Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Park View Nursing And Subacute during CMS and state inspections, most recent first.
A resident with type 2 DM, severe cognitive impairment, and insulin use had multiple elevated BS readings, including values above the physician’s notification threshold. The DON confirmed there was no documentation that the physician was notified in the progress notes or COC form when the resident’s BS was high.
Failure to protect resident PHI in medication waste: A RN observed medication bubble packs and a manufacturer package with pharmacy labels still attached in a medication room waste container, making resident names, DOBs, pharmacy information, medication names, doses, indications, and instructions visible. The RN stated a third-party vendor routinely removes the waste, and the DON confirmed that medication packages should not be discarded with resident PHI attached; facility policy required safeguarding resident records and removing identifiers such as names.
A resident with anxiety was prescribed buspirone for repetitive worrying about her health condition, and the care plan required monitoring of anxiety episodes every shift. However, the MARs showed the medication was given without documentation that the resident’s anxiety symptoms were monitored as required, and the DON acknowledged the missing documentation during record review.
A resident’s care plan for enoxaparin used for CVA prophylaxis lacked measurable goals, duration, and outcomes. Another resident prescribed buspirone for anxiety had a care plan requiring every-shift monitoring, but the MARs did not show that the anxiety monitoring was completed. A third resident at risk for hypo- and hyperglycemia had a care plan calling for monitoring of blood sugar symptoms, but the EMAR did not document that this monitoring occurred; the DON acknowledged each of these gaps.
A facility failed to provide appropriate catheter care and UTI monitoring for three residents. Two residents with Foley catheters were observed with tubing coiled or looped, including stagnant urine and sediment in the tubing, while staff and the DON stated the tubing should hang straight to allow free drainage. For another resident with a suprapubic catheter, the TAR lacked documentation of ordered urine output measurements and UTI monitoring on multiple shifts, despite physician orders and a facility policy assigning the licensed nurse responsibility for implementing and documenting orders.
Failure to Change Oxygen Tubing Every 7 Days: Three residents receiving oxygen therapy had tubing dated with the same date during observation, even though RTs and the DON stated oxygen tubing should be changed every 7 days and as needed. The affected residents had significant respiratory diagnoses and severely impaired cognition or lacked decision-making capacity, and one resident had a tracheostomy. Facility policy for oxygen administration also stated tubing should be changed and dated every 7 days.
A resident prescribed bumetanide for CHF missed a scheduled dose because the medication was not available in the cart or facility. In the Subacute med room, an eKIT containing CMs was not reconciled at each shift change, two medication disposition logs lacked witness initials, and a red waste bin contained intact medication containers and bubble packs that had not been rendered unretrievable.
Failure to Monitor Heparin Side Effects: A resident with acute respiratory failure, DM2, and sepsis received daily heparin for DVT prophylaxis, but the eMAR had no documentation that nursing staff monitored for ordered anticoagulant side effects such as bleeding, bruising, discolored urine, black tarry stools, or changes in mental status/vitals. The DON and MDS nurse both confirmed the lack of documentation despite the physician order and facility anticoagulation policy requiring monitoring.
Medication Error Rate Exceeded Allowed Threshold: Surveyors found 2 medication errors out of 32 opportunities, resulting in a 6.25% error rate. One resident with CHF did not receive ordered bumetanide because it was not available in the med cart or facility, and another resident with HTN was given crushed metoprolol succinate ER instead of the tablet being administered whole. The DON confirmed the missed dose and crushing of the slow-release medication were medication errors, and facility policy required meds to be given as ordered and timed-release tablets not to be crushed.
An RN left the keys to Medication Cart 2 unattended on top of the cart near the nursing station, allowing access to locked drawers containing controlled meds, noncontrolled meds, and OTC meds. The RN stated she was responsible for the keys but forgot them on the cart, and the DON confirmed the keys should remain with licensed staff at all times.
Unsafe food storage and distribution practices were observed in the kitchen. A thickened dairy drink was kept past its printed best by date, an open bag of dry pasta was stored without a seal or closure, and a scoop with flour residue was stored inside a bulk flour container. The DS confirmed the date issue and stated the dairy drink should not be served, and also stated the pasta and scoop storage methods created contamination concerns.
Failure to maintain dignity and privacy when a CNA entered a resident’s room without knocking or asking permission. The resident had paraplegia and GERD, could make self-understood and understand others, and required substantial/maximal assistance with several ADLs. An LVN observed the entry, and both the LVN and CNA acknowledged that staff should knock and request permission before entering a resident’s room.
Unclean and Cluttered Resident Room: A resident with impaired cognition, pneumonia, COPD, and a need for eating clean-up assistance was found with brown food crumbs, dry spilled liquids, an undated cup of milk on the bedside table, and gloves and sugar packets on the floor. CNA, LVN, and RN staff all stated the bedside table and floor should have been cleaned, and the facility’s policy called for a clean, sanitary, and orderly homelike environment.
Resident and Representative Not Included in Care Planning: A resident with paraplegia and GERD, who could make self-understood and understand others, was not included with his representative in the ICC care planning process. RN confirmed the ICC attendees did not include the resident or representative, despite the facility policy encouraging resident and family/representative participation in care plan development and revisions.
An LVN crushed a metoprolol succinate ER tablet and mixed it with applesauce for a resident during medication administration, then handed the mixture to the resident before the surveyor stopped the dose. The LVN acknowledged the tablet should not have been crushed, and the DON confirmed that slow-release medications should be given whole because crushing changes the release of the medication. Facility policy and the DO NOT CRUSH list identified metoprolol succinate as a slow-release tablet.
Failure to offload heels and set support surface correctly: Two residents with significant medical needs and pressure injury risk were observed with care not matching their plans and equipment instructions. One resident with heel wounds was found in bed with both feet flat instead of heels floated on pillows, despite staff stating the heels needed to be offloaded to support healing. Another resident with severe cognitive impairment and total ADL dependence was on a LALM set at 355 lbs even though the resident weighed 155 lbs; an LVN confirmed the setting was too high and not therapeutic.
Over-bed table left on floor mat in resident room. A resident with DM, difficulty walking, muscle weakness, and limited decision-making capacity had an over-bed table placed directly on top of a floor mat beside the bed. Staff observed the table in the same unsafe position more than once, and CNA stated nothing should be on the mat because the resident could trip or fall and hit her head. The DON stated floor mats are meant to cushion a fall and that the metal-legged over-bed table was especially dangerous on top of the mat.
Incomplete Post-Dialysis Assessments: The facility failed to complete the post-dialysis assessment for a resident receiving dialysis. The resident had DM II, renal dialysis dependence, and lacked capacity to make decisions. Review of the dialysis binder showed multiple missing post-dialysis weights, missing BP documentation, and one completely blank post-dialysis form. An LVN and the DON stated charge nurses/licensed nurses were responsible for completing the post-dialysis assessment when the resident returned from dialysis.
Incomplete MAR documentation was found for a resident with acute respiratory failure, DM, and sepsis who was receiving sliding-scale Insulin Lispro. The MAR left blank the BG results and insulin units for two evening doses, and the DON and an LVN confirmed the entries were not documented after the BG checks and insulin administration.
A resident on EBP for MDRO risk and a history of Proteus mirabilis did not receive care with proper PPE during high-contact activities. A CNA handled dirty linen without PPE, stating only a bed sheet was changed, and a PA performed an ear exam without PPE after overlooking the EBP sign. Record review also showed the CNA's PPE competency documentation was incomplete and did not show EBP or PPE training.
Missing EBP Competency Training for CNA and LVN: The facility failed to document EBP competency training for two staff members, a CNA and an LVN. Record review and interviews showed the IPN and DSD could not provide evidence that either staff member completed the required annual competency assessment or EBP training, and the facility policies required infection control competency and EBP training upon hire and at least annually.
A resident with DM, stroke, and HTN had an order for SQ insulin lispro per sliding scale before meals and at bedtime. Review of the MAR showed that a RN repeatedly documented insulin doses at times significantly later than the scheduled administration times. In interview, the RN stated insulin was given around mealtime as ordered but documentation on the MAR was completed late rather than immediately after administration. The DON and facility policy both indicated that licensed nurses must document medication administration directly after giving medications and that medication times must follow established timing guidelines.
A resident with a history of stroke, DM, and HTN, and intact cognition, had family concerns about care submitted by email to the ADM. Although the ADM acknowledged receipt, the concern was never entered on a grievance form, logged in the grievance binder, or investigated as required by the facility’s grievance P&P. The SSD and DON confirmed that no grievance was recorded for this resident, despite facility policy requiring staff to initiate a grievance/concern form and log upon receipt of any complaint. This failure violated the resident’s right to voice grievances and have the facility respond.
A resident admitted with stroke, DM, and HTN, who had intact cognition and required moderate assistance with ADLs, did not receive a written summary of the baseline care plan. ICC documentation showed the section indicating that a copy of the care plan was provided was left blank, and the CM and DON could not locate any record that a written baseline care plan summary had been given. Review of the facility’s baseline care plan policy confirmed requirements for timely development of a baseline care plan but did not clearly address providing a written summary to the resident or representative.
A resident with a sacrococcygeal stage III PI was admitted with orders and a care plan for use of a low air loss mattress (LALM) to support wound management, including monitoring for proper settings and functionality. During observation, the resident was found on the LALM with an incontinence brief, a flat sheet, and a cloth incontinence pad, creating four linen layers between the resident and the mattress, contrary to staff statements that only one to two layers should be used for the LALM to work properly. The DSD and DON confirmed that excess linen layers interfere with LALM function and acknowledged there was no specific facility P&P for LALM use, while the existing pressure ulcer protocol only generally referenced physician orders for pressure reduction surfaces.
Surveyors found that multiple residents with orders for low air loss mattresses (LALM) for PU/PI prevention and wound healing were using these specialty beds without any facility policy or procedure in place to guide their use. The DON confirmed there was no written P&P for LALM, including no direction on linen use, and that staff relied on manufacturer guidelines, which did not address linen. The administrator acknowledged that a P&P for LALM should exist to guide care for the many residents using these mattresses, despite job descriptions assigning responsibility for developing and implementing such policies.
A resident with severe cognitive impairment, functional quadriplegia, and multiple comorbidities was observed lying in bed with the call light placed on a bedside table out of reach, despite needing staff assistance for incontinence care and other ADLs. An LVN confirmed the call light was not within reach as required, and a CNA later stated he typically checks call light placement at the start of his shift but had forgotten to do so for this resident. The DON acknowledged that call lights must be within reach so residents can request assistance and that lack of access can lead to delayed care and negatively affect dignity. Facility policies on the call system and dignity require that residents have a means to call staff from bed and be cared for in a way that promotes self-worth and self-esteem.
A resident with traumatic brain injury, seizures, hydrocephalus, type 2 DM, and limited decision-making capacity had a physician order for bilateral AFOs to be applied to the lower extremities several times per week for specified hours with skin checks. During observation, the resident was found in bed with the right AFO rotated to the side and not providing proper support. The DOR confirmed the device was improperly applied, and the RNA who applied it stated he was unaware it was incorrect, while acknowledging it should remain correctly positioned. The DON stated staff should monitor AFO placement and skin condition. Facility policies required trained, competent staff to maintain and supervise assistive devices and to provide appropriate services and equipment to maintain or improve mobility, but the improper AFO application showed these requirements were not followed.
Three residents were placed at increased risk for injury when staff failed to ensure bed siderails were fully padded as ordered for two residents with seizure disorders, and did not provide a required floor mat, adequate lighting, or open curtains for a resident with impaired mobility. Nursing staff confirmed these safety measures were necessary, and facility policies required their implementation.
A licensed nurse failed to measure and document a resident's apical pulse before administering Flecainide, as required by a physician's order for a resident with atrial fibrillation. The nurse relied only on blood pressure and radial pulse checks, was unaware of the specific order, and did not follow established medication administration protocols, resulting in repeated administration of the medication without the necessary assessment.
The facility did not ensure timely replacement or proper documentation of emergency medication kits (E-kits) in two medication rooms after they were opened, and failed to notify the pharmacy as required by policy. A resident with sepsis and severe cognitive impairment was involved, and staff interviews confirmed lapses in following procedures for E-kit management and documentation.
A nurse failed to check a resident's apical pulse before administering Flecainide, as required by the physician's order for a resident with atrial fibrillation. The medication was given multiple times without the necessary pulse check, and the electronic medical record did not prompt for this parameter. The facility's policy and pharmacy recommendations to follow physician orders and monitor vital signs were not followed.
Seven residents on a puree diet were served a lemon crisp dessert that was too thick and did not meet IDDSI Level 4 standards, as confirmed by dietary staff during a test tray observation. The dessert failed the required spoon tilt test, indicating it was not prepared in the appropriate form for residents with dysphagia.
Surveyors found that kitchen staff failed to label and date stored bell peppers, did not check temperatures for several food items on the tray line, and a dietary aide touched his face and glasses with gloved hands without immediately washing hands or changing gloves. These actions were not in accordance with facility policies for food safety and staff hygiene.
A resident with a tracheostomy and ventilator dependence did not have an individualized care plan for oral care, resulting in observed dry, cracked lips and lack of staff intervention. Another resident, with multiple serious diagnoses, was found on the floor without a required floor mat in place, despite an active order and care plan intervention for fall prevention. Both deficiencies were confirmed through observation, staff interviews, and record review.
A resident with an enteral tube did not receive the full dose of crushed medications when an LVN left excess medication in the cups after administration and failed to flush the tube with the physician-ordered amount of water between medications. Both the LVN and DON confirmed that the full dose and proper flush volume were required by orders and facility policy.
A resident who was fully dependent on staff for all ADLs, including oral care, was found with severely dry, cracked lips and a thick layer of dried saliva and skin. The resident, who had multiple complex medical conditions and was on a ventilator and feeding tube, did not receive necessary oral hygiene, as confirmed by a nurse and facility policy review.
A resident with a history of neurogenic bladder and urinary retention, who was dependent on staff for care, was observed with a urinary catheter that had a long dependent loop, coils, and a kink, with visible sediment in the tubing. Staff and policy confirmed that catheter tubing should remain straight and unobstructed, but this was not maintained, contributing to improper catheter care and increased risk of UTI.
A resident with end stage renal disease and severe cognitive impairment did not have their post-dialysis weight documented by the dialysis center, and facility staff did not follow up as required by policy. This resulted in incomplete post-dialysis assessment documentation for the resident's hemodialysis care.
A deficiency was found when an LVN discovered an unlabeled, unpackaged tablet in a medication cart drawer. The LVN and DON both confirmed that all medications should be properly packaged and labeled to ensure correct administration and compliance with facility policy, which requires medications to be stored in legally compliant containers and contaminated medications to be removed immediately.
A resident with multiple diagnoses and unable to provide informed consent was incorrectly documented as having an Advance Directive in their medical record, despite confirmation from both the responsible party and facility staff that no such document existed. This resulted in inaccurate medical recordkeeping regarding the resident's Advance Directive status.
A facility failed to create a comprehensive care plan for a resident who preferred to keep food at their bedside. Despite the resident's diagnoses and preference, the care plan lacked specific interventions to address this, as confirmed by the DON. The facility's policy requires individualized care plans, but this was not implemented, potentially affecting the resident's quality of life and care.
A facility failed to complete a discharge summary for a resident who was readmitted with cervical disc degeneration and other conditions. Despite the resident having intact cognition, no discharge summary was documented upon their discharge, as confirmed by the Medical Records Director and DON. This oversight was against the facility's policy, which requires a discharge summary to be completed within 30 days of discharge.
A facility failed to document a resident's fluid intake, contrary to its hydration policy, placing the resident at risk for dehydration. The resident, with severe cognitive impairment and chronic conditions, required assistance with daily activities. Staff interviews revealed that CNAs did not document fluid intake in milliliters, and the Director of Nursing confirmed that intake was not documented unless ordered. This oversight could lead to dehydration and medical complications.
A facility failed to follow its policy on preventing foodborne illness by not discarding cooked eggs left on a resident's bedside table for over 24 hours. The resident, with COPD and functional quadriplegia, confirmed the eggs were not refrigerated. The Dietary Supervisor acknowledged the eggs should have been discarded after two hours, as per facility policy, to prevent bacterial growth.
A facility failed to implement its Enhanced Barrier Precautions and Hand Hygiene policies, leading to a deficiency in infection control. A CNA did not wear a gown while changing bed linen for a resident on EBP and did not perform hand hygiene after removing gloves. The resident had conditions including diabetes with a skin ulcer and cellulitis, requiring enhanced precautions. Staff interviews confirmed the failure to adhere to policies requiring gowns and gloves during high-contact activities and hand hygiene after removing PPE.
The facility failed to maintain room temperatures between 71-81°F, affecting a resident who reported discomfort due to cold conditions. Observations showed two rooms with temperatures below the required range, and the Maintenance Supervisor acknowledged the need for thermostat adjustments. The resident, with multiple health issues, used an extra blanket to stay warm, highlighting the deficiency in maintaining a homelike environment.
The facility failed to follow its policy on the safe placement of power strips, leading to potential hazards. During a tour, a power strip was found on the floor next to a resident's bed, and another was improperly secured to a bed rail with plastic gloves. Both residents involved had intact cognition. The facility's policy requires power strips to be stored safely to prevent tripping hazards.
A resident with a history of falls experienced an unwitnessed fall, and the facility failed to conduct the required neurological assessment as per its policy. Despite the protocol mandating a 72-hour post-fall assessment, it was not completed, and the assessment was not resumed after the resident returned from the hospital. The DON incorrectly believed a physician's order was needed to continue the assessment, leading to incomplete monitoring and documentation.
A resident with multiple health conditions experienced unrelieved pain due to the facility's failure to ensure timely physician notification for additional pain medication. The LVN faced technical difficulties contacting the on-call physician and did not escalate the issue, instead passing it to the next shift. The facility's pain management policy requires timely physician notification to maintain resident comfort.
Failure to Notify Physician of Elevated Blood Sugar
Penalty
Summary
The facility failed to notify the physician when Resident 48’s blood sugar was elevated, despite a physician order to notify the physician if blood sugar was greater than 400 mg/dL. Resident 48 was admitted with diagnoses including acute respiratory failure, type 2 diabetes mellitus, and sepsis. The MDS dated 2/27/2026 indicated the resident’s cognition was severely impaired and that the resident was receiving high-risk medications for hypoglycemia, including insulin. A review of the order summary showed an order for Insulin Lispro with sliding scale coverage and notification parameters for blood sugar less than 70 mg/dL or greater than 400 mg/dL. During interview and record review with the DON, multiple blood sugar readings were identified in the MAR, including values of 450 mg/dL, 444 mg/dL, 442 mg/dL, and other elevated readings. The DON stated there was no documentation in the progress notes or COC form showing the physician was notified for the dates and times when the resident’s blood sugar was high.
Failure to Protect Resident PHI in Medication Waste
Penalty
Summary
The facility failed to maintain resident protected health information by disposing of medication bubble packs and manufacturer medication packages with pharmacy labels still attached in a red plastic waste container in the Medication Room Subacute. During a concurrent observation and interview, a RN observed one manufacturer medication package for Resident 48 and two medication bubble packs for Resident 6 and Resident 73 with the pharmacy labels intact and visible in the waste container. The labels contained resident names, dates of birth, pharmacy name, medication name, dose, indication, and instructions for use. The RN stated that a third-party vendor routinely picks up the waste containers for disposal of wasted medications and that medication packages in the waste container should not contain resident health information. During a later interview, the DON stated that no medication should be disposed of in waste containers with pharmacy labels and resident PHI attached, and that the labels should be removed and placed in the shredder. The facility's policies on confidentiality and PHI stated that resident personal and medical records must be safeguarded and that identifiers such as names must be removed for health information to be considered not individually identifiable.
Failure to Monitor Anxiety Symptoms for Buspirone Use
Penalty
Summary
The facility failed to ensure that one sampled resident with a diagnosis of anxiety was free from unnecessary use of a psychotropic medication by not monitoring episodes of anxiety as ordered for buspirone use. Resident 75 was admitted and re-admitted to the facility with anxiety and was prescribed buspirone 10 mg by mouth twice daily for anxiety manifested by repetitive worrying about her health condition, starting 4/1/2026. The resident’s care plan, revised 9/18/2024, directed staff to monitor episodes of anxiety manifested by repetitive worrying about her health condition every shift. Review of the May and June 2026 MARs showed buspirone was administered at 9 a.m. and 5 p.m., but there was no documentation that anxiety episodes were monitored every shift. During the concurrent record review and interview, the DON acknowledged the care plan requirement and confirmed the MARs lacked documentation of the required monitoring. The DON stated that without monitoring, it was unknown whether buspirone was effective and that the facility failed to monitor the resident’s anxiety for the use of buspirone.
Incomplete Care Plans and Missing Monitoring for CVA Prophylaxis, Anxiety, and Blood Glucose
Penalty
Summary
Resident 32 had an admission record showing diagnoses including heart failure, morbid obesity, and difficulty walking. Hospital discharge records indicated the resident was to continue enoxaparin 0.4 ml once daily subcutaneously, and the physician order summary showed enoxaparin 40 mg/0.4 ml SQ in the evening for CVA prophylaxis starting 5/19/2026. The resident’s care plan, initiated 5/4/2026, was not revised and did not include goals, duration, or outcomes for enoxaparin use for CVA prophylaxis. During a concurrent record review and interview, the DON reviewed the admission record, order summary, and care plan and acknowledged that the care plan did not have goals, duration, or outcomes for enoxaparin use for CVA prophylaxis. The DON stated the care plan should include goals, duration, and outcomes for residents’ areas of concern and that the lack of a care plan for enoxaparin did not provide person-centered care for Resident 32. The DON also stated that without a care plan for enoxaparin, the facility would not be able to identify improvements or concerns or determine whether goals were met with the current treatment for CVA prophylaxis. Resident 75 had an admission record showing a diagnosis including anxiety. The physician order summary indicated buspirone 10 mg, one tablet by mouth twice daily for anxiety manifested by repetitive worrying about her health condition. The care plan, revised 9/18/2024, included an intervention to monitor episodes of anxiety manifested by repetitive worrying about her health condition every shift, but the May and June 2026 MARs did not contain documentation that this monitoring occurred every shift. The DON acknowledged the care plan required every-shift monitoring for anxiety related to buspirone use and that the MARs did not show the monitoring was completed. Resident 48 had diagnoses including acute respiratory failure, type II diabetes mellitus, and sepsis, and the MDS indicated severely impaired cognition. The physician order summary included heparin for DVT prophylaxis and insulin lispro sliding scale with instructions to notify the physician if blood glucose was less than 70 mg/dL or greater than 400 mg/dL. The care plan identified the resident as at risk for hypoglycemia and hyperglycemia and included monitoring for signs and symptoms of both conditions, but the EMAR from 5/17/2026 to 5/31/2026 did not show documentation that the resident was monitored for hypoglycemia or hyperglycemia. The DON reviewed the EMAR and stated there was no record indicating the resident was monitored for these conditions.
Improper catheter tubing positioning and missed UTI monitoring
Penalty
Summary
The facility failed to ensure appropriate urinary catheter care for two residents with indwelling catheters. Resident 25 was admitted with diagnoses including neuromuscular dysfunction of the bladder, dysphagia, and muscle weakness. The MDS indicated the resident was usually understood and usually understood others, and required substantial assistance with toileting and bathing. The order summary showed an active order for a Foley catheter. During observation, the resident was lying in bed with the catheter bag hanging on the bed frame, and the catheter tubing had a coil and a long loop with urine backing up into the resident. The coiled portion of the tubing contained yellow liquid with sediments. RN 1 stated the tubing should be straight to allow urine to drain into the bag and that coiling or looping could allow urine to backflow into the body. The DON stated the tubing should not be coiled or kinked and should be below the level of the bladder. The facility’s manufacturer instructions stated the tubing should hang straight from bedside to drainage bag to permit good flow and minimize migration of bacteria due to urine pooling. Resident 10 was originally admitted and later readmitted with diagnoses including obstructive and reflux uropathy and acute kidney failure. The MDS indicated the resident could make self-understood and understand others, and required partial/moderate assistance with toileting hygiene, lower body dressing, and footwear, with supervision or touching assistance for upper body dressing and personal hygiene. The order summary showed an order for a Foley catheter attached to a urinary drainage bag at bedside every shift for Foley catheter use related to neuromuscular dysfunction of the bladder. During observation with LVN 1, the resident’s urinary catheter tubing was forming a loop filled with stagnant urine with white sediments. LVN 1 stated the urine should be free flowing and should not form a loop because it could cause contents of the tubing to back up into the bladder and lead to infection. RN 1 stated catheter care includes emptying the drainage bag, monitoring for signs and symptoms of UTI, and ensuring urine is free flowing by preventing loops in the tubing. The manufacturer instructions again stated the tubing should hang straight from bedside to drainage bag. The facility also failed to implement physician orders for Resident 99. The resident was admitted with diagnoses including benign prostatic hyperplasia, sepsis, and pressure ulcer of the sacral region, and later expired at the facility. The MDS indicated the resident rarely or never made self-understood or understood others and was totally dependent on staff for activities of daily living. The order summary included orders to measure urine output every shift for suprapubic catheter use and to monitor for signs and symptoms of UTI every shift. During review with the DON, the TAR for February 2026 showed no documentation of urine output and no documentation of monitoring for signs and symptoms of UTI on multiple day shifts. The DON stated it was important to monitor urine output and assess for signs and symptoms of UTI, and that physician orders should be carried out to ensure quality of care and adherence to professional standards of practice. The facility policy stated the licensed nurse receiving the order is responsible for documenting and implementing the order.
Failure to Change Oxygen Tubing Every 7 Days
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care by not changing oxygen tubing every seven days for three sampled residents receiving oxygen therapy. The deficiency was identified for Resident 7, Resident 48, and Resident 5, all of whom had orders for oxygen at 4 L/min through a ventilator or oxygen concentrator and had severely impaired cognition or lacked capacity to make decisions. The report states that the oxygen tubing for each of these residents was dated 5/18/2026 during observations on 6/1/2026, even though the tubing should have been changed on 5/25/2026. Resident 7 had diagnoses including acute respiratory failure, COPD, and hypertension, and the H&P stated the resident did not have capacity to understand and make decisions. Resident 48 had diagnoses including acute respiratory failure, type 2 diabetes mellitus, and sepsis, and the MDS indicated severely impaired cognition and that the resident was receiving oxygen therapy. During observation, Resident 48 was in bed receiving oxygen at 4 L/min, and the oxygen tubing was observed dated 5/18/2026. RT 2 stated the tubing should be changed every seven days to help prevent infection and should have been changed on 5/25/2026. Resident 5 had diagnoses including tracheostomy, chronic respiratory failure, and nontraumatic intracerebral hemorrhage. The H&P stated the resident did not have capacity to understand and make decisions, and the MDS indicated severely impaired cognitive skills. During observation, Resident 5 was in bed receiving oxygen at 4 L/min, and the oxygen tubing was dated 5/18/2026. RT 1 stated the tubing should be changed once a week on Mondays during night shift and should have been changed on 5/25/2026. The facility policy and procedure titled SNF Clinic Oxygen Administration stated nasal catheter tubing is changed and dated every 7 days and as needed, and staff interviews confirmed that oxygen tubing should be changed every seven days.
Medication availability, controlled substance reconciliation, and medication disposal failures
Penalty
Summary
The facility failed to have bumetanide available for a resident who was prescribed bumetanide 0.5 mg via G-tube once daily for CHF. During observation, the resident received several other scheduled medications via G-tube, but bumetanide was not administered at the 9 a.m. dose because it was not available in Medication Cart 1 or in the facility. The LVN stated the dose was missed because the medication was not on hand and that the medication should have been ordered in advance and followed up with pharmacy to prevent missed doses. The facility also failed to reconcile one medication eKIT containing controlled medications in the Subacute Medication Room for June 2026. The eKIT, labeled REF232 and stored in the refrigerator, did not have an accountability log documenting reconciliation of controlled medication inventory at each shift change. RN 2 stated that controlled medications, including medication eKITs containing controlled substances, should be counted and reconciled at every shift, and the DON stated the eKIT was not reconciled at each shift change in June 2026. In addition, two Medication Disposition Record/Pass logs dated 5/31/2026 were signed by RN 4 without witness initials documenting destruction of eight medications. The DON and RN 2 were unable to locate witness signatures or initials on the logs. During observation in the Subacute Medication Room, a red waste bin contained intact medication bottles, packages, and bubble packs with medications still in their original form, and the bin did not contain water or liquid to disintegrate them. The DON acknowledged the medications were not destroyed in a manner that made them unretrievable and stated the facility failed to destroy the medications safely and according to policy and state regulations.
Failure to Monitor Heparin Side Effects
Penalty
Summary
The facility failed to ensure that a resident receiving heparin was monitored for potential side effects as ordered by the physician. Resident 48 was admitted with diagnoses including acute respiratory failure, type II diabetes mellitus, and sepsis, and had severely impaired cognition on the MDS. The physician order summary included heparin sodium injection 5,000 units subcutaneously daily for DVT prophylaxis, along with an order to monitor for signs and symptoms of anticoagulant side effects such as discolored urine, black tarry stools, sudden severe headache, nausea and vomiting, diarrhea, muscle joint pain, lethargy, bruising, sudden changes in mental status or vital signs, shortness of breath, and nose bleeds. During review of the eMAR, the DON and MDS Nurse stated the resident received heparin injections from 5/17/2026 through 5/31/2026, but there was no documentation that licensed nurses monitored for side effects associated with heparin use, including bleeding. Both staff members stated that nurses should monitor and document these effects in the eMAR, and the facility policy on anticoagulation stated staff and the physician would monitor for complications and that the nurse would discuss signs of excessive bruising, hematuria, hemoptysis, or other evidence of bleeding with the physician before the next dose.
Medication Error Rate Exceeded Allowed Threshold
Penalty
Summary
The facility failed to keep its medication error rate below 5 percent. Surveyors identified 2 medication errors out of 32 total opportunities, resulting in a 6.25% medication error rate and affecting 2 residents observed during medication administration. One error involved a resident with CHF and a G-tube order for bumetanide 0.5 mg daily at 9 a.m.; during observation, the LVN administered several medications through the G-tube but did not administer bumetanide. The LVN later stated the medication was not available in the medication cart or facility and that the dose was omitted. The second error involved a resident with HTN who was ordered metoprolol succinate ER 24-hour 50 mg once daily at 9 a.m. During observation, the LVN crushed the tablet and mixed it with applesauce for oral administration. The LVN later acknowledged the tablet should not have been crushed and stated it was a slow-release medication intended to be given whole. The DON also stated that slow-release medications should not be crushed and that doing so alters the delivery of the medication. Record review confirmed the bumetanide order for CHF and the metoprolol succinate ER order for HTN. The facility’s medication administration policy required medications to be given as prescribed and within 60 minutes of the scheduled time, and its crushing guidelines stated that timed-release tablets should not be crushed. The facility’s medication error policy defined medication error to include administration at the wrong time or via the wrong route.
Unattended Medication Cart Keys Left Accessible
Penalty
Summary
Facility staff failed to secure the keys for Medication Cart 2, leaving four keys unattended on top of the cart next to Nursing Station 1. During observation on 6/1/2026 at 10:18 a.m., the keys were seen on top of the cart attached to a key ring labeled Med Cart 2. During a concurrent observation and interview, RN 3 stated the keys had been handed to her at the beginning of her shift around 7 a.m. and that she was responsible for them, but she forgot and left them on top of the cart. RN 3 stated the keys provided access to Medication Cart 2, which contained controlled medications, noncontrolled medications, and over-the-counter medications. She stated the keys must remain with her at all times because leaving them unattended could allow residents or staff to access the cart contents. The DON also stated that the medication cart keys must remain with licensed staff at all times and that the licensed nurse should not have left the key unattended on the cart. Facility policy stated that only authorized persons may access locked medications and that the charge nurse maintains the keys to controlled substance containers.
Unsafe Food Storage and Expired Thickened Dairy Drink Served
Penalty
Summary
Safe and sanitary food storage and distribution practices were not maintained in the facility kitchen. During observation in the walk-in refrigerator, a half-full carton of thickened dairy drink had a printed best by date of 05/27/26, with 5/22 written on the carton to indicate the received date and Open 6/1/26 written on the side. Five additional unopened cartons of the same thickened dairy drink with the same best by date and 5/22 written on them were also observed in the refrigerator. The Dietary Supervisor confirmed the 5/22 dates were used to show when the product was received and stated the dairy drink should not be served and should be discarded because bacteria could grow in it. The supervisor also stated she usually checks best by and expiration dates when food shipments are received, but could not do so while on leave. During observation in dry food storage, an open bag of dry pasta was found resting on a rack with no seal or closure. In the same area, a large white bulk food container lined with plastic held a torn-open 50 lb bag of white flour, and a large metal scoop with flour residue was stored inside the container with the flour. The Dietary Supervisor stated the pasta should be in a tight container to protect it from contamination and that the scoop should not be kept inside the container with food between uses because it poses a contamination risk. The supervisor also stated the wall storage for the scoop was in disrepair and that the scoop should be kept in a sealable bag in the interim.
Failure to Knock Before Entering Resident Room
Penalty
Summary
The facility failed to provide care in a manner that maintained a resident’s dignity and respect when Certified Nursing Assistant 1 entered Resident 92’s room without knocking or asking permission. Resident 92 was admitted on 1/24/2025 with diagnoses including paraplegia and gastro-esophageal reflux disease. The Minimum Data Set dated 5/08/2026 indicated the resident could make self-understood and understand others, and required substantial/maximal assistance for toileting hygiene, showering, upper and lower body dressing, putting on/taking off footwear, and personal hygiene. During a concurrent observation and interview on 6/01/2026 at 11:11 a.m., Licensed Vocational Nurse 1 observed CNA 1 enter Resident 92’s room without knocking or asking permission. LVN 1 stated CNA 1 should have knocked and asked permission before entering the resident’s room, and that all staff should respect residents’ privacy by asking permission or consent before entering their rooms. During an interview later that morning, CNA 1 stated LVN 1 spoke to her about entering Resident 92’s room without knocking or asking permission and stated she should have asked the resident’s permission before entering to show respect for the resident’s privacy and rights. The facility’s Dignity policy stated staff are expected to knock and request permission before entering residents’ rooms.
Unclean and Cluttered Resident Room
Penalty
Summary
The facility failed to provide Resident 32 with a safe, clean, comfortable, and homelike environment when the resident’s living area was not kept clean and clutter-free. Resident 32 was admitted to the facility on 1/29/2026 and later readmitted with diagnoses including metabolic encephalopathy, pneumonia, and COPD. The MDS dated 5/22/2026 indicated the resident had moderate impaired cognition and required eating clean-up assistance. During an observation on 6/1/2026 at 11:35 a.m. in Resident 32’s room, surveyors observed brown food crumbs, dry spilled liquids, an undated cup with milk on the bedside table, and a bundle of disposable gloves plus four sugar packets on the floor beside the bed. During a concurrent observation and interview, CNA 2 stated the sugar packets, used gloves, and bedside table should have been cleaned and that if the milk was out too long and the resident drank it, the resident could get sick. LVN 3 stated the CNA caring for the resident should maintain the area clean, that the crumbs and floor should have been cleaned up, and that the milk should have been removed, though the resident sometimes refuses to have food or drinks taken away. RN 1 also stated the bedside table and floor should have been cleaned. The facility’s Homelike Environment policy stated staff and management maximize, to the extent possible, a clean, sanitary, and orderly homelike environment.
Resident and Representative Not Included in Care Planning
Penalty
Summary
The facility failed to ensure that a resident or the resident’s representative participated in the interdisciplinary team care planning process conducted on 11/9/2025 for Resident 92. Resident 92 was admitted on 1/24/2025 with diagnoses including paraplegia and gastro-esophageal reflux disease. The resident’s MDS dated 5/08/2026 indicated the resident had the ability to make self-understood and to understand others, and also required substantial/maximal assistance with toileting hygiene, showering, upper and lower body dressing, putting on/taking off footwear, and personal hygiene. During a concurrent interview and record review on 6/03/2026, RN 1 reviewed the resident’s ICC notes from 11/09/2025 and confirmed that the attendees did not include Resident 92 or his representative. RN 1 stated that resident involvement in the care planning process is important so the resident can verbalize concerns and issues regarding care, and that involving the resident helps the IDT develop a resident-centered care plan that addresses the resident’s specific needs, preferences, and goals. The facility’s policy stated that the resident, the resident’s family, and/or the resident’s representative are encouraged to participate in the development of and revisions to the resident’s care plan.
Crushed ER Metoprolol Given During Medication Pass
Penalty
Summary
The facility failed to provide medication administration in accordance with professional standards of quality and facility policy for one resident who was receiving metoprolol succinate ER 24-hour. During medication administration, an LVN was observed crushing the metoprolol succinate ER tablet and mixing it with applesauce for oral administration. The LVN then handed the resident a spoonful of applesauce containing the crushed medication, and the surveyor stopped the administration before it was given. In interview, the LVN stated the tablet should not have been crushed and acknowledged that it was a slow-release medication intended to be administered whole. The DON stated that slow-release medications should not be crushed because doing so alters the delivery time of the medication and can make it immediate release. The DON also stated that crushing metoprolol succinate ER could cause adverse effects, including stomach irritation and inadequate blood pressure control. The facility's Medication Crushing Guidelines stated that timed-release tablets should not be crushed, and the facility's DO NOT CRUSH LIST identified metoprolol succinate as a slow-release tablet.
Failure to Offload Heels and Set Support Surface Correctly
Penalty
Summary
The facility failed to ensure pressure injury care was provided consistent with professional standards of practice for two residents. One resident was admitted with diagnoses including type II DM, Alzheimer’s disease, and aphasia, and the H&P indicated the resident did not have the capacity to understand and make decisions. The MDS showed the resident was usually understood by others, usually able to understand others, needed supervision/touch assistance for toileting, bathing, and personal hygiene, and had two PU/PI. The care plan for risk of PI, initiated on 1/31/26, directed staff to offload and float the heels while in bed with pillows. During a concurrent observation and interview on 6/1/26, the resident was found lying in bed with both feet flat on the bed rather than floated on pillows. RN 1 stated the resident had PU on both heels and they must be floated on pillows to prevent further injury and promote healing, and noted there were not extra pillows available in the room at that time. During another observation on 6/3/26, the resident was again observed lying in bed with both feet flat and not elevated. LVN 5 stated the pillows should be placed under the lower legs to elevate the heels and prevent further skin breakdown. The DON later stated the resident had wounds on both heels and they must be offloaded on pillows while in bed to redistribute weight and allow the heels to continue to heal. A second resident, originally admitted in 2021 and readmitted with diagnoses including quadriplegia and epilepsy, had severely impaired cognition and was totally dependent on staff for ADLs. During observation, the resident was lying in bed on a LALM, and the air pump was set to 355 lbs while a sticker on the pump indicated the resident weighed 155 lbs. LVN 1 confirmed the setting and reviewed the chart, verifying the resident’s current weight was 155 lbs. LVN 1 stated that 355 lbs was too high for a 155-pound resident, would make the mattress too firm and no longer therapeutic, and could cause skin breakdown and delay wound healing. The facility’s support surface guidelines and the mattress user manual indicated support surfaces are used for pressure redistribution and that the control knob should be set to the patient’s weight.
Over-bed table left on floor mat in resident room
Penalty
Summary
The facility failed to ensure the environment was free from accidents and hazards when an over-bed table was left directly on top of a floor mat in Resident 29’s room. Resident 29’s admission record showed diagnoses including type II diabetes mellitus, difficulty in walking, and muscle weakness. The H&P dated 5/27/2026 indicated Resident 29 did not have the capacity to understand and make decisions. The MDS dated 6/29/2025 indicated the resident required partial assistance from facility staff for activities such as toileting, bathing, lower body dressing, putting on or taking off shoes, and personal hygiene. During a concurrent observation and interview on 6/1/2026 at 9:05 a.m., the over-bed table was observed directly on top of the floor mat on the right side of the bed, with Resident 29 lying on her side facing the right and in the direct path of the table if she were to fall out of bed. CNA 4 stated nothing should be on top of the floor mat because the resident could trip over it or fall and hit her head. During another observation and interview later that day at 2:45 p.m., the over-bed table was again observed directly on top of the floor mat on the right side of the bed, and CNA 4 stated she must have forgotten to move it after providing care. The DON stated staff must make sure residents are safe and nothing should be on top of any floor mat because the mats are intended to provide a cushion if a resident falls off the bed, and the over-bed table was especially dangerous because it had metal legs and a metal bar attached to the wheel legs.
Incomplete Post-Dialysis Assessments
Penalty
Summary
The facility failed to ensure that a resident receiving dialysis had the post-dialysis assessment completed after returning from treatment. The resident had diagnoses including type II diabetes mellitus and dependence on renal dialysis, and the history and physical indicated the resident did not have the capacity to understand and make decisions. The Minimum Data Set showed the resident required partial assistance from facility staff with activities such as toileting, bathing, lower body dressing, shoes, and personal hygiene, and also required dialysis. A review of the resident’s Pre and Post Dialysis binder showed multiple dialysis dates where the post-dialysis portion was incomplete or blank, including missing post-dialysis weights, missing post blood pressure, and one form that was completely blank. During interview and record review, an LVN verified that the post-dialysis assessment was not completed on those dates and stated charge nurses were responsible for completing the form when the resident returned to the facility to check for complications such as abnormal vital signs, bleeding, or altered mental status. The DON stated licensed nurses were responsible for completing the post-dialysis assessment upon the resident’s return and documenting vital signs, weights, and signs or symptoms of bleeding to ensure the resident was stable and had no signs of complications.
Incomplete MAR Documentation for Insulin Administration
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for one sampled resident with acute respiratory failure, type 2 diabetes mellitus, and sepsis. The resident’s MDS dated 2/27/2026 indicated severely impaired cognition and that the resident was receiving high-risk medications for hypoglycemia, including insulin. An order dated 5/16/2026 directed Insulin Lispro 100 u/ml to be given as per sliding scale. Review of the MAR for 5/1/2026 through 5/31/2026 showed that the sections for documenting the resident’s blood glucose level and the insulin administered were left blank on 5/28/2026 and 5/30/2026 at 6 p.m. During interview, the DON stated the MAR was incomplete and that licensed nurses should have documented the blood sugar results and units of insulin administered immediately after checking the blood sugar and giving the insulin. An LVN stated he was the assigned nurse on 5/28/2026 and forgot to document the blood sugar result and insulin administered on the MAR.
Failure to Use PPE During EBP Care
Penalty
Summary
The facility failed to ensure CNA 3 and the Physician Assistant wore appropriate PPE while performing high-contact activities for Resident 47, who was admitted with diagnoses including pressure ulcer of the sacral region, pyogenic arthritis, and severe protein-calorie malnutrition. Resident 47's H&P stated the resident did not have the capacity to understand and make decisions. The physician orders dated 3/20/2026 included EBP for high risk for infection or transmission related to MDRO and a history of Proteus mirabilis in the urine every shift, and the care plan revised the same date directed staff to use gown and gloves for high-contact activities such as dressing, bathing, transferring, hygiene, changing linens, changing briefs, toileting, device care, and wound care. During a concurrent observation and interview on 6/1/2026, CNA 3 changed and put away Resident 47's dirty linen without using PPE and stated PPE was not worn because only the bed sheet was changed, although she also stated she had received PPE training about two weeks earlier and knew PPE should be worn when providing incontinence care and changing linens. During an observation on 6/2/2026, the PA performed an ear exam on Resident 47 without wearing PPE and later stated PPE was not worn because the EBP sign was overlooked before entering the room. Record review with the IPN showed CNA 3's PPE competency form did not include the date training was completed, the evaluator's signature and date, or competency skill check marks, and the DSD reviewed CNA 3's annual competency form dated 9/25/2025, which did not indicate EBP or PPE training.
Missing EBP Competency Training for CNA and LVN
Penalty
Summary
The facility failed to ensure that two of three sampled staff members, CNA 3 and LVN 3, received enhanced barrier precautions (EBP) competency training. During a concurrent interview and record review, the Infection Preventionist Nurse was unable to provide documentation showing that either staff member had completed EBP training. During a later review with the Director of Staff Development, the Annual CNA Competency form for CNA 3 and the Initial/Annual License Nurse Competency form for LVN 3 were reviewed, and neither form indicated that EBP training had been completed. The facility’s policy titled Competency of Nursing Staff stated that competency skills include infection control and that competency evaluations are to be conducted upon hire, annually, and as necessary based on assessment. The policy titled Enhanced Standard/Barrier Precautions stated that staff are to receive EBP training upon hire and at least annually. The Infection Preventionist stated she did not have records showing that CNA 3 and LVN 3 completed annual competency assessments and evaluations, and the DON stated the facility was unable to locate documentation of their annual competency assessments and EBP training.
Late Documentation of Insulin Administration on MAR
Penalty
Summary
The deficiency involves the failure of a registered nurse to document insulin administration on the Medication Administration Record (MAR) immediately after giving the medication. The resident involved was admitted with diagnoses including cerebral infarction, diabetes mellitus, and hypertension, and had intact cognition, was independent with eating and oral hygiene, and required moderate assistance with some activities of daily living. The resident had an order for insulin lispro to be administered subcutaneously per sliding scale before meals and at bedtime for diabetes management. Review of the MAR for the month showed multiple instances where insulin lispro doses scheduled for specific times were documented as administered significantly later than the scheduled times. During interviews and concurrent record reviews, the RN who documented the insulin administrations stated that insulin was actually given at the scheduled times but that documentation was completed late. The RN explained that blood sugar was typically checked about 30 minutes before dinner and insulin lispro was administered right before the resident ate, but the MAR entries were made after the fact rather than immediately following administration. The DON confirmed that licensed nurses are expected to document medication administration right after giving all medications. The facility’s medication administration policy specified that medications are to be administered within 60 minutes of the scheduled time, except for before- or after-meal orders, and that the person administering the medication must record the administration on the MAR directly after the medication is given and review the MAR at the end of each pass to ensure doses were administered and documented.
Failure to Document and Investigate Family Grievance per Facility Policy
Penalty
Summary
The facility failed to follow its grievance policy and procedure by not documenting and investigating a grievance submitted on behalf of a resident’s family member. The resident was admitted with diagnoses including cerebral infarction, diabetes mellitus, and hypertension, and had intact cognition per the MDS, requiring varying levels of assistance with activities of daily living. Review of the grievance binder for the relevant period showed no grievance filed for this resident. The Social Services Director stated that any concerns or complaints received from staff or residents should result in completion of a grievance form, communication with social services for follow-up and documentation, and logging into the grievance binder. The DON similarly stated that all complaints should be documented in the grievance binder and that the Administrator, DON, and Social Services Director were designated grievance coordinators who should be informed so an investigation could be started right away. The family member reported sending an email to the facility outlining concerns about the resident’s care and receiving an email response from the Administrator acknowledging receipt the same day. The family member stated that no one from the facility informed the family about what had been done to address their concerns. The Administrator later confirmed receiving the email regarding the family’s concerns but acknowledged that the concerns were not placed on a grievance form and that no investigation was initiated at that time. Review of the facility’s grievance/concern policy indicated that upon receipt of a grievance or concern, a grievance/concern form must be initiated by the staff member receiving the concern and documented on the grievance/concern log. The resident rights policy stated that residents have the right to voice grievances without discrimination or reprisal and to have the facility respond to their grievances. These required steps were not followed for the grievance submitted on behalf of this resident’s family member.
Failure to Provide Written Baseline Care Plan Summary to Resident
Penalty
Summary
The facility failed to provide a written summary of a baseline care plan to a resident and/or the resident’s representative following admission. A resident was admitted with diagnoses including cerebral infarction (stroke), diabetes mellitus, and hypertension. The resident’s MDS assessment showed intact cognition, independence with eating and oral hygiene, and a need for moderate assistance with toileting, showering, and dressing. An Interdisciplinary Care Conference (ICC) note dated shortly after admission documented that the checkbox indicating a copy of the care plan was provided to the resident or representative was left blank. During an interview and concurrent record review, the Case Manager was unable to recall whether a written baseline care plan summary had been provided and could not locate any documentation confirming that it had been given to the resident or family. In a subsequent interview and record review, the DON confirmed that the facility’s practice was to develop a baseline care plan within 48 hours of admission and to provide a written summary of that plan to the resident and/or family. The DON reviewed the ICC notes and clinical record for the resident and was unable to find any indication that a written baseline care plan summary had been provided. Review of the facility’s baseline care plan policy, last revised for 1/2026–1/2027, showed that it required development and implementation of a baseline care plan within 48 hours of admission but did not specify the requirement to provide a written summary to the resident or family, even though the DON stated that copies of the baseline care plan summary should be provided. The absence of documentation and the unmarked ICC checkbox demonstrated that the resident and/or representative did not receive the required written baseline care plan summary.
Improper Use of Low Air Loss Mattress for Resident With Stage III Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper use of a low air loss mattress (LALM) for a resident with a sacrococcygeal stage III pressure injury. The resident was admitted with osteoarthritis of the left knee, a left artificial knee joint, and a stage III sacral pressure ulcer, and had intact cognition per the MDS. The physician’s orders and the care plan included use of a LALM with settings based on the resident’s comfort and/or weight, and monitoring for proper settings and functionality, with the goal that the resident would not have further skin breakdown by monitoring the LALM in the correct setting. During observation, the resident was found lying on a LALM while wearing an incontinence brief, with a flat sheet and a cloth incontinence linen pad underneath, resulting in four layers of linen between the resident and the mattress. During interviews, CNA staff stated that the resident was on the LALM due to an open wound on the resident’s bottom and acknowledged that there were four layers of linen under the resident, while indicating there should only be one layer between the resident’s skin and the LALM. The DSD stated that for residents on a LALM, only flat sheets should be used and staff should use either disposable pads or an incontinence brief, but not both at the same time, and that there should be no more than two layers of linen between the bed and the resident for the LALM to function appropriately. The DON stated that LALMs are used primarily for skin management and that using more than two layers of linen would defeat the purpose of the LALM and delay wound healing. The DON also stated the facility did not have a policy and procedure specific to LALM use, and the existing pressure ulcer/skin breakdown protocol only generally referenced physician orders for pressure reduction surfaces without detailing LALM application or linen use.
Lack of Policies and Procedures for Low Air Loss Mattress Use
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement policies and procedures for the use of low air loss mattresses (LALM) for all 12 sampled residents who were using these specialty beds for pressure ulcer/injury (PU/PI) prevention and treatment. Record review of the facility’s Order Listing Report showed that each of the 12 residents had active physician orders for LALM, with start dates ranging from the prior year to the current month. During observation, all 12 residents were confirmed to be on LALM, and the treatment nurse stated that the mattresses were being used to prevent pressure ulcers and promote wound healing for residents with existing pressure ulcers. In interviews, the DON acknowledged that the facility did not have any written policy or procedure governing LALM use, including guidance on linen use with the mattresses, and stated that the facility followed the manufacturer’s guidelines. However, the manufacturer’s guidelines provided did not address linen use with LALM. The administrator also stated that the facility should have a policy and procedure for LALM use to guide management of residents on these mattresses and noted that many residents were using them. Review of the DON and administrator job descriptions showed that both positions were responsible for developing, maintaining, and ensuring implementation of facility policies and procedures, including nursing policies that conform to current standards and regulations.
Failure to Keep Call Light Within Reach for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was within reach while the resident was in bed. The resident had been admitted with multiple diagnoses, including metabolic encephalopathy, functional quadriplegia, type 2 diabetes, hypertension, and difficulty swallowing. The resident’s History and Physical documented that the resident did not have the capacity to understand and make decisions, and the MDS indicated severely impaired cognition. The MDS further showed the resident required supervision with eating and oral hygiene, moderate assistance with upper body dressing and personal hygiene, and maximal assistance with toileting hygiene, lower body dressing, and footwear. During an observation and interview in the resident’s room, the resident was found lying in bed, stating they required staff assistance with changing soiled briefs, and the call light was observed on the bedside table out of the resident’s reach. In a concurrent observation and interview, an LVN confirmed that the call light was out of reach and acknowledged it should be within the resident’s reach at all times. Later, a CNA reported that at the start of the shift he ensures residents’ call lights are within reach but stated he must have forgotten to check this resident’s call light position, and reiterated that all call lights should remain within residents’ reach so they can call for assistance when needed. The DON stated that call lights need to be within reach of all residents to enable them to call for assistance when needed and acknowledged that when a call light is out of reach there is a potential for delayed care, increased risk of falls, and decreased feelings of self-worth, self-esteem, and dignity. Review of the facility’s Call System policy indicated each resident is to be provided with a means to call staff directly for assistance from the bed, toileting/bathing facilities, and the floor, and the Dignity policy stated residents are to be treated with dignity and respect in a manner that promotes individuality, well-being, satisfaction with life, self-worth, and self-esteem.
Improper Application and Monitoring of AFO for Resident With Limited Mobility
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure proper application and monitoring of an ankle foot orthosis (AFO) as ordered by the physician for a resident with significant neurological and medical conditions. The resident had a history of traumatic brain injury, seizures, hydrocephalus, type 2 DM, and difficulty swallowing, and the H&P documented that the resident lacked capacity to understand and make decisions. A physician order dated 6/9/2025 directed that bilateral AFOs be placed on the resident’s lower extremities five times per week for 4–6 hours as tolerated, with skin checks. During an observation in the resident’s room, the resident was found lying in bed with an AFO on the right foot and ankle that was rotated to the side and not providing the intended support. During a concurrent observation and interview at the bedside, the Director of Rehabilitation confirmed that the right AFO was not applied properly and stated that the brace should be supporting the right foot and ankle to prevent further foot drop. Later, the RNA reported that he had applied the right AFO that morning in accordance with the physician’s order but was unaware that it was not correctly positioned, and acknowledged that the AFO should remain in the correct position on the foot and ankle. The DON also stated that the AFO should remain correctly positioned at all times and that staff should monitor both the placement of the AFO and the resident’s skin condition while it is in place. Facility policies on assistive devices and on resident mobility and ROM required that staff be trained and competent in the use of devices and that residents with limited mobility receive appropriate services and equipment based on professional standards of practice, but the observed improper application of the AFO demonstrated noncompliance with these requirements.
Failure to Prevent Accident Hazards and Ensure Resident Safety
Penalty
Summary
The facility failed to maintain an environment free from accident hazards and did not provide adequate supervision to prevent accidents for three residents. For two residents with seizure disorders and severely impaired cognitive skills, the facility did not ensure that bed siderails were fully covered with padding as ordered by their physicians and outlined in their care plans. Observations revealed that one resident's bed rail padding had slipped, leaving hard rails exposed, and another resident's bed rail had no padding on one side. In both cases, nursing staff confirmed that the padding was necessary to protect the residents from injury during seizures, in accordance with physician orders and care plans. Additionally, the facility did not provide a required floor mat for a resident with impaired mobility and multiple medical conditions, including respiratory failure and cancer. This resident was found on the floor without a floor mat in place, despite a physician order and care plan intervention indicating its necessity for injury prevention. The resident's bed was positioned against the wall, and the room had low lighting with curtains drawn, making it difficult to see the resident from the hallway. Nursing staff acknowledged that the floor mat should have been present and that the room should have been better lit with curtains open for visibility. The facility's own policies and procedures require the prevention or reduction of hazards associated with bed rails, the provision of a safe and homelike environment, and adequate lighting to promote safety. The failure to follow these policies, physician orders, and care plan interventions resulted in an environment that placed the affected residents at increased risk for injury.
Failure to Follow Physician's Order for Apical Pulse Prior to Heart Medication Administration
Penalty
Summary
A licensed vocational nurse (LVN) failed to follow a physician's order requiring the measurement of a resident's apical pulse prior to administering Flecainide, a heart medication. The resident, who had a diagnosis of atrial fibrillation and was cognitively intact, had a physician's order specifying that Flecainide should be held if the apical pulse was less than 60 beats per minute. Despite this, the LVN did not take the apical pulse before administering the medication on multiple occasions, as evidenced by the Medication Administration Records (MAR) for March, April, and May, which showed no documentation of the apical pulse being taken prior to administration. During a medication pass observation, the LVN was seen taking only the resident's blood pressure and radial pulse before giving Flecainide, and stated there was no need to check anything else. When questioned, the LVN indicated he was unaware of the order to check the apical pulse and had never done so for this resident before administering the medication. The LVN also stated that the electronic medical record system did not prompt for an apical pulse entry, and believed that the order should have been entered with a parameter requiring this check. The Director of Nursing (DON) and the facility's Pharmacist Consultant both confirmed that the apical pulse should have been checked and documented prior to each administration of Flecainide, as per the physician's order and pharmacy recommendations. The DON verified that the medication was given without the required apical pulse check on multiple occasions. The LVN's competency records indicated training on following medication parameters, but this was not adhered to in practice. The facility's policy required medications to be administered according to physician orders, which was not followed in this instance.
Failure to Timely Replace and Document Emergency Medication Kits
Penalty
Summary
The facility failed to ensure timely replacement and proper documentation of emergency medication kits (E-kits) in both the Subacute and Skilled Nursing Facility Medication Rooms, as required by facility policy. In the Subacute Nursing Station, documentation indicated that two vials of Ceftazidime were removed from the E-kit for a resident with sepsis, but subsequent interviews revealed that the medication was not actually removed and the documentation was incorrect. Additionally, the E-kit was not exchanged within the required 72-hour timeframe after being opened, and the pharmacy was not notified promptly for replacement. In the Skilled Nursing Facility Medication Room, the E-kit was found to be opened without the appropriate yellow zip tie or documentation indicating medication removal, and the pharmacy was not notified for replacement as per policy. A resident involved had been admitted with sepsis and was severely cognitively impaired, requiring total assistance for daily activities. Physician orders indicated the need for intravenous antibiotics, and the facility's failure to follow procedures for E-kit management had the potential to delay access to critical medications. Staff interviews confirmed lapses in following the established process for E-kit documentation, notification, and replacement, as outlined in the facility's policy and procedure.
Failure to Check Apical Pulse Before Administering Heart Medication
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to check a resident's apical pulse prior to administering Flecainide, a heart medication, as required by the physician's order. The resident, who had a diagnosis of atrial fibrillation and was cognitively intact, had a specific order to hold the medication if the apical pulse was less than 60 beats per minute. Despite this, the LVN administered the medication without taking the apical pulse, relying only on the radial pulse and blood pressure measurements. Review of the Medication Administration Records (MAR) for three consecutive months showed that the apical pulse was not taken before administering Flecainide on multiple occasions. The MARs for March, April, and May indicated repeated failures to document the apical pulse prior to medication administration, confirming that this was an ongoing issue rather than an isolated incident. The resident's care plan also specified the need to assess and monitor vital signs as ordered, which was not followed in practice. Interviews with the LVN and the Director of Nursing (DON) revealed that the LVN was unaware of the requirement to check the apical pulse and that the electronic medical record system did not prompt for this parameter. The facility's policy required medications to be administered according to physician orders, but this was not adhered to in the case of this resident. The facility pharmacist had also recommended that the apical pulse be checked before administering Flecainide, but this recommendation was not implemented prior to the survey.
Puree Diet Food Served with Incorrect Consistency
Penalty
Summary
Seven of eight residents on a puree diet were served a puree lemon crisp dessert that was too thick in consistency. During a test tray observation, the Dietary Supervisor (DS) and Regional Dietary Supervisor (RDS) confirmed that the dessert did not meet the required texture for a puree diet, as it was too thick and failed the spoon tilt test, which is used to assess the appropriateness of food texture for individuals with dysphagia. The DS stated that the dessert should be smooth, similar to mashed potatoes, and should slide off the spoon easily, but the observed dessert did not meet these criteria. A review of the facility's diet manual for the Dysphagia Diet, Puree IDDSI Level 4, indicated that all puree foods should be lump-free, not firm or sticky, and should pass both the fork drip and spoon tilt tests before being served. The manual also specified that all prepared recipes should be tested prior to service to ensure they meet IDDSI guidelines. The DS acknowledged that the dessert served did not comply with these requirements, which could result in residents having difficulty swallowing.
Deficient Food Storage, Temperature Monitoring, and Staff Hygiene in Kitchen
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen regarding food storage, preparation, and staff hygiene. Bell peppers stored in the walk-in refrigerator were not labeled with the date they were placed inside, contrary to facility policy requiring all foods to be labeled and dated to prevent cross contamination. Additionally, during a tray line observation, staff failed to check the temperatures of several food items, including mashed potatoes, gravy, various modified diet potatoes, chicken, pasta, and carrots. Both the Dietary Supervisor and the staff member acknowledged that all food temperatures should have been taken to ensure proper hot and cold holding, as outlined in facility policy. Further, a Dietary Aide was observed touching his face and eyeglasses with a gloved hand during food service and did not immediately wash hands or change gloves until prompted by the Dietary Supervisor. Both the Dietary Supervisor and the aide confirmed that hand washing and glove changes are required after touching the face, in accordance with facility policy. These deficiencies were identified during observations and interviews, and the facility's policies were reviewed to confirm the requirements that were not followed.
Failure to Implement Individualized Care Plans for Oral Care and Fall Prevention
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan with individualized oral care interventions for a resident with a tracheostomy who was dependent on a ventilator. The resident was observed with very dry, cracked lips and a thick layer of dry crust, and was seen rubbing her lips with her hand. During interviews and record reviews, nursing staff confirmed that there was no care plan or intervention in place for oral care, despite the resident's dependence on staff for all activities of daily living and the facility's own policies requiring individualized care plans and oral hygiene support for residents unable to perform these tasks independently. Additionally, the facility failed to implement a care plan intervention for another resident who required a floor mat for injury prevention as ordered. The resident, who had diagnoses including respiratory failure, cancer of the larynx, and dysphagia, was found on the floor without a floor mat in place, despite an active order for one to be provided on the left side of the bed. Nursing staff confirmed that the floor mat was not present, and the care plan indicated the intervention should be in place if indicated. Both deficiencies were identified through direct observation, interviews with nursing staff, and review of facility policies and resident records. The facility's policies require ongoing assessment and revision of care plans to meet residents' medical, physical, and psychosocial needs, including specific protocols for oral care and fall prevention, which were not followed in these cases.
Improper Enteral Medication Administration and Inadequate Tube Flushing
Penalty
Summary
A deficiency was identified when a licensed vocational nurse (LVN) failed to follow proper technique during medication administration through an enteral tube for a resident with severe cognitive impairment and total dependence on staff for activities of daily living. The LVN crushed magnesium oxide and zinc tablets, placed them in separate medication cups with water, and administered them via the resident's enteral tube. After administration, excess crushed medication remained in both cups, indicating the resident did not receive the full prescribed dose. Additionally, the LVN flushed the enteral tube with only 10 milliliters of water between medications, despite a physician's order specifying a 15 milliliter flush between each medication. The resident's medical records confirmed the presence of an enteral tube and orders for medication administration, including the required flush volume. Both the LVN and the Director of Nursing acknowledged during interviews that the full dose of medication should be administered and the tube should be flushed with the ordered amount of water to ensure proper delivery and prevent tube clogging. Facility policies also required adherence to prescriber orders for medication administration and flushing volumes.
Failure to Provide Oral Hygiene for Dependent Resident
Penalty
Summary
Facility staff failed to provide necessary oral hygiene services to a resident who was completely dependent on staff for all activities of daily living. The resident, who had diagnoses including hemiplegia, respiratory failure with hypoxia, dysphagia, and was dependent on a ventilator and feeding tube, was observed lying in bed with very dry, cracked lips covered by a thick layer of dried saliva and skin. The resident was unable to communicate effectively and required total assistance for hygiene and movement. During the observation, a registered nurse acknowledged the resident's lips were very dry and in need of oral care, noting the potential for bleeding or pain and the possible impact on the resident's feelings. Facility policies reviewed indicated that residents unable to perform ADLs independently should receive appropriate care, including oral care, and that care should promote well-being and dignity. However, the observed condition of the resident's lips demonstrated that these services were not provided as required.
Failure to Maintain Proper Catheter Tubing Positioning
Penalty
Summary
A resident with a history of hemiplegia, hemiparesis following cerebral infarction, neuromuscular bladder dysfunction, and urinary retention was admitted with an indwelling urinary catheter. The resident was dependent on staff for all activities of daily living, including hygiene and toileting, and had documented episodes of confusion. The resident had a physician order for a urinary catheter due to retention and neurogenic bladder, and had experienced urinary tract infections (UTIs) on two separate occasions during their stay. During an observation, the resident was found lying in bed with the urinary catheter bag improperly positioned and the catheter tubing exhibiting a long dependent loop, two coils, and a kink. The tubing contained yellow liquid with white sediments. Both the Minimum Data Set Coordinator and a registered nurse confirmed that the catheter tubing should not be looped, coiled, or kinked, as this can impede urine flow and increase infection risk. Facility policy required catheter tubing to be kept free of kinks to maintain unobstructed urine flow, but this was not followed in the resident's care.
Failure to Document Post-Dialysis Weight for Resident Receiving Hemodialysis
Penalty
Summary
The facility failed to ensure that a post-dialysis assessment was completed for a resident with end stage renal disease who required hemodialysis. Specifically, on 5/15/2025, the dialysis center did not record the resident's post-dialysis weight on the Dialysis Communication Record. This omission was verified during record reviews and interviews with both a registered nurse and the Director of Nursing, who confirmed that the post-dialysis weight was missing and that the facility's protocol required staff to contact the dialysis center to obtain this information if it was not documented. The resident involved was severely cognitively impaired and dependent on staff for daily activities, as indicated by the Minimum Data Set. The resident's care plan required pre- and post-dialysis weights to be taken at the dialysis center to help avoid fluid overload. Facility policy and licensed nurse competency guidelines both specified that missing post-dialysis weights should be immediately followed up with the dialysis center, but this was not done, resulting in incomplete documentation for the resident's dialysis care on the specified date.
Unlabeled and Unpackaged Tablet Found in Medication Cart
Penalty
Summary
A deficiency was identified when, during an observation and interview with an LVN at one of the medication carts, a white, round, unlabeled and unpackaged tablet was found in the bottom of a cart drawer. The LVN confirmed that medications should be packaged and labeled when stored in the cart to ensure the correct medication is administered and to verify expiration dates. The DON also stated that all medications should be packaged and labeled to prevent accidental administration to the wrong resident and to reduce medication errors. Review of the facility's policy indicated that medications are to be kept in containers that meet legal requirements and that contaminated medications are to be immediately removed and disposed of.
Inaccurate Documentation of Advance Directive Status
Penalty
Summary
The facility failed to ensure the accuracy of a medical record for one resident when the Advance Directive Acknowledgement form incorrectly indicated that the resident had an Advance Directive, despite no such document existing. The resident in question was admitted with diagnoses including pneumonia, bipolar disorder, and schizophrenia, and was noted to be deaf and non-speaking. The Minimum Data Set assessment indicated that no Advance Directive was completed for this resident. Additionally, a letter from the regional center clarified that the resident was not capable of providing informed consent, had no court-appointed conservator or guardian, and that a regional center designee would provide consent for medical treatments. During interviews, the responsible party from the regional center confirmed there was no Advance Directive for the resident, and the Social Services Director acknowledged that the Advance Directive Acknowledgement form was incorrect. The facility's policy required staff to inquire about the existence of an Advance Directive upon admission and to document its presence or offer the opportunity to create one if it did not exist. However, the documentation in the resident's medical record inaccurately reflected the existence of an Advance Directive, resulting in a deficiency related to the maintenance of accurate medical records.
Failure to Develop Comprehensive Care Plan for Resident's Food Preference
Penalty
Summary
The facility failed to develop a comprehensive care plan with resident-centered interventions for a resident who preferred to keep food at their bedside. The resident, who was readmitted to the facility with diagnoses including chronic obstructive pulmonary disease, noncompliance with medical treatment, and functional quadriplegia, was observed to have two eggs wrapped in plastic on their bedside table. The resident expressed a preference for keeping food at their bedside, which was confirmed by the Dietary Supervisor. The Director of Nursing acknowledged that the resident's care plan, revised on 2/6/2025, did not include specific interventions related to the resident's preference for keeping food at the bedside. The facility's policy requires the Interdisciplinary Team to develop individualized comprehensive care plans, but this was not done in this case. The lack of specific interventions in the care plan had the potential to negatively affect the resident's quality of life and care.
Failure to Complete Discharge Summary for Resident
Penalty
Summary
The facility failed to ensure a discharge summary was completed for a resident, identified as Resident 3, upon their discharge. Resident 3 was readmitted to the facility with diagnoses including cervical disc degeneration, a laceration on the head, and a history of falling. The Minimum Data Set (MDS) indicated that the resident had intact cognition. Despite these details, there was no documented evidence of a discharge summary being completed when Resident 3 was discharged from the facility. Interviews with the Medical Records Director and the Director of Nursing revealed that a discharge summary should have been documented upon the resident's discharge, as per the facility's policy. The discharge summary is intended to provide a summary of the services provided and the resident's condition during their stay, and it is crucial for ensuring consistent care coordination. The facility's policy mandates that a discharge summary be completed within 30 days of discharge, but this was not adhered to in the case of Resident 3.
Failure to Document Resident's Fluid Intake
Penalty
Summary
The facility failed to implement its hydration and prevention of dehydration policy by not ensuring that a resident's fluid intake was documented in the medical record. This deficiency was identified for a resident who was admitted with osteomyelitis, low back pain, and chronic kidney disease, and who had severely impaired cognition requiring assistance with daily activities. The facility's policy required that intake be documented in medical records and that aides report intake of less than 1,200 mL/day to nursing staff. Interviews with staff revealed that Certified Nursing Assistants (CNAs) did not document residents' fluid intake in milliliters, and there was no specific area in the medical records for such documentation. The Director of Nursing confirmed that unless there was an intake and output order or fluid restrictions, fluid intake was not documented. This lack of documentation had the potential to place the resident at risk for dehydration and related medical complications.
Failure to Discard Perishable Food Puts Resident at Risk
Penalty
Summary
The facility failed to adhere to its policy on preventing foodborne illness by not ensuring that cooked eggs found on a resident's bedside table were discarded after being left out for over 24 hours. The resident, who was readmitted to the facility with chronic obstructive pulmonary disease and functional quadriplegia, was observed to have two hard-boiled eggs wrapped in plastic on their bedside table. These eggs were labeled with a date indicating they had been there since the previous day. The resident confirmed that the eggs had not been refrigerated and had been at their bedside since the previous day. The Dietary Supervisor acknowledged that the resident receives cooked eggs as a snack upon request and confirmed that cooked eggs should be refrigerated if not consumed immediately. The facility's policy, reviewed in July 2024, states that food served without temperature controls should be discarded if not eaten within two hours to minimize the risk of foodborne illness. The Dietary Supervisor reiterated that cooked eggs are perishable and should be discarded after two hours if not refrigerated, as they could lead to bacterial growth. This oversight placed the resident at risk for foodborne illnesses.
Failure to Implement Enhanced Barrier Precautions and Hand Hygiene
Penalty
Summary
The facility failed to implement its Enhanced Barrier Precautions (EBP) and Hand Hygiene (HH) policies, leading to a deficiency in infection control practices. Certified Nurse Assistant 1 (CNA 1) did not don a gown while changing the bed linen for a resident on EBP, despite the signage on the resident's door indicating the requirement to wear a gown and gloves for such tasks. Additionally, CNA 1 did not perform hand hygiene after removing gloves, which is a critical step in preventing the spread of infections. The resident involved was admitted with diagnoses including idiopathic peripheral autonomic neuropathy, diabetes mellitus with a skin ulcer, and cellulitis of the lower limb. The resident's Minimum Data Set indicated intact cognition and a need for maximum assistance with personal hygiene and moderate assistance with bed mobility. Physician orders specified enhanced barrier precautions due to the resident's risk of infection from wounds. Interviews with facility staff, including CNA 1, Licensed Vocational Nurse 2 (LVN 2), the Infection Prevention Nurse (IP), and the Director of Nursing (DON), confirmed the failure to adhere to the facility's policies. The facility's policy required staff to wear gowns and gloves during high-contact activities, such as changing bed linens, to prevent the transmission of multidrug-resistant organisms. The policy also mandated hand hygiene after removing personal protective equipment, which was not followed in this instance.
Failure to Maintain Required Room Temperature
Penalty
Summary
The facility failed to maintain the required room temperature levels between 71-81 degrees Fahrenheit for residents, as observed in two rooms and affecting one resident. During an observation, Room A was found to have a temperature of 65 degrees F, and Room B had a temperature of 69.5 degrees F. The Maintenance Supervisor confirmed that the resident rooms are required to be within the specified temperature range and acknowledged the need to adjust the thermostat to meet these requirements. Resident 3, who was admitted with diagnoses including a left pelvic fracture, left hip fracture, heart failure, and insomnia, reported discomfort due to the cold room temperature. The resident was observed using an extra blanket to keep warm, indicating the room's temperature was below the required level. The facility's policy on providing a homelike environment also specifies maintaining a comfortable and safe temperature range, which was not adhered to in this instance.
Improper Placement of Power Strips Creates Hazards
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the safe placement of power strips, leading to potential hazards for residents, visitors, and staff. During a facility tour, it was observed that a power strip was placed on the floor next to a resident's bed, creating a tripping hazard. Additionally, another power strip was improperly secured to a bed rail using plastic gloves, which was acknowledged by the Maintenance Supervisor as not being secured properly. These observations were made in the rooms of two residents, both of whom had intact cognition and the capacity to understand and make decisions. The facility's policy, revised in July 2024, clearly states that power strips should not be mounted to any permanent structure and must be stored in a manner that does not create a tripping hazard. Despite this, the power strips were not stored safely, posing an increased risk of falls, trips, and occupational hazards. The Administrator confirmed that the power strips should not be lying on the floor or tied to bed rails with plastic gloves, indicating a lapse in following the established guidelines for maintaining a safe environment.
Failure to Conduct Neurological Assessment After Unwitnessed Fall
Penalty
Summary
The facility failed to adhere to its policy and procedure on Fall Management and Neurological Evaluation by not completing a neurological assessment after an unwitnessed fall involving a resident. The resident, who had been admitted with diagnoses including sepsis, autonomic neuropathy, muscle weakness, and repeated falls, experienced an unwitnessed fall on 8/17/2024. Despite the facility's protocol requiring a neurological assessment for 72 hours post-fall, this was not conducted, potentially leading to a delay in care and placing the resident at risk. Interviews and record reviews revealed that the MDS Nurse acknowledged the requirement for a neurological assessment following an unwitnessed fall, which should be performed by licensed nurses without needing a physician's order. However, the assessment was not completed, and the resident was transferred to the hospital for evaluation. Upon the resident's return to the facility, the neurological assessment was not resumed, as the Director of Nursing incorrectly believed that a physician's order was necessary to continue the assessment. The facility's policies on Fall Management and Neurological Evaluation clearly state the need for immediate and ongoing neurological checks following an unwitnessed fall. Despite this, the Neurological Flow Sheet for the resident was not completed, and the Director of Nursing maintained that the facility staff did not err, citing the absence of a physician's order as the reason for not continuing the assessment. This oversight resulted in incomplete documentation and monitoring of the resident's condition post-fall.
Failure to Ensure Timely Pain Management for a Resident
Penalty
Summary
The facility failed to implement its pain management policy by not ensuring timely notification of the physician to obtain orders for treating a resident's pain. The resident, who was admitted with conditions including sepsis, autonomic neuropathy, muscle weakness, and repeated falls, required substantial assistance with daily activities. Despite having orders for pain medications such as Acetaminophen, Gabapentin, and Tramadol, the resident continued to experience pain. On a specific day, the resident complained of pain, and the Licensed Vocational Nurse (LVN) attempted to contact the on-call physician for additional pain medication but faced technical difficulties with the phone service. The LVN did not take further action to resolve the issue, such as contacting the medical director, and instead endorsed the situation to the next shift. The Director of Nursing later stated that the LVN should have informed them, so they could have contacted the medical director. The facility's pain management policy, last reviewed in July 2024, emphasizes maintaining the highest possible level of comfort for residents by providing a system to identify, assess, treat, and evaluate pain, which includes notifying the physician and obtaining treatment orders as needed.
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What surveyors actually found near you
We read the 4,011 citations issued within 25 miles in the last 12 months — including the 20 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
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Nursing homes near Reseda
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Grancell Village Of The Jewish Homes For The Aging | 0.6 mi | — | 5 | 0 |
| Joyce Eisenberg Keefer Medical Center D/p Snf | 0.6 mi | ★★★★★ | 28 | 0 |
| Eisenberg Village | 0.9 mi | ★★★★★ | 22 | 0 |
| Northridge Care Center | 0.9 mi | ★★★★★ | 47 | 0 |
| Woodland Care Center | 1.1 mi | ★★★★★ | 36 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.