Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pavilion On Pico Healthcare & Wellness Centre, Lp during CMS and state inspections, most recent first.
A resident with ESRD on hemodialysis, along with multiple comorbidities including DM2, COPD, heart failure, and HTN, had a missing post-dialysis evaluation in the medical record for one treatment date. During an interview and record review, an LVN confirmed that the post-dialysis evaluation form for that date was not completed, noting this could result in missed changes of condition or undocumented medications given during treatment. Review of the facility’s dialysis management policy showed that licensed nurses are required to complete both pre- and post-dialysis evaluations and maintain all dialysis-related documentation in the resident’s medical record, which was not done in this case.
An LVN administered meds without checking a resident’s ID band and was observed not wearing gloves during MedPass. The same resident’s PRN Norco orders were not followed as written, with doses given closer together than the ordered frequency, while the resident reported severe pain and said staff were not helping. In addition, lorazepam oral solution was stored in the refrigerator with other meds, and controlled substance disposition logs were missing DON signatures.
Medication Labeling and Expiration Date Deficiencies: A resident’s levofloxacin bubble pack label did not match the physician order, and two compounded vancomycin IV bags plus escitalopram for two other residents were found without expiration dates. An LVN stated the order-label mismatch and missing expiration dates could affect medication administration, and the DON stated discrepancies between orders and labels must be addressed immediately.
Infection prevention and control practices were not followed when multiple bleach wipe containers on the nursing floor were left open, and staff did not use PPE as required for enhanced barrier precautions. An MDSN entered a resident’s room without a gown to empty a urinal for a resident with cellulitis, open leg lesions, and other diagnoses, while a CNA fed another resident on EBP without a gown or gloves despite the posted precautions and available PPE.
The facility failed to follow its antibiotic stewardship process for two residents by starting antibiotics without documented McGeer UTI criteria being met. One resident had cephalexin ordered based on UA and culture results, but no documented signs or symptoms of infection, and another resident had Macrobid and levofloxacin ordered for UTI without documentation of change in condition, care plan initiation, or infection control surveillance assessment. The DON and IPN stated the facility expected clinical criteria, lab support, and documentation before antibiotic use.
Missing COVID-19 Vaccination Documentation for Staff: The facility failed to maintain documentation for two sampled employees, including the Medical Director and an IPN, showing COVID-19 vaccination status, education on the benefits and potential side effects of the vaccine, and that the vaccine was offered. The IPN and DON stated that vaccination screening and ongoing records must be kept in the employee files, and the facility policy required HCP to be fully vaccinated or have an approved waiver.
A resident with schizoaffective disorder, depression, and dementia received Divalproex for aggressive behavior without documented written informed consent. The resident was moderately cognitively impaired, the MAR showed 22 doses were given, and the DON and MR confirmed no consent was in the record despite facility policy requiring written informed consent for psychoactive meds.
Failure to Offer GDR for Antipsychotic Use: A resident with dementia and schizoaffective disorder was receiving Risperidone 4 mg at bedtime, but the IDT did not offer a GDR and there were no progress notes showing an attempted dose reduction. The MDS mood section was not completed, the DON stated GDR should be offered quarterly, and the consultant pharmacist review did not include a recommendation for GDR or continued justification for the medication.
MDS assessment was not completed accurately for a resident with dementia, Alzheimer’s disease, and a history of falls. The resident returned from GACH with a right hip fracture after a fall, but the clinical admission assessment had unanswered items, including the safety section, and did not properly reflect fall risk. The MDS nurse also stated Section J, Health Conditions, incorrectly addressed whether the resident had a fracture related to a fall within the prior 6 months, meaning the re-admission assessment was not accurately triggered.
Medication Crushed Without Physician Order: An LVN crushed and administered a resident’s morning meds, including tablets and capsules, mixed with applesauce, without a physician order authorizing crushed medications. The resident was cognitively intact and had diagnoses including metabolic encephalopathy, UTI, bacteremia, and type I DM. Record review showed no documentation permitting crushing and no care plan addressing crushed meds, and the DON confirmed an order is required.
A resident with dementia, Alzheimer’s disease, and a history of falls was ordered by the MD to transfer to an acute hospital for further evaluation and treatment after a recent fall. The transfer did not occur when planned because transportation did not arrive until the next morning, and the DON acknowledged staff did not document notifying the MD of the delay.
Failure to follow a physician’s fluid restriction order for a resident receiving hemodialysis. The resident had CHF, COPD, and UTI, and the chart showed a 1,000 ml daily fluid restriction divided across dietary and nursing shifts. Review of the fluid intake record showed the resident received/documented 1,100 ml in one day, including duplicate or incorrectly timed entries, and the RN and DON stated the order was not followed. The facility policy stated diet and fluid restrictions will be followed as ordered.
Failure to assess and document use of four side rails: A resident with seizures, hydrocephalus, and GERD was observed in bed with four unpadded side rails up, no floor mats, and the bed in low position. The chart lacked documentation of an entrapment risk assessment, alternatives attempted, informed consent for four-rail use, and a care plan for bed rail use; staff said the rails were raised at the family’s request while mats were being cleaned, and the consent on file was incomplete and did not clearly cover four side rails.
Medication Error Rate Exceeded 5 Percent: Surveyors identified 2 medication errors out of 26 opportunities, resulting in a 7.69% error rate. One resident had a mismatch between the EMR order and the bubble pack label for levofloxacin, and an LPN administered the medication while also crushing medications without an order authorizing crushing. A second resident’s ordered Vitamin D3 was not found in the med cart, and there was no documentation of administration or physician notification.
Excess Residents in Shared Rooms: Surveyors observed two resident rooms with five residents each, exceeding the limit of four residents per room. Staff interviews indicated they could move around the rooms easily and had no obstacles hindering care, and a resident reported no concerns about the living space. The facility’s accommodation analysis form also showed the rooms housed five beds per room, and the ADM submitted a waiver request for the rooms.
Room Size Requirement Not Met in Multiple Resident Rooms: The facility failed to provide at least 80 sq. ft. per resident in 17 of 20 resident rooms. Review of the room-size waiver request showed several rooms with 2 or 3 beds that did not meet the federal square footage requirement. During observations and interviews, OT, CNA, and a resident stated they could move around the rooms easily and had no concerns about the living space, and the MD described how the rooms were measured for verification.
A resident with multiple health conditions and mild cognitive impairment experienced inadequate discharge planning due to the facility's failure to conduct an IDT meeting and address the resident's personal requests. The Social Services Director's approach was perceived as rude, and the resident felt forced out. Staff acknowledged the resident's rights, but the facility did not follow its discharge policy, leading to ineffective planning.
A facility failed to provide necessary behavioral health care and services to a resident with major depressive disorder, who made unrealistic demands. The facility did not develop a care plan to address these behaviors, and the Social Services Director attempted to transfer the resident without proper discharge planning. Staff interviews revealed the facility could accommodate the resident's needs, but the lack of a person-centered care plan led to a deficiency in care.
A facility failed to provide adequate social services to a resident with multiple health conditions, including major depressive disorder. The resident's specific requests, such as early rising and daily laundry, were not accommodated, leading to psychosocial distress. The Social Services Director's approach was perceived as rude, and there was no proper discharge planning or understanding of resident rights, contributing to the deficiency.
Two residents experienced a delay in receiving their meals due to a mix-up with the food trays, leading to a failure in maintaining their dignity. The facility's usual process of serving all residents simultaneously was not followed, as confirmed by an LVN and the DON.
The facility did not follow its menu plan for residents on pureed diets, serving scrambled eggs instead of the prescribed Florentine torta. This substitution was not documented or approved by the Registered Dietitian, potentially compromising the nutritional intake of five residents. The Dietary Supervisor acknowledged the issue, noting the importance of adhering to standardized recipes to ensure adequate nutrition.
The facility failed to provide food in appropriate textures for residents on pureed and soft mechanical diets. Residents on a pureed diet received lumpy oatmeal, contrary to IDDSI standards, posing a choking risk. Additionally, residents on a soft mechanical diet were served bread with hard edges, which was against the facility's guidelines and also posed a choking hazard.
The facility was found to have multiple deficiencies in food storage and hygiene practices, including uncovered trash cans, improper hand hygiene, incorrect food storage, and unsanitary kitchen equipment. These issues could lead to cross-contamination and foodborne illnesses among residents.
The facility failed to maintain a clean garbage area, with debris such as masks and dog poop bags observed around the dumpster. Additionally, a dumpster was overflowing with trash and left uncovered due to a lack of Sunday trash pickup. This failure to adhere to cleanliness and waste management guidelines posed a potential infection risk to residents.
The facility failed to maintain sanitary conditions in the food services department, with six flies observed in the kitchen over two days. The Dietary Supervisor was unaware of the last pest control visit, and the pest control report only noted treatment in the exterior garbage area. This oversight potentially exposed 53 of 54 residents to foodborne illnesses.
A resident with hypothyroidism had an elevated TSH level, but the facility failed to document this change or notify the physician and resident's representative, as required by policy. The resident also refused a follow-up blood draw, and the physician was not informed of this refusal.
A resident with hypothyroidism had an elevated TSH level, but the facility failed to notify the physician as required by policy. Additionally, the resident refused a follow-up TSH test, and there was no documentation of physician notification. Interviews confirmed lapses in communication and documentation, contrary to facility policy.
A resident's LAL mattress was incorrectly set for a weight of 400 lbs instead of the resident's actual weight of 187 lbs, increasing the risk of pressure ulcer development. The resident, with conditions including diabetes and hemiplegia, required maximal assistance. The facility's policies and training materials indicated that mattress settings should be based on weight, but this was not followed, leading to the deficiency.
A resident with an indwelling urinary catheter did not receive appropriate care to prevent urinary tract infections due to the absence of a securement device and improper monitoring of catheter drainage. Despite the care plan's requirements, the catheter was not secured, leading to leakage and improper function. Facility staff, including a CNA and LVN, confirmed the catheter's mismanagement, and the resident was transferred to the hospital for further evaluation.
An LVN failed to follow a physician's order to hold Amlodipine for a resident with a pulse rate below the specified threshold. The resident's pulse was 58 BPM, but the LVN prepared the medication for administration until a surveyor intervened, highlighting a significant medication error.
The facility failed to maintain the correct temperature in a medication storage room, with the thermostat reading 90°F, above the acceptable range of 68-77°F. The fan, controlled by the light switch, was off when the light was off, causing the temperature rise. The temperature log was incomplete, missing an entry for one day, contrary to facility policy.
The facility was found non-compliant with room capacity regulations, as two rooms housed five residents each. Despite this, observations indicated sufficient space for resident movement and care provision. Staff and residents reported no concerns, and the administrator requested a waiver, asserting that care was not impeded.
The facility failed to meet federal room size requirements, with 17 out of 20 rooms not providing the mandated square footage per resident. Despite this, staff reported no concerns, and observations showed sufficient space for resident movement and care. A waiver request was submitted, but measurements confirmed non-compliance.
A facility failed to monitor and supervise residents with wandering behaviors, resulting in two elopement incidents. A resident with severe cognitive impairment left the facility unsupervised and was found at a previous address. Another resident, identified as high risk for elopement, left with a family member without triggering the wander-guard alarm. The Maintenance Supervisor could not explain the alarm failure, despite regular checks. Facility policies for wandering and elopement were not effectively implemented.
Incomplete Post-Dialysis Evaluation Documentation for Hemodialysis Resident
Penalty
Summary
The deficiency involves the facility’s failure to complete required post-dialysis evaluation documentation for a resident who received hemodialysis. The resident was admitted with multiple diagnoses, including DM type 2, muscle weakness, COPD, heart failure, HTN, ESRD, and dependence on renal dialysis. An MDS assessment indicated the resident had intact cognition and required varying levels of assistance with ADLs, and that the resident received hemodialysis treatments. During a concurrent interview and record review with an LVN, the surveyor reviewed the resident’s pre- and post-dialysis evaluation records for March and found that the post-dialysis evaluation for a specific treatment date was missing from the medical record. The LVN confirmed that the post-dialysis evaluation for that date was not present in the record and acknowledged that this omission could result in missing changes of condition or medications given during the treatment. Review of the facility’s “Dialysis Management” policy, last reviewed on 6/20/25, showed that a pre- and post-dialysis evaluation was required to be completed by a licensed nurse and that all documentation concerning dialysis services and care of dialysis residents must be maintained in the resident’s medical record. The missing post-dialysis evaluation demonstrated that the facility did not follow its own policy and procedures for dialysis management and did not maintain a complete medical record for this resident.
Medication administration, pain order implementation, and controlled substance handling deficiencies
Penalty
Summary
Proper resident identification was not completed before medication administration for one resident who had a history of hemiplegia, hemiparesis following cerebral infarction, hypertension, severe obesity, and moderate cognitive impairment. During a concurrent observation of MedPass, an LVN administered medications without checking the resident’s ID band and stated that residents must be identified with two identifiers before medications are given. The LVN also was observed not wearing gloves while assisting the resident with medication administration. The DON later stated that residents must be identified using at least two identifiers and that gloves are required during medication administration. Pain medication orders for the same resident were not accurately implemented. The resident had diagnoses including right knee replacement, hemiplegia, cognitive communication deficit, schizophrenia, bipolar disorder, and moderately impaired cognition. The resident was observed moaning in pain and stated that staff did not help with pain and that nothing was done. The physician’s orders included Norco 10 every 4 hours as needed for severe pain and Norco 5 every 6 hours as needed for moderate pain, but the MAR showed Norco 10 was given at 10:56 a.m. and Norco 5 was given again 3 hours and 42 minutes later at 2:38 p.m. The LVN stated she could give Norco 5 two hours after a prior dose regardless of the ordered frequency, while the pharmacist stated the timing should align with the ordered frequency. Controlled substances were not handled in accordance with storage and documentation requirements. Lorazepam oral solution 2 mg/ml was observed in the medication room refrigerator stored next to other medications, and the LVN stated she was unable to identify whether controlled medications had to be stored separately in the refrigerator. In addition, review of the Controlled Substance Disposition Logs for 10/2025 through 12/2025 showed multiple missing DON signatures. The DON stated that controlled medications awaiting destruction were kept in a double-locked drawer and that destruction was done every 3 months and as needed with the pharmacist present, but the logs reviewed were incomplete because the required DON signatures were missing.
Medication Labeling and Expiration Date Deficiencies
Penalty
Summary
The facility failed to ensure that medication labels matched physician orders for a resident with a history of metabolic encephalopathy, UTI, bacteremia, and type I DM. The resident’s order summary showed levofloxacin 250 mg, 2 tablets by mouth once daily for UTI for 5 days, but during a concurrent medication pass observation, the bubble pack label showed levofloxacin 500 mg, 1 tablet by mouth once daily for UTI for 5 days. The LVN stated the order and label did not match and that the discrepancy should be communicated with the physician and pharmacy for clarification and correction. The facility also failed to ensure that medications were labeled with expiration dates. During observation of the medication room, two compounded vancomycin HCl IV infusion bags for a resident with pressure ulcer of the sacral region, osteomyelitis of the vertebra, and dysphagia were found in the refrigerator without expiration dates. During observation of medication cart 1, escitalopram for another resident with fibromyalgia, asthma, and major depressive disorder was also found without an expiration date. The LVN stated that all medications must be labeled with expiration dates and that administering medications without expiration dates may cause decreased efficacy and harm residents. The DON stated that if there is a discrepancy between a medication order and the label on the bubble pack, it needs to be addressed immediately and the pharmacy must be contacted to obtain a corrected medication matching the physician order. The facility policy titled Medication Storage in The Facility stated that infusion therapy labels should include the resident name, medication name, date of preparation, initials of compounder, ancillary labeling, and expiration date, and that drugs repackaged by pharmacy staff will generally carry an expiration date.
Infection Prevention and Control Practices Not Followed
Penalty
Summary
Standard infection prevention and control practices were not followed when eight of 16 bleach wipe containers on the nursing floor were observed with lids left open in multiple locations throughout the facility. During the observation, the Infection Prevention Nurse confirmed the containers were open and stated that if the containers are not properly closed, the wipes will not be able to eliminate bacteria. The product label for the bleach wipes stated they should be kept in a tightly closed container when not in use and that the center flap should be snapped down when finished to retain moisture. Resident 48 was admitted with diagnoses including cellulitis of both lower limbs, a urinary tract infection, a chronic ulcer of the right lower leg, and peripheral vascular disease. The resident’s MDS indicated intact cognitive skills for daily decisions and need for substantial to maximum assistance with toileting, showering, lower body dressing, and footwear, with supervision or touching assistance needed for eating, oral hygiene, and personal hygiene. The care plan identified the resident as having potential impairment to skin integrity of the bilateral legs related to cellulitis with open lesions. During observation, the MDSN entered the resident’s room without a gown, emptied the resident’s urinal, and placed it back on the bed while the linens were visibly soiled and had brown stains. The MDSN stated she only wore gloves and did not wear a gown because the sign outside the room did not indicate a gown was required for emptying the urinal. Resident 11 was admitted with diagnoses including Alzheimer’s disease, dysphagia, and failure to thrive, and the MDS indicated the resident was dependent in activities of daily living. An EBP sign was posted at the doorway and PPE was available in the room. During observation, CNA 3 fed the resident and held the resident’s hand without wearing a gown or gloves, and stated she saw the EBP sign but forgot to wear PPE. RN 1 stated staff are supposed to wear a gown and gloves when feeding residents on EBP because it is a high-contact activity, and the DON stated PPE for EBP should be worn when helping with ADLs, including feeding, toileting, and mobility.
Failure to Verify UTI Criteria Before Starting Antibiotics
Penalty
Summary
The facility failed to implement its antibiotic stewardship program for two residents by not ensuring that UTI criteria were met before antibiotics were started. The report states that the facility’s antibiotic stewardship process required use of McGeer criteria, including clinical symptoms, supporting laboratory results, and a documented medical diagnosis, and that laboratory findings alone were not sufficient to justify antibiotic therapy. For Resident 47, the record showed diagnoses including osteomyelitis of the vertebra, a sacral pressure ulcer, UTI, and dysphagia. The resident’s MDS indicated moderate cognitive impairment and need for substantial to maximal assistance with toileting, showering, lower body dressing, and personal hygiene. The record showed cephalexin was ordered on 1/9/2025 for UA WBC >50 for 7 days, and lab results dated 1/8/2026 showed WBC >50 and urine culture with multi-drug-resistant E. coli. The Change in Condition Evaluation dated 1/9/2026 did not document signs or symptoms of infection. For Resident 14, the record showed diagnoses including metabolic encephalopathy, UTI, bacteremia, and type I DM. The MDS indicated the resident was cognitively intact and dependent for toileting hygiene, showering, lower body dressing, and footwear. The record showed Macrobid was ordered with a start date of 1/19/2025 and levofloxacin with a start date of 1/20/2025 for UTI, but there was no documentation of a change in condition related to the UTI and antibiotic treatment, no documentation of initiation and implementation of a care plan addressing the UTI and antibiotic treatment, and no documentation of infection control surveillance assessment related to the UTI and antibiotic treatment.
Missing COVID-19 Vaccination Documentation for Staff
Penalty
Summary
The facility failed to ensure documented evidence was maintained for two of four sampled employees, the Medical Director and the Infection Prevention Nurse (IPN), regarding COVID-19 vaccination status and the provision of education on the benefits and potential side effects of the vaccine. During a concurrent interview and record review with the IPN, employee records for the Medical Director and IPN 2 showed no documentation of COVID-19 vaccination status, education on the benefits and potential side effects, or that the COVID-19 vaccine had been offered. During interview, the IPN stated the facility must maintain documentation related to staff COVID-19 vaccinations, including vaccination status, education provided regarding benefits and potential side effects, and documentation that the vaccine was offered. The DON stated that all staff, including the Medical Director and IPN 2, are required to have COVID-19 vaccination screening completed upon hire and that ongoing vaccination records must be maintained in both the facility records and individual employee files. The facility policy titled, COVID-19 Vaccination Program, stated that all HCP are required to be fully vaccinated and boosted when eligible, unless they have a medical or religious waiver, and that vaccination card information must be transcribed into the employee's health file as proof of vaccination.
Failure to Obtain Written Informed Consent for Divalproex
Penalty
Summary
The facility failed to obtain written informed consent before administering Divalproex to one resident with diagnoses including schizoaffective disorder, depression, and dementia. The resident’s MDS indicated moderate cognitive impairment, and the physician ordered Divalproex 250 mg by mouth daily for schizoaffective behavior manifested by aggressive behavior, including cursing at a roommate and staff. A review of the resident’s medical record found no documented evidence of informed consent for the use of Divalproex in either Informed Consent Documentation or Verification of Informed Consent. The MAR showed the resident received Divalproex every morning for 22 doses, and both the DON and MR confirmed there was no written informed consent in the record. The facility policy titled Behavior/Psychoactive Medication Management stated that written informed consent is required for psychoactive drugs and must be renewed every 6 months.
Failure to Offer GDR for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that one sampled resident, Resident 7, was offered a gradual dose reduction while receiving an antipsychotic medication to be free from unnecessary medications. Resident 7’s record showed an original admission and later readmission to the facility with diagnoses including hypothyroidism, dementia, and adult failure to thrive. The Minimum Data Set dated 10/27/2025 indicated the resident’s cognition was intact, but the facility did not complete Section D for mood and did not complete a Staff Assessment of mood, leaving symptom presence, frequency, and severity undocumented. Resident 7 had an active order for Risperidone 4 mg at bedtime, effective 9/18/2025, prescribed for schizoaffective disorder with auditory hallucinations. During interview and record review with the DON, it was stated that the IDT met on 9/26/25 and no GDR was offered, and there were no progress notes from social services or the MD showing that a gradual dose reduction was attempted. The DON stated GDR should be offered quarterly and that the resident did not have a diagnosis of schizophrenia and should have been trialed for a medication dose reduction. The care plan identified use of antipsychotic medication and included an intervention to consult with pharmacy and MD to consider dosage reduction at least quarterly, and the consultant pharmacist’s medication regimen review did not include recommendations for GDR or continued justification for ongoing Risperidone use.
MDS Assessment Did Not Accurately Reflect Resident’s Fracture and Safety Status
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) accurately reflected Resident 19’s status. Resident 19’s record showed an original admission and a readmission with diagnoses including dementia, Alzheimer’s disease, and a history of falling. The MDS dated [DATE] indicated the resident’s cognition was severely impaired and that the resident was dependent for eating, oral hygiene, toileting, showering, upper and lower body dressing, putting on and taking off footwear, and personal hygiene. A review of the nurses’ progress notes showed that on 10/29/2025 at 11:54 p.m., a nurse documented that Resident 19 returned from the GACH at 11:50 p.m. with a right hip fracture from a fall. During interview and record review, RN 1 stated the clinical admission assessment was not completed accurately because not all questions were answered, including the safety section, and said the assessment was inaccurate because it did not properly indicate that Resident 19 was not at high risk for falls. The MDS nurse also stated that the resident’s re-admission assessment was not completed accurately, specifically noting that Section J, Health Conditions, incorrectly addressed whether the resident had sustained any fractures related to a fall in the 6 months prior to admission/entry or reentry. The MDS nurse stated that Resident 19 was re-admitted with a right hip fracture on 11/3/2025 and that the question should have been triggered properly to ensure the resident received the care needed.
Medication Crushed Without Physician Order
Penalty
Summary
The facility failed to meet professional standards of quality when an LVN crushed and administered Resident 14’s medications without a physician’s order allowing medications to be crushed. Resident 14 was admitted and readmitted with diagnoses including metabolic encephalopathy, UTI, bacteremia, and type I DM. The MDS dated 11/14/2025 indicated the resident was cognitively intact and dependent for toileting hygiene, showering, lower body dressing, and putting on/taking off footwear. During a concurrent observation of the medication pass and interview on 1/21/2026, the LVN prepared Resident 14’s morning medications, including Macrobid, aripiprazole, buspirone, gabapentin, metoprolol tartrate, vitamin C, and levofloxacin, then crushed all listed tablets and emptied all capsules into a medication cup mixed with applesauce before administering them. Later, the LVN stated medications could be crushed only with a physician order indicating may crush all crushable medications and acknowledged there was no such order. RN 1’s record review showed no documentation authorizing crushing medications and no care plan addressing the resident’s needs or preferences for crushed medications. The DON stated that medications in crushed form were acceptable if it was the resident’s preference, but that physicians need to be aware and an order allowing medications to be crushed must be placed. The facility policy also stated that if medication is to be crushed, a physician order is required.
Delayed transfer after physician-ordered hospital evaluation
Penalty
Summary
The facility failed to ensure that Resident 19’s care was not delayed when transportation did not pick the resident up on 10/28/25 for transfer to an acute hospital per physician’s orders. Resident 19’s record showed diagnoses including dementia, Alzheimer’s disease, and a history of falling. The MDS dated 10/17/25 indicated the resident’s cognition was severely impaired and that the resident was dependent for eating, oral hygiene, toileting, showering, dressing, footwear, and personal hygiene. Nursing progress notes dated 10/28/25 documented that the MD reviewed the resident’s chart and ordered transfer to a GACH for further evaluation and treatment due to a recent fall. The order summary report also indicated transfer to an acute hospital for further evaluation related to the fall and possible direct admission. During interview, the DON stated the resident was not transferred for further evaluation and treatment because of a transportation delay, that licensed nurses were responsible for arranging transportation, and that if transfer did not occur during certain hours the MD should be notified to determine alternative treatment while the resident remained in the facility. The DON acknowledged that nursing staff did not document that the MD was notified of the delay. The resident’s DPOA stated the facility told her transportation did not come until the next morning because of a schedule conflict.
Failure to Follow Fluid Restriction for Resident on Hemodialysis
Penalty
Summary
The facility failed to follow the physician’s fluid restriction order for a resident receiving hemodialysis. The resident was admitted with diagnoses including UTI, COPD, and CHF, and the MDS indicated the resident required maximum assistance with ADLs. A physician’s order dated 12/30/25 directed a 1,000 ml daily fluid restriction divided among dietary and nursing shifts, and the resident also had an order for hemodialysis every Tuesday, Thursday, and Saturday. During review of the January 2026 Fluid Intake record, staff identified that on 1/4/26 the resident’s total fluid intake was documented as 1,100 ml, which exceeded the ordered limit. The record showed two 500 ml entries at 2:45 p.m. and one 100 ml entry at 5:00 p.m. CNA 4 stated CNAs are responsible for charting all fluids, including those given during medication administration, and LVN 2 stated duplicate documentation is inaccurate and can affect the daily total. RN 1 and the DON both stated the fluid restriction order was not followed and that the 2:45 p.m. entries were either duplicate documentation or documented at the incorrect time. The facility’s Dialysis Management policy stated that diet and fluid restrictions will be followed as ordered.
Failure to assess and document use of four side rails
Penalty
Summary
Resident 21, who was admitted with diagnoses of seizures, hydrocephalus, and GERD, had four side rails in use without documentation that the resident had been assessed for entrapment risk before installation. The resident’s MDS dated 11/21/25 indicated cognitive status was intact and that the resident was independent with eating, needed setup or clean-up assistance with upper body dressing, and required supervision or touching assistance with oral hygiene, lower body dressing, and personal hygiene. On 1/21/26 at 10:32 a.m., Resident 21 was observed lying in bed with four side rails up, the rails were not padded, there were no floor mats on the side of the bed, and the bed was in the low position. The physician’s orders in effect for Resident 21 required bilateral padded side rails to decrease potential injury related to seizure and allowed bilateral side rails up with padding and floor mats for seizure precaution and fall risk. The record review found no documentation of alternatives attempted, no documentation of entrapment risk, and no evidence of informed consent for four bed rail use. There was no care plan addressing bed rail use or potential entrapment. Staff interviews indicated the four side rails were raised at the family’s request while floor mats were being cleaned, that no alternative measures were attempted before using four side rails, that the lower side rails had been added without being measured, and that the informed consent on file referred to bilateral side rails but did not include the four side rails and was incomplete because it lacked a second nurse’s signature.
Medication Error Rate Exceeded 5 Percent
Penalty
Summary
The facility failed to ensure that the medication error rate remained below 5 percent. During observation, interview, and record review, surveyors identified 2 medication errors out of 26 opportunities, resulting in an overall error rate of 7.69% and affecting two residents during medication administration. One error involved a discrepancy between the physician order in the EMR and the bubble pack label for levofloxacin for a resident with diagnoses including metabolic encephalopathy, UTI, bacteremia, and type I DM. The resident was cognitively intact and dependent for some ADLs, and the medication was prepared during morning MedPass along with several other ordered medications. During the same MedPass observation, the LVN stated that the levofloxacin label did not match the physician order in the EMR, which listed levofloxacin 250 mg, 2 tablets by mouth daily for UTI, while the bubble pack reflected levofloxacin 500 mg, 1 tablet by mouth daily. The LVN stated she could still administer the medication because the dosage would be the same. The LVN also stated the resident was on a pureed diet and began crushing the listed tablets and emptying capsules into medication cups with applesauce, and administered the medications. Later interview and record review showed the physician order did not indicate that medications could be crushed, and the facility policy required verification of the 6 rights of medication administration and a physician order if medications were to be crushed. A second medication error involved a resident with diagnoses including chronic atrial fibrillation, type 2 DM, and anemia, who was cognitively intact and largely independent with ADLs. During medication administration, Vitamin D3 125 mcg (5,000 IU) was scheduled but the LVN could not locate it in the medication cart. Review of the eMAR showed no documentation that the dose had been given, and progress notes showed no documentation of physician notification or instructions regarding the missing medication. The DON stated that when a medication is ordered but not available, the nurse must immediately contact the physician and follow instructions regarding whether the dose can be skipped, delayed, or substituted.
Excess Residents in Shared Rooms
Penalty
Summary
The facility failed to meet the requirement for no more than four residents per room in 2 of 20 resident rooms, with the identified rooms housing five residents each. During an unannounced recertification survey tour on 1/22/2026 at 12:57 p.m., surveyors observed that the two rooms had five residents per room. The rooms were observed to have enough space for residents to move freely inside the room and adequate space for wheelchairs, walkers, and canes. During interviews, the Occupational Therapist stated she could move around the room easily and had no obstacles hindering patient care, and a CNA stated she could also move around the room easily with no obstacles hindering patient care. A resident interviewed stated he had no concerns or issues regarding his living space. Review of the facility's client accommodation analysis form completed on 1/22/2026 showed the rooms housed five beds per room. The administrator submitted a letter requesting a waiver for the two rooms with more than four residents per room, and the Administrative Assistant stated the facility had submitted a written request for the continued room waiver because the room sizes did not impede resident care.
Room Size Requirement Not Met in Multiple Resident Rooms
Penalty
Summary
The facility failed to provide at least 80 square feet per resident in 17 of 20 resident rooms, including Rooms 4, 5, 6, 7, 8, 9, 10, 11, and 14 through 22. The deficiency was identified during review of the Administrator’s Request for Room Size Waiver letter dated 1/22/2026, which stated that these rooms did not meet the federal room-size requirement. The report listed the room dimensions and bed counts for the affected rooms, including several 14 ft. x 10 ft. rooms with 2 beds and several 20 ft. x 10 ft. rooms with 3 beds. During multiple observations from 1/20/2026 through 1/22/2026, residents were observed to have ample space to move freely in the rooms, and there was sufficient space for bedside tables, side tables, and resident care equipment. In interviews, OT 1 stated she could move around the room easily and had no obstacles hindering patient care, CNA 1 stated she could move around the room easily and had no obstacles hindering patient care, and Resident 35 stated he had no concerns or issues regarding his living space. The Maintenance Director stated he measured the rooms from the window to the door for length and from the wall to the start of the closet for width, and the Administrative Assistant stated the facility submitted a written request for the continued room waiver although the room sizes do not impede resident care.
Inadequate Discharge Planning and Resident Rights Violation
Penalty
Summary
The facility failed to adequately prepare and orient a resident for a safe and orderly discharge. The deficiency involved the lack of an Interdisciplinary Team (IDT) meeting to discuss the discharge planning for a resident with multiple health conditions, including type II diabetes mellitus, chronic obstructive pulmonary disease, and major depressive disorder. The resident required maximal assistance for activities of daily living and had mild cognitive impairment. Despite these needs, the facility did not conduct an IDT meeting to ensure a comprehensive discharge plan was in place. The discharge planning was initiated not based on the resident's health needs but rather on the resident's personal requests, such as wanting to get up early and requesting daily laundry services. The Social Services Director (SSD) indicated that the facility could not accommodate these demands and sought alternative facilities for the resident, which the resident declined. The SSD's approach to the resident was perceived as rude, and the resident felt as though they were being forced out of the facility. The resident expressed a desire to remain at the facility and was particular about their living arrangements. The facility's staff, including a Certified Nursing Assistant and a Registered Nurse, acknowledged the resident's rights to make choices about their care and daily routine. However, the SSD was unable to articulate the resident's rights regarding freedom of choice and did not follow the facility's policy on discharge and transfer, which requires a discharge summary and post-discharge plan of care. The facility's failure to honor the resident's rights to be treated with kindness, respect, and dignity contributed to the incomplete and ineffective discharge planning process.
Failure to Address Behavioral Health Needs and Implement Person-Centered Care Plan
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident, identified as Resident 1, who was admitted with diagnoses including type II diabetes mellitus, chronic obstructive pulmonary disease, and major depressive disorder. The resident's Minimum Data Set indicated mild cognitive impairment and a need for maximal assistance with activities of daily living. Despite these needs, the facility did not develop a care plan to address the resident's behavior of making unrealistic demands, as required by the facility's policy on Behavior/Psychotropic Drug Management. The resident's psychosocial note from a psychiatrist highlighted the need to address the resident's mood and emotional state, which influenced her behavior towards staff. However, the Social Services Director (SSD) failed to accommodate the resident's requests, such as being up by 6 a.m., having laundry done daily, and storing all belongings in her room. The SSD attempted to transfer the resident to another facility without conducting an interdisciplinary team meeting or understanding the facility's policy on discharge and transfer, which led to the resident feeling unwanted and neglected. Interviews with staff revealed that the facility could accommodate the resident's needs, but the SSD's approach and lack of understanding of residents' rights contributed to the deficiency. The Registered Nurse confirmed that the facility should not transfer the resident due to high demands and emphasized the importance of communicating with the resident to ensure she felt secure and respected. The facility's failure to implement a person-centered care plan and address the resident's behavioral health needs resulted in a deficiency in providing the highest practicable physical, mental, and psychosocial well-being for the resident.
Failure to Provide Adequate Social Services
Penalty
Summary
The facility failed to provide medically-related social services to Resident 1, who was admitted with diagnoses including type II diabetes mellitus, chronic obstructive pulmonary disease, and major depressive disorder. The resident's Minimum Data Set indicated mild cognitive impairment and a need for maximal assistance with activities of daily living. Despite these needs, the facility did not develop a care plan to address Resident 1's behavior of making unrealistic demands and requests, which contributed to the resident's psychosocial distress. The Social Services Director (SSD) failed to accommodate Resident 1's specific requests, such as being up by 6 a.m., having laundry done daily, and storing all belongings in her room. The SSD's approach to Resident 1 was perceived as rude, and the resident felt pressured to leave the facility. The SSD did not conduct an interdisciplinary team meeting for discharge planning and was unaware of the facility's policy on resident rights regarding freedom of choice. This lack of appropriate social services and communication contributed to Resident 1's distress. Interviews with staff, including a Certified Nursing Assistant and a Registered Nurse, revealed that Resident 1 was generally friendly and understood the limitations of the facility's services. However, the SSD's handling of the situation, including the suggestion of transferring Resident 1 to another facility without proper planning or understanding of resident rights, was inadequate. The facility's failure to address Resident 1's psychosocial needs and demands led to a deficiency in providing the highest practicable well-being for the resident.
Failure to Serve Meals Simultaneously
Penalty
Summary
The facility failed to maintain or enhance the dignity of two residents by not serving their meals at the same time as other residents in the dining room. Resident 2, who was admitted with chronic obstructive pulmonary disease, dysphagia, and type 2 diabetes, was observed waiting for her meal while other residents were served. The Minimum Data Set indicated that Resident 2 was severely cognitively impaired and required assistance with eating. During the observation, it was noted that the first food cart arrived, and seven residents received their meals while six others, including Resident 2, continued to wait. Licensed Vocational Nurse 3 acknowledged that the trays were not served simultaneously due to a mix-up and stated that this was not the usual process. The Director of Nursing also confirmed that the expectation was for all residents to receive their meals at the same time to prevent feelings of deprivation or neglect. The delay in serving meals was attributed to a communication issue with the kitchen, resulting in Resident 2 and Resident 42 receiving their meals later than others.
Failure to Follow Menu Plan for Pureed Diets
Penalty
Summary
The facility failed to adhere to its menu plan, which resulted in five out of 54 residents on pureed texture diets receiving scrambled eggs instead of the prescribed Florentine torta. This discrepancy was identified through observation, interviews, and record reviews. The facility's daily menu spreadsheet for residents on pureed diets indicated that they should receive a pureed Florentine torta, but scrambled eggs were served instead. The Dietary Supervisor acknowledged the substitution, stating that the Florentine torta recipe was not smooth when cooked, prompting the use of scrambled eggs for a smoother consistency. However, this change was not documented on the menu spreadsheet, and the Registered Dietitian was not informed of the substitution. The facility's Policies and Procedures for Menu Planning require that any menu changes be documented and approved by the Registered Dietitian or the Food and Nutrition Services Director. The failure to follow the standardized recipe and menu plan potentially compromised the residents' nutritional intake, as the substitution was not aligned with the planned nutritional content. The Dietary Supervisor admitted that not following the standardized recipe could lead to residents receiving inadequate nutrition, which could affect their overall health and well-being.
Failure to Provide Appropriate Food Textures for Residents
Penalty
Summary
The facility failed to prepare foods in a form designed to meet individual needs, specifically for residents on pureed and soft mechanical diets. Residents on a pureed International Dysphagia Standardization Initiative (IDDSI) level 4 diet, which requires food to be smooth and pudding-like, were served oatmeal with lumps. This was observed during a trayline inspection, and the Dietary Supervisor confirmed that the lumpy oatmeal posed a potential choking hazard. The facility's policy and procedures, as well as the diet manual, clearly stated that pureed diets should be smooth and free of lumps, aligning with IDDSI standards. Additionally, residents on a soft mechanical diet, intended for those with chewing or swallowing difficulties, received toasted bread with hard edges. The facility's standardized recipe for mechanical soft diets specified that breads should be soft and without hard crusts. The Dietary Supervisor acknowledged that the hard crusts on the bread were inappropriate for residents on this diet, as they could also pose a choking risk. The facility's diet manual reinforced that breads with hard crusts should be avoided for residents on a mechanical soft diet.
Deficiencies in Food Storage and Hygiene Practices
Penalty
Summary
The facility failed to maintain safe and sanitary food storage and preparation practices in the kitchen, as observed during a survey. The trash can in the handwashing sink room was not covered when not in use, which was against the facility's policy and could lead to the transport of bacteria. Staff members were observed not performing hand hygiene after touching potentially contaminated surfaces, such as the lids of garbage cans, and then handling clean trays and dishes. This lack of hand hygiene was contrary to the facility's policies and the Food Code 2022, which emphasize the importance of handwashing to prevent cross-contamination. In the kitchen, improper food storage practices were noted, with raw chicken stored above ground beef and cooked chicken stored below raw fish, violating the facility's food storage hierarchy. Additionally, several pieces of kitchen equipment and utensils were found to be in poor condition, with dust, rust, and debris present in refrigerators and freezers, and chipped and cracked trays and shelves. These conditions could lead to contamination and were not in compliance with the facility's policies or the Food Code 2022. Other issues included the improper handling of kitchenware, such as using cloths to dry steam table covers instead of air drying, and storing scoops in different orientations, which increased the risk of contamination. Staff food was also found stored in the resident's refrigerator, which could lead to mix-ups and potential allergic reactions for residents. These practices were not aligned with the facility's policies and posed a risk of foodborne illness to the residents.
Improper Garbage Disposal and Overflowing Dumpster
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, as observed during a survey. The garbage area was not maintained free from debris, including masks, dog poop bags, boxes, and dirt on the floor and surroundings of the dumpster. During an observation and interview with the Dietary Supervisor, it was noted that the trash area should be cleaned for infection control purposes. The Maintenance Director also confirmed the presence of debris and stated that it was coming from people walking by, emphasizing the need for cleanliness to prevent contamination. Additionally, one of the dumpsters was observed to be overflowing with trash, and its lid was not closed. This was noted during multiple observations, and the Maintenance Director acknowledged that the trash pickup schedule did not include Sundays, leading to the overflow. The facility's policies and procedures, as well as the Food Code 2022, require that garbage areas be kept clean and receptacles covered to prevent contamination and attract pests. The failure to adhere to these guidelines posed a potential risk of infection to the facility's residents.
Sanitation Deficiency in Food Services Due to Flies
Penalty
Summary
The facility failed to maintain sanitary conditions in the food services department, as evidenced by the presence of six flies observed in the kitchen over a two-day period. Observations were made on different occasions, with flies seen around the preparation area, preparation table, and trayline. During interviews, the Dietary Supervisor acknowledged the presence of flies and expressed uncertainty about the last pest control visit, indicating a lack of awareness regarding pest management in the kitchen. The facility's Policy and Procedures on Pest Control, dated June 28, 2024, emphasized the importance of keeping the facility free from insects and other pests to ensure the health and safety of residents, staff, and visitors. However, a review of the pest control report from October 23, 2024, showed that treatment for large flies was only applied in the exterior garbage area, with no mention of the kitchen. This oversight potentially exposed 53 of 54 residents to foodborne illnesses due to the risk of consuming contaminated food.
Failure to Document and Notify Change in Resident's Condition
Penalty
Summary
The facility failed to document a significant change in condition for a resident, identified as Resident 2, in accordance with its policy and procedure. Resident 2, who was admitted with diagnoses including hypothyroidism, generalized muscle weakness, and hypertension, had a lab result indicating an elevated thyroid-stimulating hormone (TSH) level of 27.71 uIU/ml, which was significantly above the normal range. Despite this abnormal result, there was no documentation of a change of condition (COC) being completed, nor was there evidence that the attending physician or the resident's representative was notified of this change. Additionally, Resident 2 refused a follow-up blood draw for TSH, and again, there was no documented notification to the physician regarding this refusal. Interviews with the Registered Nurse Supervisor/Minimum Data Set Nurse (RNS/MDSN) and the Director of Nursing (DON) confirmed that the facility's process for handling such situations was not followed. The facility's policy requires prompt notification of the physician and the resident's representative in the event of a significant change in condition, which was not adhered to in this case.
Failure to Notify Physician of Abnormal Lab Results
Penalty
Summary
The facility failed to notify the physician of abnormal laboratory test results for a resident, as required by their policy and procedure. The resident, who was admitted with diagnoses including hypothyroidism, had a thyroid-stimulating hormone (TSH) level of 27.71 uIU/ml, which is significantly above the normal range. Despite the facility's policy to notify the attending physician of abnormal lab results, there was no documented evidence that the physician or the resident's representative was informed of the elevated TSH level. Additionally, a change of condition (COC) was not completed, which is part of the facility's process for handling deviations from a resident's baseline condition. Furthermore, the resident refused a follow-up TSH laboratory draw that was ordered six weeks after the initial test. Again, there was no documentation indicating that the physician was notified of the resident's refusal to undergo the blood draw. Interviews with the Registered Nurse Supervisor/Minimum Data Set Nurse (RNS/MDSN) and the Director of Nursing (DON) confirmed these lapses in communication and documentation. The facility's policy requires that lab results be promptly communicated to the physician to prevent delays in necessary interventions, but this protocol was not followed in this case.
Improper LAL Mattress Setting for Resident
Penalty
Summary
The facility failed to ensure that the Low Air Loss (LAL) mattress setting was appropriately set for a resident, identified as Resident 205, which could potentially lead to the redevelopment of pressure ulcers. Resident 205 was admitted with diagnoses including diabetes, hemiplegia, and generalized muscle weakness, and was cognitively intact but required maximal assistance for daily activities. During an observation, it was noted that the LAL mattress pump was set to a weight of 400 lbs, while the resident's actual weight was 187 lbs. This discrepancy was confirmed by a Licensed Vocational Nurse (LVN), who acknowledged that the incorrect setting could increase the risk of pressure ulcer development. The resident's care plan focused on skin integrity management and included interventions to prevent skin breakdown. The Director of Nursing (DON) confirmed that LAL mattress settings should be based on the resident's weight, and incorrect settings could lead to a high risk of skin breakdown. The facility's policy and procedures, as well as training materials, indicated that mattress settings should be adjusted according to the resident's weight to provide appropriate pressure reduction. However, the failure to adhere to these guidelines resulted in the deficiency observed during the survey.
Failure to Secure and Monitor Catheter Leads to Deficiency
Penalty
Summary
The facility staff failed to provide appropriate treatment and services to prevent urinary tract infections for Resident 16, who had an indwelling urinary catheter. The deficiency was identified when it was observed that the resident's suprapubic catheter did not have a securement device or anchor in place, which is necessary to prevent the catheter from being dislodged and causing trauma or infection. The resident's care plan required the catheter to be secured and assessed for proper placement and drainage, but these measures were not followed. As a result, the urine bag was not draining properly, and the resident's diaper was consistently wet, indicating leakage and improper catheter function. The resident, who was admitted with diagnoses including sepsis and acute kidney failure, was unable to understand and make decisions. Despite the care plan's instructions to assess urinary drainage and maintain proper catheter alignment, staff failed to ensure these interventions were implemented. Observations and interviews with facility staff, including a CNA and LVN, confirmed the catheter's improper management and the lack of a securement device. The Director of Nursing acknowledged the oversight, and the resident was eventually transferred to the hospital for catheter reinsertion and evaluation.
LVN Fails to Hold Amlodipine Despite Low Pulse Rate
Penalty
Summary
The Licensed Vocational Nurse (LVN) 4 failed to adhere to a physician's order regarding the administration of Amlodipine, a blood pressure medication, for a resident. The physician's order specified that Amlodipine should be held if the resident's systolic blood pressure was less than 100 or if the pulse rate was below 60 beats per minute (BPM). On the day of the incident, the resident's blood pressure was recorded at 144/73 mmHg, and the pulse rate was 58 BPM, which was below the specified threshold for administering the medication. Despite the resident's pulse rate being outside the parameters for safe administration, LVN 4 proceeded to prepare the Amlodipine for the resident. It was only after the surveyor intervened and prompted LVN 4 to review the blood pressure and pulse rate parameters that LVN 4 acknowledged the error and refrained from administering the medication. This oversight placed the resident at risk for a further decrease in heart rate, as the medication was not held as per the physician's directive.
Medication Storage Room Temperature Deficiency
Penalty
Summary
The facility failed to maintain the correct temperature in one of its medication storage rooms, which could potentially compromise the efficacy of the medications stored there. During an observation and interview, it was noted that the thermostat in the medication storage room indicated a temperature of 90 degrees Fahrenheit, which is above the acceptable range of 68 to 77 degrees Fahrenheit for controlled room temperature. The Registered Nurse Supervisor acknowledged the discrepancy in temperature. Further investigation revealed that the room's fan, which is controlled by the light switch, was not operating when the light was off, contributing to the elevated temperature. Additionally, a review of the room temperature log sheet showed that temperatures were recorded within the acceptable range from November 1 to November 15, but the entry for November 16 was left blank. The Licensed Vocational Nurse confirmed that the log should be completed daily. The facility's policy, revised in January 2018, requires that all medications be stored within specific temperature ranges as per the United States Pharmacopeia and the Centers for Disease Control guidelines. The failure to maintain the correct temperature and to consistently log the temperatures as per policy led to this deficiency.
Non-Compliance with Resident Room Capacity
Penalty
Summary
The facility was found to be non-compliant with the requirement that resident rooms hold no more than four residents. During an unannounced recertification survey, it was observed that two rooms housed five residents each. Despite the additional occupancy, the rooms were noted to have sufficient space for residents to move freely and for nursing staff to provide care. The residents had enough room to operate wheelchairs, walkers, and canes, and there was adequate space for bedside tables and other resident care equipment. Interviews with staff and residents revealed no concerns regarding the room sizes or the care provided. During a resident council meeting, attendees did not express any issues with their living space. The facility's administrator submitted a request for a waiver to allow more than four residents per room, citing that the room sizes did not impede resident care. The facility's client accommodation analysis confirmed the presence of five beds in the rooms in question.
Non-Compliance with Room Size Requirements
Penalty
Summary
The facility failed to provide the required minimum square footage per resident in multiple resident bedrooms, as mandated by federal regulations. Specifically, 17 out of 20 resident rooms did not meet the requirement of at least 80 square feet per resident. The rooms in question were designed to accommodate either two or three residents, but their sizes were insufficient, with two-bedroom units measuring only 140 square feet and three-bedroom units measuring 200 square feet. This deficiency was identified during a recertification survey, where it was noted that the rooms did not meet the federal standards of 160 square feet for two residents and 240 square feet for three residents. Despite the deficiency, staff interviews during the survey indicated no concerns regarding the room sizes, and observations showed that residents had ample space to move freely. The rooms were equipped with necessary furniture and equipment, allowing for freedom of movement and care provision. The facility had submitted a request for a room size waiver, arguing that the room sizes did not impede resident care, and the rooms provided adequate sunlight and ventilation. However, the measurements taken by the maintenance director confirmed the non-compliance with the required room dimensions.
Failure to Monitor and Prevent Resident Elopement
Penalty
Summary
The facility failed to ensure adequate monitoring and supervision of residents with wandering behaviors, leading to two incidents of elopement. Resident 1, who had severe cognitive impairment and was at high risk for elopement, left the facility unsupervised through the front reception area doors. The resident was later found at their previous address, 3.5 miles away. The staff, including a Certified Nurse Assistant (CNA), were unaware of the resident's whereabouts, and the wander-guard alarm system did not activate to alert staff of the resident's departure. Resident 2, who also had cognitive impairments and was identified as a high risk for elopement, left the facility with a family member for a doctor's appointment. Despite wearing a wander-guard bracelet, the alarm system failed to notify staff of the resident's exit. The Maintenance Supervisor, responsible for the wander-guard system, was unable to explain why the alarm did not trigger during these incidents, despite regular checks being conducted to ensure functionality. The facility's policies and procedures for wandering and elopement, as well as the signaling device, were not effectively implemented. The policies required verification of the signaling device's placement and functionality every shift and testing of the alarm functioning of exit doors weekly. However, these measures were insufficient in preventing the elopement of residents, as evidenced by the failure of the wander-guard system to activate during the incidents involving Residents 1 and 2.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Los Angeles
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| West Pico Terrace Healthcare & Wellness Centre Lp | 0.1 mi | ★★★★★ | 15 | 0 |
| Flower Villa, Inc | 0.6 mi | ★★★★★ | 19 | 0 |
| Miracle Mile Healthcare Center, Llc | 0.7 mi | ★★★★★ | 46 | 0 |
| Beverly Hills Rehabilitation Centre | 1 mi | ★★★★★ | 3 | 0 |
| Guardian Rehabilitation Hospital | 1.2 mi | ★★★★★ | 17 | 0 |
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