerns about medication orders to be clarified with the pharmacy. However, the facility lacked a specific policy for addressing the monthly Medication Regimen Review (MRR) and the timeframe for addressing issues raised in the report, contributing to the deficiencies observed.
Failure to Monitor Side Effects of Cymbalta
Penalty
Summary
The facility failed to monitor a resident for side effects associated with the use of Cymbalta, a medication prescribed for depression. The resident, who had a history of Guillain-Barre syndrome, diabetes mellitus type 2, and hypertension, was admitted to the facility with intact cognition but required maximal assistance with activities of daily living. Despite the care plan's directive to monitor for adverse side effects every shift, there was no documentation indicating that the licensed nurses were performing this monitoring. During an interview, a registered nurse confirmed the administration of Cymbalta to the resident over several consecutive days but could not provide evidence of side effect monitoring. The Director of Staff Development acknowledged the necessity of monitoring for adverse side effects to inform the physician and adjust the medication dosage if needed. The facility's policy on psychoactive drug monitoring also required documentation of monitoring for adverse consequences, which was not adhered to in this case.
Failure to Maintain Safe Room Temperatures in Sub-Acute Unit
Penalty
Summary
The facility failed to maintain acceptable room temperatures ranging from 71 to 81 degrees Fahrenheit for 51 residents in the Sub-Acute Unit. This deficiency was identified through observations, interviews, and record reviews. The facility's chillers, which are essential for the air conditioning system, were not functioning properly, and the temporary rental chillers installed as replacements were also not working correctly. The engineering staff did not monitor or record the room temperatures as required by the facility's policies, leading to unsafe conditions for the residents. Interviews with various staff members, including the Chief Nursing Officer, House Supervisor, and engineering staff, revealed that the chillers had malfunctioned, and the rental chillers were installed incorrectly by the vendor. Despite the installation of rental chillers, the engineering staff failed to verify the room temperatures, and no temperature logs were maintained. Observations confirmed that the room temperatures ranged from 77 to 82 degrees Fahrenheit, exceeding the acceptable range and creating a hot environment in the Sub-Acute Unit. The facility's policies and procedures required daily monitoring and documentation of room temperatures, but these were not followed. The engineering department was expected to have a contingency plan for air conditioning failures, but this was not effectively implemented. The lack of proper monitoring and maintenance of the air conditioning system placed the residents at risk, as confirmed by staff interviews and temperature readings.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Sun Valley
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| All Saints Healthcare Subacute | 2.3 mi | ★★★★★ | 36 | 1 |
| Totally Kids Specialty Healthcare - Sun Valley | 2.3 mi | ★★★★★ | 23 | 0 |
| Villa Scalabrini Special Care | 2.4 mi | ★★★★★ | 10 | 0 |
| Panorama Gardens Nursing And Rehabilitation Center | 2.9 mi | ★★★★★ | 22 | 0 |
| Country Manor Healthcare | 3 mi | ★★★★★ | 26 | 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.