Below average — CMS composite of the measures below.
The next survey window likely opens around October 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 Penn Mar Healthcare Center during CMS and state inspections, most recent first.
A resident with a history of schizophrenia and aggression was not provided with the required 1:1 supervision as outlined in their care plan, allowing them to strike another resident without provocation. This resulted in significant injuries, including facial lacerations and a nasal bone fracture, requiring emergency medical treatment. Staff interviews confirmed the resident's unpredictable behavior and lack of clear triggers, and the discontinuation of supervision was made without physician order or documented team review.
RN Staffing Deficiency: The facility failed to provide RN coverage for at least 8 consecutive hours a day, 7 days a week, with multiple days showing no RN on duty. The DSD stated there had been no full-time RN since August 2025, and the DON acknowledged there was no RN working weekends during the review period. The facility’s staffing policy required sufficient nursing staff on a 24-hour basis to meet resident needs.
A facility failed to obtain written informed consent before giving psychotropic medications to two residents. One resident with anxiety and schizophrenia received Lithium Carbonate without documented consent, and another resident with schizophrenia received Clozapine and Fluvoxamine Maleate without consent in the record. Interviews with MR staff, an RP, an LVN, and the DON confirmed the missing consents, and facility policy required consent before administration of these medications.
Incomplete AD documentation was found for three residents. One resident with impaired decision-making capacity and conservatorship had an ADA signed by the resident instead of the conservator, another resident’s ADA lacked required acknowledgements and the RP/agent signature, and a third resident’s ADA was blank with missing resident ID, treatment preferences, signature, date, and witness signatures. Staff stated the forms were incomplete and should have been completed on admission or within 72 hours.
The facility failed to develop and implement person-centered care plans for two residents with anxiety and schizophrenia who had orders for psychotropic medications. Staff stated there was no documentation that care plans were initiated for one resident’s Lithium Carbonate and Benztropine use or for another resident’s Seroquel use, despite the residents having intact cognition and being independent with basic ADLs. The facility’s policy required comprehensive care plans with measurable objectives and timetables.
Missing Competency Evaluations for Licensed Nurses: The facility failed to complete competency evaluations for an LVN and an RN. The DON stated she was responsible for licensed nurse competencies but had not completed the LVN's competency or obtained the LVN's signature, and there was no clinical documentation that the RN's competency had been done. The facility policy required nursing staff to have the appropriate competencies, skills set, and qualifications to provide resident care and services.
Unlabeled and expired food items were found in the kitchen refrigerator and in a nursing station refrigerator. Two salads were missing dates, several sandwiches were past their use-by date, and four meat sandwiches for residents had no resident identifiers or date made/use-by date. The DS, LVNs, and AD all stated that refrigerated food must be labeled and dated so expired items are not served.
A resident’s antipsychotic side effect monitoring was charted incorrectly on multiple shifts, with dashes entered instead of the required zero or symptom code. The resident had schizoaffective disorder and was ordered to be monitored every shift. In addition, two residents had records that were not accessible in the chart: one was missing a PASRR level II, and another had incomplete consents and an advance directive that staff could not consistently locate.
QAPI committee records showed the MD was listed as a member, and the facility's QA/Risk Management Plan assigned the MD joint responsibility with the Administrator for the program. However, the QAPI sign-in sheets reviewed by the DON showed the MD did not attend any monthly or quarterly meetings, and the DON confirmed the MD had not been seen participating in the committee meetings.
A resident with anxiety and schizophrenia had orders for Lithium Carbonate and Benztropine, but the chart did not identify the specific target behavior for the Lithium and had no documented monitoring of that behavior. An LVN stated the Cogentin indication was not accurate because it is used for antipsychotic side effects, not schizophrenia, and the DON confirmed psychotropic orders should include target behaviors and daily monitoring.
MDS Did Not Accurately Reflect Antidepressant Use: A resident with schizophrenia had an MDS that listed antipsychotic use but did not document an antidepressant, even though the MAR and order summary showed fluvoxamine maleate 25 mg was ordered and administered. The MDSC acknowledged the omission, and the DON stated the MDS needed to be coded accurately to reflect the resident’s care.
A resident with anxiety and schizophrenia was prescribed Gabapentin 600 mg TID for anxiety/restlessness related to schizophrenia. The Pharmacy Consultant identified the use as non-FDA labeled and potentially duplicate or unnecessary therapy, and requested physician review of the risks and benefits. The DON stated there was no clinical documentation showing the monthly MRR recommendation was carried out, despite facility policy requiring monthly pharmacist review and reporting of irregularities to the MD, DON, and attending physician.
Failure to Maintain an Antibiotic Stewardship Program: The facility did not have an active ASP to monitor, track, or review antibiotic use for 13 sampled residents. The DSD and VPC both stated the facility did not have an ASP, and QAC minutes showed no documentation of ASP activity or medication monitoring. The facility policy called for an IP and Medical Director to oversee the ASP and report antibiotic trend reviews to the QAC.
The facility failed to offer COVID-19 vaccine education, vaccination, and required documentation for sampled residents and staff. Leadership stated residents and staff had not been offered the vaccine or education since the committee decision, and QAC minutes did not show tracking or administration of COVID-19 immunization. The facility policy required education, offer, and documentation of acceptance or refusal for both residents and staff.
A facility failed to ensure five resident bedrooms held no more than four residents, with each of Rooms 25, 27, 29, 31, and 33 occupied by five ambulatory residents and set up with five beds. The CAA form and waiver request documented the room sizes and occupancy, and the ADM confirmed the rooms were being used for five residents each. The facility P&P stated resident rooms must not accommodate more than four residents.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
Annual performance evaluations for three CNAs were not completed as required by facility policy. The DSD confirmed that evaluations had not been done consistently, and personnel files showed missing evaluations for multiple years.
Two residents involved in a physical altercation with potential for head trauma did not receive neurological assessments at the required 15-minute intervals during the first hour post-incident, as mandated by facility policy. Instead, neuro checks were performed only every hour for 72 hours, missing the critical initial monitoring period. The DON confirmed the deviation from policy during record review.
The facility did not post daily nurse staffing information in a prominent and accessible location as required by policy. Surveyors observed that the staffing data was not displayed anywhere in the facility, and an interview with the DSD confirmed that updates had not been made for nearly two weeks. Review of records showed no staffing postings for 13 consecutive days, despite facility policy mandating daily updates.
A resident with paranoid schizophrenia and insomnia was identified as being at risk for inappropriate social behavior, but the care plan lacked specific goals and interventions to address these behaviors. Both the ADON and Program Director confirmed the care plan was incomplete, and facility policy requiring comprehensive, measurable care plans was not followed.
A resident who was struck in the face by another resident did not receive complete neurological assessments for the required 72-hour period, as facility policy mandates after head injuries. Review of documentation showed missing neurocheck entries for one shift, and staff confirmed the assessments were not fully performed or recorded.
A resident with schizophrenia and other medical conditions was physically assaulted by another resident, resulting in facial injuries and a hospital transfer. The incident was discovered by a CNA who intervened, and staff interviews confirmed the need for monitoring residents for agitation. Despite a zero-tolerance abuse policy, the facility failed to prevent this resident-to-resident altercation.
A CNA worked for 30 days with an expired certification, as the facility failed to monitor certification expiration. The Director of Nursing confirmed the lapse, which violated the facility's policy requiring current CNA certification.
The facility failed to maintain in-service training records for CNAs in 2024, as required by policy. Interviews revealed that CNAs were unsure or confirmed not receiving necessary training in dementia care and abuse prevention. The DSD, who started in December 2024, confirmed the absence of records and training, which are crucial for staff competency and resident safety.
A facility failed to develop a care plan for a resident at high risk for elopement, resulting in the resident eloping during a court hearing. The resident, diagnosed with schizophrenia and lacking capacity for medical decisions, was part of a special treatment program where all residents were at high risk for elopement. Despite this, no care plan was created, leaving staff unaware of the specific risks and necessary interventions.
A facility failed to conduct an elopement risk assessment for a resident with schizophrenia, leading to the resident eloping during a court hearing. The LVN did not complete the assessment upon admission, and the DON confirmed it was required by policy. The resident was not identified as high risk, and proper protocols were not followed, resulting in the elopement.
A resident with schizophrenia eloped from a court hearing, and the facility failed to document the MD's notification of this change of condition in the medical record. Although the MD was informed via text, this communication was not recorded, contrary to the facility's policy. The DON acknowledged the oversight, emphasizing the importance of documentation for care team awareness.
The facility failed to complete Advance Directive Acknowledge (ADA) Forms for three residents upon admission, as required by policy. One resident's form was not initialed, another's was not check marked, and a third resident's form was missing entirely. This lack of documentation indicated that residents were not informed about their rights to refuse or accept treatment and to develop advance directives.
The facility failed to complete MDS assessments within federal time frames for three residents, potentially affecting their care. One resident's assessment was overdue, another's was not submitted before discharge, and a third's was prepared but not exported. The facility's policy requires timely transmission of MDS assessments as per CMS guidelines.
The facility failed to ensure that initial face-to-face visits were conducted by a physician for two residents. One resident was seen by a PA in person, while another was seen via telemedicine by a PA. Both residents had intact cognition and were independent in personal hygiene. The DON confirmed that initial visits should be conducted by the attending physician, as per facility policy.
The facility failed to provide RN coverage for at least 8 consecutive hours a day on three occasions, as confirmed by the DON. The absence of RN coverage was identified through a review of the facility's Assignment/Sign-In Sheet, and the DON highlighted the importance of RN availability for resident assessments, which LVNs cannot legally perform. The facility lacked a policy specifying the need for RN services for the required hours.
The facility did not conduct annual performance reviews for two CNAs, with the last reviews dated over a year ago. The DON acknowledged the importance of yearly evaluations to ensure CNAs' competencies but noted the absence of a policy requiring such reviews.
The facility failed to maintain safe food storage and handling practices, as observed in the kitchen and dry storage area. A sealed frozen roast beef lacked a received date, and expired frozen raspberries and bread products were not discarded. The DSS and DON confirmed the importance of labeling food items with received and opened dates to prevent food-borne illnesses, as per the facility's policy.
A facility failed to create a comprehensive care plan for a resident with PTSD, despite the resident's admission records indicating this diagnosis. The resident, who was independent in daily activities and had intact cognition, did not have a care plan addressing PTSD. Interviews with staff revealed a lack of awareness about the resident's PTSD, and the DON acknowledged the oversight, emphasizing the importance of care plans in addressing residents' needs.
A resident with limited range of motion and leg edema did not receive the ordered intervention of elevating her legs, as observed during a survey. Despite having an order to elevate both lower extremities due to swelling, the resident was not informed to do so and was seen limping with a swollen ankle. There was no documentation of the intervention being implemented or monitored, contrary to the facility's policies.
A CNA at the facility was scheduled to work despite having an expired CPR certification, which is a job requirement. The DON acknowledged the lapse, noting the importance of active CPR certification for responding to emergencies. The facility's policy requires licensed staff to maintain active CPR certification, but the facility failed to ensure compliance, potentially risking resident safety.
A facility failed to act on a pharmacist's recommendation regarding a resident's off-label use of Propranolol for anxiety, which was not addressed by the nurses or reviewed by the physician. The resident, diagnosed with depression and schizophrenia, was independent in daily activities. The absence of a DON during two months contributed to the oversight, as the facility did not respond to the pharmacist's monthly review as required by policy.
A facility failed to specify a behavior for the use of Ativan in a resident's physician order, which is required by policy. The resident, with diagnoses including major depression disorder and schizophrenia, had an order for Ativan for agitation/anxiety without a specific behavior indicated. The DON confirmed that specific behaviors should be noted to monitor and measure medication effectiveness.
The facility was found non-compliant with regulations as five resident rooms each housed five residents, exceeding the maximum of four per room. Despite a waiver request and claims of adequate space, the facility's policy mandates no more than four residents per room, leading to the deficiency.
A facility failed to provide individual deodorants to residents, leading to shared use and potential infection risk. Residents with schizoaffective disorder, who were independent in personal hygiene, used a shared deodorant from the nurses' station. The Interim Director of Nursing acknowledged the need for individualized deodorants to prevent infection, contrary to the facility's infection control policy.
The facility failed to protect residents from physical abuse, with multiple incidents involving aggressive behavior among residents. A resident with psychosis assaulted another resident, and staff did not intervene. Another resident was attacked with a broken plate, and two more residents were punched in separate incidents. The facility's policy emphasizes zero tolerance for abuse, yet these incidents occurred.
The facility failed to implement specific action plans under its QAPI program after identifying 31 resident-to-resident altercations over several months. Meeting minutes lacked detailed plans, only noting behavior monitoring, contrary to the facility's policy emphasizing structured processes to correct deficiencies.
A resident receiving Clozaril for hallucinations was not monitored as ordered, leading to an incident where the resident hit another. The MAR showed missing documentation for several shifts, which was confirmed by both an LVN and the DON. The facility's policy required daily monitoring of psychotropic drug use, which was not adhered to.
The facility failed to protect residents from abuse, as evidenced by incidents of physical altercations and inadequate supervision. A resident sustained a cut during a fight, and another resident with a history of aggression had an outdated care plan, increasing the risk of further incidents. Staff interviews highlighted the unpredictability of the aggressive resident, yet the facility did not revise care plans or ensure adequate supervision.
A facility failed to notify the MD of a physical altercation between two residents, where one resident punched another in the eye and forehead. Despite the incident being reported to the Administrator, DON, and Social Worker, the MD was not informed, and no change of condition was completed. This oversight could have led to serious injury, as no medical orders were obtained for monitoring the residents' conditions.
A resident with schizophrenia and auditory hallucinations was not adequately monitored by the LTC facility, despite MD orders for regular behavior checks and one-to-one supervision. The resident, who was on Depakote, was involved in physical altercations with other residents, yet monitoring lapses occurred on specific dates, increasing the risk of further incidents.
A facility failed to report an alleged abuse incident where a resident with schizophrenia hit another resident in the face. Despite the incident being reported to a charge nurse, it was not communicated to the CDPH or other authorities. Staff interviews revealed a lack of action and adherence to the facility's abuse reporting policy, which mandates reporting known or suspected abuse.
The facility failed to protect residents from physical abuse, resulting in two incidents where one resident was slapped on the head and another was kicked on the elbow by other residents. Both incidents were unprovoked and witnessed by staff, leading to feelings of fear and insecurity among the affected residents.
The facility failed to follow an MD's order for neuro-checks for a resident who sustained a head injury from a physical altercation. The checks were not completed as ordered, placing the resident at risk of not properly assessing their neurological functions.
The facility failed to prevent the elopement of a resident diagnosed with anxiety, psychosis, and schizoaffective disorder by not ensuring that locked gates were opened one at a time. Staff members simultaneously opened two gates, allowing the resident to push past them and leave the facility, resulting in the resident being missing for four days.
Failure to Provide Supervision Resulting in Resident-to-Resident Altercation
Penalty
Summary
The facility failed to provide adequate supervision to a resident with a known history of schizophrenia, anxiety, and aggressive behaviors, as outlined in the resident's care plan. The care plan specified that the resident was at risk for aggression and unsafe behaviors, with documented incidents of striking peers due to paranoid ideation. Interventions included 1:1 supervision during meals and restricted access to common areas unless accompanied by staff and deemed psychiatrically stable. However, the care plan did not specify the duration of these interventions, and there was no documented behavioral evaluation or interdisciplinary team note addressing the discontinuation of 1:1 supervision prior to the incident. On the day of the incident, the resident was not under 1:1 supervision and was able to access the patio area where another resident was present. The unsupervised resident struck the other resident in the face without provocation, resulting in significant injuries including a laceration under the left eye, a skin tear on the eyelid, and a displaced fracture of the left nasal bone. The injured resident required transfer to an emergency department for further evaluation and treatment. Staff interviews confirmed that the resident who initiated the altercation had a history of unpredictable aggression, paranoia, and auditory hallucinations, and that staff had difficulty identifying specific triggers for the aggressive behavior. Facility staff, including the administrator and mental health workers, acknowledged that the resident was no longer on 1:1 supervision based on staff discretion, without a physician's order or documented interdisciplinary review. The facility's policy required comprehensive care planning and revision as needed based on changes in the resident's condition or behavior, but there was no evidence that the care plan was appropriately updated or that supervision protocols were maintained in accordance with the resident's assessed needs. This lapse in supervision directly led to the resident-to-resident altercation and subsequent injury.
RN Staffing Deficiency
Penalty
Summary
The facility failed to use the services of an RN for at least 8 consecutive hours a day, seven days a week from 11/1/2025 through 11/19/2025 on 6 of 19 days. During a concurrent interview and record review on 11/19/2025, the Nurse Staffing Sign-in Sheet for November 2025 showed no RN on duty on 6 days, and the facility’s Assignment/Sign-In Sheets for all shifts also showed no RN coverage on 11/1/2025, 11/2/2025, 11/8/2025, 11/9/2025, 11/15/2025, and 11/16/2025. The DSD stated the facility had no full-time RN who worked 8 hours per day, 7 days a week since August 2025. During interview, the DON stated there was no RN working on weekends from 11/1/2025 through 11/19/2025 and acknowledged the facility needed RN coverage for 8 consecutive hours for 7 days per week because the RN was responsible for overseeing LVNs and CNAs and for completing residents’ initial assessments. The facility’s policy on Nursing Department-Staffing, Scheduling & Postings stated the facility would employ sufficient nursing staff on a 24-hour basis to meet resident needs and provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for each resident.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain written informed consent before administering psychotropic medications to two residents. For one resident admitted with anxiety and schizophrenia, the record showed an order for Lithium Carbonate 300 mg, two capsules by mouth in the evening related to schizophrenia, and the MDS indicated intact cognition for daily decision making. During record review and interviews, Medical Records staff and the DON stated that no informed consent had been obtained before Lithium Carbonate was administered, and the resident’s RP stated no consent discussion or call from the facility had occurred regarding the medication. For another resident admitted with schizophrenia, the H&P noted fluctuating capacity to make medical decisions and the MDS indicated cognitive intactness. The OSR showed active orders for Clozapine 400 mg in the evening for thought disorganization related to schizophrenia and Fluvoxamine Maleate 25 mg in the evening to augment Clozapine. The MAR showed both medications were administered from 11/1/2025 through 11/17/2025, and a concurrent record review found no informed consent for either medication in the medical record. During interviews, an LVN stated informed consents were needed for these psychotropic medications and should be completed before the medications were started, with education about side effects and the reason for use. The DON stated the licensed nurse needed to verify that informed consent was complete before administering the medication. Facility policy stated that informed consent should be obtained and documented before administration of psychotherapeutic drugs and that licensed nurses should not administer them until consent had been obtained, unless it was an emergency situation.
Incomplete Advance Directive Documentation
Penalty
Summary
The facility failed to ensure Advance Directive (AD) documentation was complete and readily available in the medical records for three sampled residents. For Resident 5, the record showed admission with schizoaffective disorder and major depressive disorder, and the history and physical stated the resident did not have capacity to understand and make decisions and was under temporary conservatorship. The Advance Directive Acknowledgement (ADA) was signed by the resident and a facility representative, but it was not signed by the responsible party or conservator. The MDS Coordinator stated that if a resident lacked decision-making capacity, the AD should have been signed by the conservator and that an incomplete document was invalid. For Resident 8, the record showed admission with schizophrenia and depression, and the history and physical stated the resident was unable to communicate and make decisions. The ADA did not include acknowledgements that the resident or responsible party had been given written material about the right to accept or refuse medical treatments, the right to formulate an AD, that there was no obligation to formulate one, or that any executed AD would be followed by facility staff and the attending physician. The form also lacked the responsible party/agent signature. Medical Records staff, the MDS Coordinator, and the DON each stated the form was incomplete because it was missing required acknowledgements and the responsible party’s signature. For Resident 21, the record showed admission with schizophrenia and a history and physical stating the resident had capacity to make medical decisions. During chart review, the ADA form was blank and missing the resident’s identification, treatment preferences, signature, date signed, and witness signatures. Medical Records staff stated the form should have been completed upon admission or within 72 hours, and the VPC stated there was no completed ADA form and that a blank form prevented the facility from acknowledging the resident’s preferences. The facility policy stated residents are to be informed of their right to execute an AD and that each resident chooses whether to complete one.
Failure to Develop Person-Centered Care Plans for Psychotropic Medications
Penalty
Summary
The facility failed to develop and implement individualized, person-centered care plans for two residents with diagnoses that included anxiety and schizophrenia. For Resident 9, the record showed orders for Lithium Carbonate 300 mg, two capsules by mouth in the evening, and Benztropine Mesylate 1 mg, one tablet by mouth twice a day, both related to schizophrenia. The MDS indicated the resident had intact cognition for daily decision making and was independent with eating, oral hygiene, toileting hygiene, showering, dressing, footwear, and personal hygiene. During interview and record review, LVN 1 stated there was no clinical documentation that a care plan had been initiated or implemented for the resident’s use of Benztropine Mesylate and Lithium Carbonate, and stated a person-centered care plan should have been initiated and implemented to guide nursing care and treatment. For Resident 31, the record showed diagnoses that included anxiety and schizophrenia, and the MDS indicated intact cognition for daily decision making and independence with eating, oral hygiene, toileting hygiene, showering, dressing, footwear, and personal hygiene. During interview and record review, the MDSC stated the care plan for Seroquel use was not initiated and implemented upon receipt of the physician order. The MDSC stated the facility should have initiated the care plan for the resident’s Seroquel use upon admission so staff would have specific interventions for care. The facility’s Care Planning policy stated that a comprehensive person-centered care plan must be developed for each resident based on assessed needs, include measurable objectives and timetables, and be completed within 7 days after the comprehensive admission assessment.
Missing Competency Evaluations for Licensed Nurses
Penalty
Summary
The facility failed to conduct competency evaluations for two licensed nurses, LVN 2 and RN 1. During record review and interviews, the Director of Staff and Development stated that LVN 2 had worked full time at the facility since 3/21/2025 and that the DON was responsible for conducting competency checks for all licensed nurses. The Bookkeeper stated RN 1 had worked per diem at the facility since 12/10/2002 and that the DON was responsible for conducting competency checks for RNs. During interviews, the DON stated she was responsible for skills competency for all licensed nurses, but she had not completed LVN 2's competency and had not obtained LVN 2's signature on the skills competency. The DON also stated there was no clinical documentation that competency had been done for RN 1. LVN 2 stated she had not completed skills competency since starting at the facility. The facility policy stated nursing staff must meet appropriate competencies, skills set, and required qualifications to provide nursing and related services to attain or maintain residents' highest practicable well-being.
Unlabeled and Expired Refrigerated Food
Penalty
Summary
The facility failed to follow proper food storage handling practices by not labeling and discarding expired food items stored in two refrigerators. During a kitchen observation, three Caesar salads and one fruit salad were found in the refrigerator, and two of the Caesar salads and the fruit salad were not labeled with a date of when they were made or a best-by date. The Dietary Supervisor stated the unlabeled salads were from the prior day and confirmed that food without a use-by or best-by date should be tossed to ensure it is safe to eat and not expired. During the same kitchen observation, a container of four ham and cheese sandwiches and a container of three peanut butter and jelly sandwiches were found with a made date of 11/15/2025 and a use-by date of 11/17/2025. The Dietary Supervisor stated the sandwiches were expired and should have been thrown away. In a separate observation at the nursing station refrigerator, a plastic bag containing four meat sandwiches was found without the resident's name, room number, date made, or use-by date. LVN1 stated the sandwiches were not dated and should be individually labeled, and LVN2 stated the sandwiches were given to residents but should have a use-by date or at least a date made. Facility staff and leadership interviewed during the survey stated that food items must be labeled with dates so staff know when they expire and should not be served if expired or unlabeled. The Activity Director stated the kitchen staff makes sandwiches for residents and leaves them in the nursing station with nurses, and that all food items provided to patients need a use-by or expiration date. Facility policy also stated that food held in refrigerated storage shall be clearly labeled and dated, and that spoiled or contaminated food shall not be served.
Inaccurate antipsychotic monitoring documentation and missing resident records
Penalty
Summary
The facility failed to maintain clinical records in accordance with accepted professional standards for one resident by inaccurately documenting monitoring for side effects of antipsychotic medication. The resident was admitted with diagnoses including schizoaffective disorder and insomnia, and the H&P stated the resident did not have capacity to make medical decisions. The resident’s order summary directed staff to monitor for antipsychotic side effects every shift and to chart 0 or use the first letters for tardive dyskinesia, cognitive impairment, akathisia, or parkinsonism. A review of the November MAR showed the side effect monitoring was documented incorrectly on multiple days across day, evening, and night shifts, with a dash entered instead of a zero or the required letter. During interview, an LVN stated the resident was on multiple antipsychotics and the monitoring had been charted incorrectly, explaining that it should be documented as zero or the appropriate symptom letter. The DON also confirmed the charting was incorrect and stated nurses should follow the order’s instructions for accurate charting and monitoring. The facility also failed to ensure medical records were accessible to staff for two residents. For one resident with schizophrenia and other long-term drug therapy, the VP of Clinic found a PASRR level I and referral letter in the chart but not the PASRR level II, and stated PASRR is important because it identifies needed services. For another resident with schizophrenia, stimulant abuse, and hypertension, MR stated the consents in the physical chart were not signed, including the advance directive. The MDSC stated the advance directive was not in the chart, while the MSW stated she had some advance directives in a separate folder and that the resident’s advance directive was there.
QAPI Committee Lacked MD Participation
Penalty
Summary
The Quality Assurance/Performance Improvement (QA/QAPI) committee did not have the Medical Director participate in its meetings as required. During review of the QAPI committee information, the undated materials indicated the MD was a member who attended monthly and quarterly QA meetings, and the Quality Assurance/Risk Management Plan stated the Medical Director had joint responsibility with the Administrator for operation of the QA/Risk Management Program. However, during a concurrent interview and record review with the DON, the QAPI meeting sign-in sheets from January 2025 through October 2025 were reviewed and showed the MD was not in attendance at any of the meetings. The DON verified the MD did not sign the QAPI attendance sheets and stated that QAPI meetings were conducted monthly and quarterly. The DON further stated the MD should be involved in the meetings and that, during her employment at the facility, she had not seen the MD attend any QAPI committee meetings. The facility's QAPI Program policy stated the QAA committee met at least quarterly to review reports, evaluate data, and monitor quality-related activities of all departments, and that the governing body was ultimately responsible for the QAPI Program.
Failure to document target behavior and accurate indication for psychotropic medications
Penalty
Summary
The facility failed to ensure that Resident 9’s target behavior was monitored for the use of Lithium Carbonate Oral Capsule and failed to ensure the indication for Benztropine Mesylate Oral Tablet was accurate. Resident 9 was admitted with diagnoses including anxiety and schizophrenia. The order summary dated 6/19/2025 directed staff to administer Lithium Carbonate 300 mg, two capsules by mouth in the evening related to schizophrenia, and Benztropine Mesylate 1 mg, one tablet by mouth twice a day related to schizophrenia. The resident’s MDS dated 9/22/2025 indicated intact cognition for daily decision making and independence with eating, oral hygiene, toileting hygiene, showering, dressing, footwear, and personal hygiene. During a concurrent interview and record review on 11/19/2025, LVN 1 stated the order summary did not indicate the specific target behavior and there was no documented monitoring for Resident 9’s target behavior for Lithium Carbonate since 6/19/2025. LVN 1 stated it was important to monitor target behavior every shift to determine whether the medication was effective. In the same review, LVN 1 stated the indication for Benztropine Mesylate was not accurate and that Cogentin is not given for schizophrenia, but is used to manage side effects caused by antipsychotic medications. The DON later stated that the target behavior should have been included in the physician’s order for psychotropic medications and that staff needed to monitor target behavior every shift to track response to medication therapy and avoid unnecessary use. The facility’s Psychotherapeutic Drug Management policy stated that psychotherapeutic medication orders must include the diagnosis, indications, and manifestations of the disorder treated, and that nursing staff must monitor target behaviors daily by charting by exception.
MDS Did Not Accurately Reflect Antidepressant Use
Penalty
Summary
The facility failed to ensure that Resident 6’s MDS assessment accurately documented the resident’s use of an antidepressant. Resident 6 was admitted with diagnoses that included schizophrenia, and the H&P dated 7/18/2025 indicated the resident had fluctuating capacity to make medical decisions. The MDS assessment dated 10/22/2025 indicated the resident was cognitively intact and was taking an antipsychotic medication, but it did not indicate use of any antidepressants. Record review showed that Resident 6 had an active order for fluvoxamine maleate 25 mg by mouth in the evening to augment clozapine, and the MAR showed the resident received fluvoxamine maleate from 11/1/2025 through 11/19/2025 each evening. During interview and record review with the MDSC, the MDS was reviewed and it was acknowledged that the antidepressant was not documented and that accurate coding was important. The DON stated the MDS was used for continuity of care and needed to be coded accurately to reflect the resident’s care in the facility.
Failure to Act on Pharmacy Consultant Medication Review
Penalty
Summary
The facility failed to ensure that a monthly medication regimen review irregularity identified by the Pharmacy Consultant was acted upon for one sampled resident. Resident 31 was admitted with diagnoses including anxiety and schizophrenia, and the history and physical noted fluctuating capacity to make medical decisions. The MDS later indicated intact cognition for daily decision making and independence with eating, oral hygiene, toileting hygiene, showering, dressing, footwear, and personal hygiene. The resident’s order summary showed Gabapentin 600 mg by mouth three times daily for anxiety/restlessness related to schizophrenia. A facility document from the Pharmacy Consultant stated that Gabapentin 600 mg three times a day for schizophrenia was a non-FDA labeled use and could be considered duplicate, unnecessary therapy, and asked the physician to evaluate the risks and benefits to remain in compliance with regulations. During interview, the DON stated the MRR was a monthly recommendation that licensed nurses were supposed to carry out once received from the pharmacy, and that there was no other clinical documentation showing the recommendation for Resident 31 had been carried out. The facility policy stated the pharmacist would review each resident’s medication regimen at least monthly and report irregularities such as unnecessary drugs to the Medical Director, DON, and attending physician within 3 business days unless emergent.
Failure to Maintain an Antibiotic Stewardship Program
Penalty
Summary
The facility failed to ensure an active, ongoing antibiotic stewardship program (ASP) for 13 sampled residents: Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 8, Resident 9, Resident 21, Resident 26, Resident 31, Resident 33, Resident 36, and Resident 37. The deficiency was identified through observation, interview, and record review and involved the facility’s failure to monitor, track, review antibiotic use, and implement interventions to promote appropriate antibiotic prescribing. During an interview on 11/19/2025 at 9:09 a.m., the DSD stated the facility did not have an ASP and was unable to identify any antibiotic screening used to treat infections for residents. During an interview on 11/19/2025 at 1:20 p.m., the VPC also stated the facility did not have an ASP in place. Review of the QAC minutes for August 2025, September 2025, and October 2025 showed no documentation of the facility’s ASP or medication monitoring. Review of the facility policy titled Antibiotic Stewardship, dated October 1, 2023, stated the leadership team would identify an IP to collaborate with the Medical Director to oversee the ASP, review antibiotic trends and outcome reports, and report ICC recommendations to the QAC during monthly or quarterly meetings.
Failure to Document and Offer COVID-19 Vaccination to Residents and Staff
Penalty
Summary
The facility failed to ensure education was provided about the benefits and risks of the COVID-19 vaccine, failed to maintain documentation of vaccine education, refusals, or acceptance, and did not follow its policy for ongoing COVID-19 immunization review for 13 of 13 sampled residents. During interview, the Director of Staff Development stated the facility had not offered COVID-19 immunizations or education to residents since January 2025 based on a decision by the Quality Assurance / Risk Management Committee, and that the facility had not tracked resident COVID-19 immunizations since that time. The Vice President of Clinical also stated the facility had not immunized residents with the COVID-19 vaccine based on the committee decision, and that the decision was not based on guidance from AFLs, QSOs, or a Health Officer Order. Record review showed the Quality Assurance / Risk Management Committee minutes for August, September, and October 2025 did not include tracking or administration of COVID-19 immunization. The facility policy titled COVID-19 Vaccination stated that when the vaccine is available, the facility will offer each resident the vaccine unless medically contraindicated or already fully vaccinated, provide education on the risks, benefits, and potential side effects, and ensure the resident record includes documentation of education and either acceptance with receipt of the vaccine or the reason for refusal. The facility also failed to ensure staff documentation was complete, as the Director of Staff Development stated staff had not been offered COVID-19 immunizations or education since January 2025 and the facility had not tracked staff immunizations since then. Committee minutes did not include tracking or administration of staff COVID-19 immunization, and the facility policy required staff education, consent/declination documentation, and maintenance of those forms in the personnel file.
Excessive Number of Residents in Multiple Bedrooms
Penalty
Summary
The facility failed to ensure that five of 11 resident bedrooms in Rooms 25, 27, 29, 31, and 33 accommodated no more than four residents. A review of the Client Accommodation Analysis form dated 11/19/2025 showed that each of these rooms was occupied by five ambulatory residents and used as a bedroom. The facility’s letter requesting a room waiver, also dated 11/19/2025, stated that each room measured 464.96 square feet and contained five beds. During observation on 11/20/2025 at 11:14 a.m., the five bedrooms for which the waiver was requested had adequate space available for resident use and movement, and there were no adverse effects noted regarding space for nursing care, comfort, or privacy. No residents expressed concerns about the room sizes. During interview on 11/20/2025 at 1:25 p.m., the Administrator verified that each of the five rooms was occupied by five residents and stated that the rooms had adequate space to provide care and would not adversely affect resident health and safety. The facility policy titled Resident Rooms and Environment, dated 10/1/2023, stated that resident rooms must not accommodate more than four residents.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Complete Annual CNA Performance Evaluations
Penalty
Summary
The facility failed to complete annual performance evaluations for three out of four Certified Nursing Assistants (CNAs) as required by its own policy and procedure on performance evaluations. During an interview, the Director of Staff Development (DSD) confirmed that CNA skills evaluations had not been conducted consistently or annually, and acknowledged not having reviewed all staff evaluations since starting in the role. Personnel file reviews revealed that one CNA had no evaluation for 2024, another had no evaluations for 2022, 2023, or 2024, and a third had no evaluations for 2023 and 2024. The facility's policy, revised in August 2010, specifies that each employee's job performance must be reviewed and evaluated at least annually.
Failure to Perform Timely Neurological Assessments After Altercation
Penalty
Summary
The facility failed to perform neurological assessments according to its own policy for two residents following a physical altercation that had the potential for head trauma. Both residents were involved in a fist fight, with one sustaining minor cuts and a bruised cheek, while the other had no visible physical marks. The facility's policy required neurological checks every 15 minutes for the first hour after such incidents, but the medical records showed that neuro checks were only performed every hour for 72 hours post-incident, omitting the more frequent assessments required immediately after the event. Resident records indicated that one resident had diagnoses including schizophrenia and seizures, with intact cognitive skills and independence in daily living, while the other had schizophrenia and insomnia, also with intact cognitive skills and independence. The Director of Nursing confirmed that the neurological checks were not completed per policy, as the initial 15-minute interval checks were missed for both residents. The facility's policy, last revised in 2014, clearly outlined the required frequency of neurological assessments following potential head injuries, which was not followed in these cases.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post daily nurse staffing information in a prominent and accessible location as required by its own policy and procedure. During an observation, surveyors noted that the daily nurse staffing posting was not displayed outside the nursing station or anywhere else in the facility. An interview with the Director of Staff Development (DSD) revealed that the required nurse staffing information had not been updated since the beginning of the month, and the DSD acknowledged overlooking this responsibility after recently starting in the role. A review of the facility's nurse staffing posting log confirmed that no updates had been made for 13 consecutive days. The facility's policy specified that nurse staffing data must be posted daily at the beginning of each shift in a clear and readable format in a prominent place accessible to residents and visitors.
Incomplete Care Plan for Resident with Behavioral Needs
Penalty
Summary
The facility failed to develop a complete, individualized, and comprehensive care plan for one resident. The resident was admitted with diagnoses including paranoid schizophrenia and insomnia, and was noted to be cognitively intact and able to ambulate independently. The resident's Behavior Care Plan identified a risk of inappropriate social behavior, specifically touching or scratching himself in common areas. However, the care plan did not include a goal or specify interventions to address this behavior. During interviews and record reviews, both the Acting Director of Nursing and the Program Director confirmed that the care plan was incomplete. They acknowledged that without a comprehensive care plan, staff would not be informed about the necessary interventions or goals for the resident. The facility's policy required that care plans include measurable objectives and timetables to meet residents' needs, but this was not followed in this case.
Incomplete Neurological Assessments After Resident Altercation
Penalty
Summary
The facility failed to ensure that a resident received complete neurological assessments for the required 72-hour monitoring period following a resident-to-resident altercation that resulted in a hit to the face. The resident, who had diagnoses including schizophrenia and depression and was assessed as having intact cognition and decision-making capacity, reported that staff had not performed neurochecks after the incident. Review of the resident's neurocheck flowsheet revealed missing documentation for one shift during the monitoring period, and staff interviews confirmed that the assigned licensed nurse did not complete the required assessments and documentation. Facility policy required neurological assessments and documentation following any head injury or when indicated by a change in condition. The Director of Nursing and a Licensed Vocational Nurse both acknowledged the importance of these assessments and that the facility's process was not followed in this case. The incomplete neurochecks and lack of documentation after the altercation constituted a failure to provide necessary care and services as outlined in the facility's policies.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, resulting in injury. On the evening of 3/17/2025, a resident with a history of schizophrenia, diabetes mellitus, and hyperlipidemia, who was cognitively intact and independent in daily activities, was physically assaulted by another resident. The incident occurred in the victim's room, where the aggressor entered and began punching the resident on the head and face without prior interaction or provocation. The assaulted resident sustained bleeding from the nose, facial discoloration, and redness on the nose, and was subsequently transferred to a general acute care hospital for evaluation. Medical imaging confirmed there were no fractures or intracranial hemorrhage, and the resident returned to the facility with visible injuries. The aggressor, also diagnosed with schizophrenia, depression, and epilepsy, was noted to have intact cognition and independence in personal care. Following the altercation, the aggressor exhibited increased agitation and physical aggression, but was later observed to be calm and interacting well with others. Staff interviews revealed that the incident was discovered when a certified nurse assistant heard calls for help and witnessed the assault in progress. The staff member immediately intervened, separating the residents. Both the CNA and an LVN confirmed the injuries and described the need for monitoring residents for agitation and behavioral changes to prevent such incidents. The facility's policy on abuse prevention explicitly states a zero-tolerance approach to abuse, neglect, and mistreatment by anyone, including other residents. Despite this policy, the incident demonstrated a failure to ensure the safety of residents from physical abuse by peers. The deficiency was identified through direct observation, interviews with staff and residents, and review of medical records and facility policies.
CNA Worked with Expired Certification for 30 Days
Penalty
Summary
The facility failed to ensure that one of its Certified Nursing Assistants (CNA 6) maintained an active CNA certification, resulting in CNA 6 working for 30 days with an expired certification. This lapse was identified through interviews and record reviews, which revealed that CNA 6's certification had expired, yet they continued to work during this period. The Director of Staff Development acknowledged the expiration, and the Director of Nursing confirmed that CNA 6 worked for 30 days post-expiration, indicating a lack of monitoring for staff certification expiration. The facility's policy requires CNAs to have a current certification, which was not adhered to in this case.
Deficiency in CNA In-Service Training Records
Penalty
Summary
The facility failed to maintain and provide necessary in-service training records for Certified Nursing Assistants (CNAs) for the year 2024, as required by their policy on record retention. This deficiency was identified during interviews and record reviews involving three CNAs and the Director of Staff Development (DSD). CNA 3 was unsure about receiving dementia care training, while CNA 4 confirmed not receiving such training. CNA 5 reported receiving only three in-services throughout the year, indicating irregular training schedules. The DSD, who began working at the facility in December 2024, confirmed the absence of training records for 2024 and the lack of in-services on critical topics like dementia care and abuse prevention. The Director of Nursing (DON) corroborated the absence of documented evidence of in-services for the entire year of 2024, which is crucial for ensuring staff competency in resident care. The facility's policy mandates that all CNA training records be retained for four years, but the records for 2024 were missing. The DSD emphasized the importance of these records in ensuring staff are trained on relevant topics to maintain resident safety and care standards. The lack of in-service training records and the failure to provide necessary training could potentially impact the quality of care provided to residents.
Failure to Develop Care Plan for High-Risk Resident
Penalty
Summary
The facility failed to develop a care plan for a resident identified as high risk for elopement, which resulted in the resident eloping while attending a court hearing. The resident was admitted with a diagnosis of schizophrenia and lacked the capacity to make medical decisions, as indicated in their History and Physical. Despite this, the Minimum Data Set showed the resident's cognitive abilities were intact. The Director of Nursing acknowledged that all residents in the special treatment program were at high risk for elopement, yet no care plan was in place for this resident. Interviews with the Director of Nursing and a Licensed Vocational Nurse revealed that there was no care plan addressing the risk of elopement for the resident. The facility's policy required a licensed nurse to initiate and update care plans as needed, but this was not done for the resident in question. The absence of a care plan meant that staff were not informed of the specific at-risk behavior or how to provide appropriate care, leading to the resident's elopement.
Failure to Conduct Elopement Risk Assessment
Penalty
Summary
The facility failed to implement its policy on wandering and elopement by not performing an elopement risk assessment upon admission for a resident diagnosed with schizophrenia. This oversight was identified during a review of the resident's admission records, which showed that the section for wandering and elopement assessment was left blank. A Licensed Vocational Nurse (LVN) confirmed that the elopement risk assessment was not completed and expressed uncertainty about whether it was required at the time of admission. The Director of Nursing (DON) acknowledged that the assessment should have been completed according to facility policy. The deficiency resulted in the resident eloping during a court hearing attended with their public conservator. The facility's policy required that residents identified as high risk for elopement be placed in restraints and escorted by trained staff when leaving the facility. However, this protocol was not followed because the resident had previously left with the conservator without incident. The failure to complete the elopement risk assessment meant that staff could not identify the resident as a high risk for elopement, potentially leading to serious injury during the incident.
Failure to Document MD Notification of Resident Elopement
Penalty
Summary
The facility failed to document the Medical Doctor's (MD) notification of a change of condition (COC) in the medical record of a resident who eloped from a court hearing. The resident, who was admitted with schizophrenia and had a history indicating a lack of capacity to make medical decisions, eloped from a court hearing. Despite the resident's cognitive abilities being noted as intact in a recent assessment, the facility did not document the MD's notification of this significant event in the resident's medical record. Licensed Vocational Nurse 1 (LVN 1) confirmed that the MD was notified via text message on the day of the elopement, but this communication was not recorded in the resident's medical record. The Director of Nursing (DON) acknowledged that the COC should have been documented in the medical record to ensure all care team members were aware of the situation. The facility's policy required documentation of the time, method, and response of the MD notification, which was not followed in this instance.
Failure to Complete Advance Directive Acknowledge Forms
Penalty
Summary
The facility failed to implement its Policy and Procedure on Advance Directives for three residents by not ensuring the completion of the Advance Directive Acknowledge (ADA) Form upon admission. For Resident 41, the ADA Form was not initialed, indicating that the resident was not provided with written materials or informed about her rights to refuse or accept treatment and to develop an advance directive. During an interview, Resident 41 could not recall receiving information about advance directives, and the Licensed Vocational Nurse confirmed the form was incomplete. Similarly, Resident 2's ADA Form was not check marked to indicate that the resident was informed about their rights regarding medical treatment and advance directives. The Licensed Vocational Nurse was unsure if the discussion about advance directives took place. The Director of Nursing emphasized the importance of knowing the resident's wishes to provide appropriate emergency treatment when incapacitated. For Resident 20, there was no ADA Form in the medical record, and the Director of Nursing stated that the form should have been part of the admission package. The absence of the form meant that the facility did not have documented information about the resident's wishes in case of incapacitation. The facility's policy required that residents be informed and provided with written information about their rights to accept or refuse medical treatment, which was not adhered to in these cases.
Failure to Complete MDS Assessments Timely
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) quarterly assessments were completed within the federal time frames as required by the Centers for Medicare and Medicaid Services (CMS) for three residents. Resident 1's quarterly MDS assessment was not completed on time, as the last assessment was done on 7/13/2024, and the next was due on 11/5/2024, but was missed. The MDS Coordinator acknowledged the oversight and emphasized the importance of timely assessments to prevent deterioration or decompensation of the resident's health condition. Resident 7's quarterly MDS was not submitted before the resident was discharged, and Resident 14's MDS was prepared but not exported, causing it to be overdue. The facility's policy and procedure require MDS assessments to be transmitted according to the CMS RAI OBRA Required Assessment Summary schedule, which mandates that the Assessment Reference Date (ARD) should be no later than 92 calendar days from the previous assessment, and completion should be within 14 days after the ARD. These lapses in timely MDS submissions could potentially affect the care provided to the residents.
Failure to Ensure Physician Conducted Initial Visits
Penalty
Summary
The facility failed to ensure that the initial face-to-face visit was conducted by a physician for two residents. Resident 41 was admitted with diagnoses including pain in the left ankle and joints, alcohol use, and schizophrenia. The initial face-to-face visit for Resident 41 was conducted by a physician assistant (PA) instead of a physician. Similarly, Resident 247, who was admitted with anxiety and psychosis, had their initial visit conducted via telemedicine by a PA. Both residents had intact cognition and were independent in personal hygiene activities. During interviews and record reviews, it was confirmed that the initial visits for both residents were not conducted by the attending physician as required. The Director of Nursing acknowledged that initial comprehensive assessments should be conducted face-to-face by the attending physician to determine the medical needs of the residents. The facility's policy indicated that initial comprehensive visits should not be performed by PAs or nurse practitioners not employed by the facility.
Failure to Provide RN Coverage for Required Hours
Penalty
Summary
The facility failed to provide the services of a Registered Nurse (RN) for at least 8 consecutive hours a day for three out of seven days in the specified period. This deficiency was identified through a review of the facility's Assignment/Sign-In Sheet for all shifts, which indicated no RN coverage on the dates of 4/7/2024, 5/5/2024, and 6/9/2024. During an interview, the Director of Nursing (DON) confirmed the absence of RN coverage on these days and emphasized the importance of having an RN available to perform resident assessments, which Licensed Vocational Nurses (LVNs) are not legally permitted to do. The lack of RN coverage could potentially lead to improper resident treatment and hospitalization. Additionally, the facility did not have a policy and procedure specifying the need for RN services at least 8 consecutive hours a day, 7 days a week.
Failure to Conduct Annual CNA Performance Reviews
Penalty
Summary
The facility failed to conduct annual performance reviews for two Certified Nursing Assistants (CNAs), specifically CNA 2 and CNA 3, as required. During an interview and review of personal files with the Director of Staff Development (DSD), it was found that CNA 2's last performance review was conducted on September 6, 2022, and CNA 3's on September 9, 2022. No subsequent reviews were completed for these CNAs in 2023 or 2024. The Director of Nursing (DON) confirmed that the facility should perform yearly evaluations to assess CNAs' strengths, weaknesses, and competencies, which are crucial for ensuring quality and safe care for residents. However, the facility lacked a policy mandating annual performance reviews for nurse aides.
Deficiency in Food Storage and Handling Practices
Penalty
Summary
The facility failed to maintain safe food storage and handling practices in its kitchen, as observed during a survey. Specifically, a sealed frozen roast beef in Freezer 1 was not labeled with a received date, which is necessary to track the freshness and safety of the food. Additionally, in the dairy freezer, an opened bag of frozen raspberries and an unopened bag of frozen raspberries were found with expiration dates but without received or opened dates labeled. This lack of labeling prevents the facility from ensuring that food items are used while they are still safe and of high quality. Further observations in the dry storage area revealed two bags of toasted bread and three bags of hamburger buns that were past their best by dates, indicating they were expired. The Dietetic Services Supervisor (DSS) confirmed that all food items should be labeled with received and opened dates to ensure they are consumed before expiration, thus preventing food-borne illnesses. The Director of Nursing (DON) also emphasized the importance of labeling to prevent the use of expired food. The facility's policy on receiving food and supplies requires items to be dated and rotated using the FIFO method, which was not adhered to in these instances.
Failure to Develop PTSD Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident diagnosed with post-traumatic stress disorder (PTSD). The resident, who was admitted with diagnoses including mood disorder, anxiety, and PTSD, had intact cognition and was independent in activities such as oral care, toileting, and personal hygiene. Despite these diagnoses, the resident's care plan did not address PTSD, which is a significant oversight given the resident's mental health needs. Interviews with facility staff revealed a lack of awareness and understanding of the resident's PTSD diagnosis. A Licensed Vocational Nurse (LVN) was unaware of the resident's PTSD and did not know of any interventions for this condition. The Director of Nursing (DON) acknowledged the importance of care plans in guiding staff to address residents' needs and stated that a care plan for PTSD should have been created upon the resident's admission. The facility's policy on care planning emphasized the need for comprehensive, person-centered care plans based on individual assessed needs, which was not adhered to in this case.
Failure to Implement Interventions for Resident's Leg Edema
Penalty
Summary
The facility failed to implement necessary interventions for a resident with limited range of motion and leg edema, as observed during a survey. The resident, who was admitted with diagnoses including pain in the left ankle and schizophrenia, had an order to elevate both lower extremities due to swelling. However, during an observation and interview, the resident was seen limping and dragging her left leg, with a swollen ankle, and reported not being informed to elevate her legs at night. Further investigation revealed that there was no documentation of the resident's legs being elevated or the swelling being monitored since the order was given. The Licensed Vocational Nurse confirmed the lack of documentation, and the Director of Nursing acknowledged the staff's responsibility to manage both the psychological and medical conditions of residents. The facility's policies emphasized maintaining residents' abilities in activities of daily living and proper documentation of physician orders, which were not adhered to in this case.
Expired CPR Certification for CNA
Penalty
Summary
The facility failed to ensure that a Certified Nurse Assistant (CNA 3) maintained an active Basic Life Support/Cardiopulmonary Resuscitation (BLS/CPR) certification, which is a requirement for employment at the facility. CNA 3 was hired and scheduled to work four days a week despite having an expired CPR certificate. The Director of Nursing (DON) acknowledged that CNA 3's CPR certification had expired and emphasized that maintaining an active CPR certification is crucial for CNAs to respond effectively to breathing and cardiac emergencies, which is a part of their job requirement. The facility's policy mandates that licensed nursing staff must be certified in basic CPR and maintain active certification. However, the facility did not follow up on the CPR status of CNA 3, leading to the scheduling of CNA 3 without an active CPR certificate. This oversight had the potential to place residents at risk by not ensuring that staff could competently respond to emergencies, thereby affecting the residents' rights and well-being.
Failure to Address Pharmacist's Medication Regimen Review Recommendation
Penalty
Summary
The facility failed to act upon the pharmacist's medication regimen review (MRR) recommendation for one of the sampled residents, Resident 24. The pharmacist identified that Resident 24 was prescribed Propranolol 10 mg twice a day for anxiety, which is an off-label use not approved by the FDA for this indication. According to CMS guidelines, this could be considered duplicate or unnecessary therapy. The facility's policy required that clinical recommendations from the pharmacist be addressed within 14 days, but there was no documentation indicating that the recommendation was addressed by the nurses, notified to the physician, or reviewed by the physician. Resident 24 was admitted with diagnoses including depression disorder and schizophrenia. The resident was independent in various activities of daily living and had clear communication abilities. The Director of Nursing (DON) confirmed that the facility had no DON in position during September and October 2024, which contributed to the oversight. The consultant pharmacist visited the facility monthly to review medication regimens and provide recommendations, but the facility staff failed to respond to the pharmacist's recommendation, potentially affecting the resident's health conditions and thought processes.
Lack of Specific Behavior Indication for Psychotropic Medication Order
Penalty
Summary
The facility failed to ensure that a physician's order for the psychotropic medication Ativan for a resident included a specific indicated behavior for its use. The resident, who was admitted with diagnoses including major depression disorder, diabetes mellitus, and schizophrenia, had a physician order for Ativan to be administered as needed for agitation/anxiety related to an anxiety disorder. However, the order did not specify the exact behavior that would necessitate the use of Ativan, which is a requirement according to the facility's policy. During an interview, the Director of Nursing acknowledged that the psychotropic medication order should indicate specific behaviors to be monitored and care planned. Without this information, staff would not be able to determine if the resident's behavior was improving or worsening, nor could they measure the effectiveness of the medication properly. This oversight had the potential to result in the resident receiving unnecessary medications, experiencing side effects, and not maintaining their highest practicable level of well-being.
Non-Compliance with Resident Room Capacity Regulations
Penalty
Summary
The facility failed to ensure compliance with the regulation that resident rooms accommodate no more than four residents. During an observation, it was noted that five out of eleven resident bedrooms, specifically Rooms 25, 27, 29, 31, and 33, each housed five residents. This arrangement was contrary to the facility's policy and procedure, which mandates that resident rooms should not accommodate more than four residents. The facility had requested a waiver for these rooms, citing that the rooms had adequate space for residents' use and movement, and there were no adverse effects on nursing care, comfort, and privacy. The Client Accommodation Analysis form confirmed that each of these rooms, measuring 464.96 square feet, was occupied by five ambulatory residents. The facility's Room Waiver Request Letter supported the claim that there was ample space for wheelchairs, medical equipment, and resident mobility. During an interview, the Administrator verified the occupancy and stated that the rooms provided adequate space for care without jeopardizing residents' health and safety. Despite these assertions, the facility's policy clearly indicated that rooms should not accommodate more than four residents, leading to the identified deficiency.
Shared Deodorant Use Among Residents
Penalty
Summary
The facility failed to ensure that three sampled residents were provided with their own deodorant for personal use, which had the potential to increase the risk of spreading infection among them. The residents involved were diagnosed with schizoaffective disorder, and they were independent in personal hygiene activities according to their Minimum Data Set (MDS) assessments. During an observation, an unlabeled deodorant spray was found in a tray at the nurses' station, which was used as a shared deodorant among residents. Interviews with the Licensed Vocational Nurse (LVN) and the Interim Director of Nursing (IDON) revealed that residents would request the deodorant from the nurses' station, use it, and then return it. The IDON acknowledged that deodorants should be individualized and not shared to prevent infection. The facility's policy and procedure on infection prevention and control emphasized maintaining a safe environment to prevent disease transmission, but this practice was not followed in the case of deodorant use.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by multiple incidents involving aggressive behavior among residents. Resident 1, who was admitted with a diagnosis of psychosis, physically assaulted Resident 2 by kicking and hitting them on the face and arms. Despite staff presence during the altercation, they did not physically intervene, and Resident 1 was able to attack Resident 2 a second time. The facility's video recording confirmed that staff did not attempt to physically stop the fight, and Resident 1 was left unescorted after the incident. In another incident, Resident 1 attacked Resident 3 with a broken plastic plate, causing multiple wounds. The attack occurred during breakfast in the dining room, where Resident 1 broke the plate and used it to stab Resident 3. The facility's video recording showed Resident 1 intentionally hitting and stabbing Resident 3, and staff did not intervene to prevent the attack. Resident 1's actions were reportedly motivated by Resident 3's involvement in a previous altercation between Residents 1 and 2. Additionally, Resident 5 was involved in two separate incidents of physical aggression. Resident 5 punched Resident 7 on the patio and later punched Resident 6 in the medication line. Both incidents were captured on video, showing Resident 5's aggressive behavior towards other residents. The facility's policy on abuse prevention and resident rights emphasizes zero tolerance for abuse, yet these incidents demonstrate a failure to protect residents from harm.
Failure to Implement QAPI Action Plans for Resident Altercations
Penalty
Summary
The facility failed to implement appropriate plans of action under its Quality Assurance and Performance Improvement (QAPI) program after identifying 31 resident-to-resident altercations from January to July 2024. During a review of the facility's Quality Assurance/Risk Management Committee Meeting minutes, it was noted that there were multiple altercations each month, with 4 in January, 1 in February, and 10 in March. Despite these incidents, the minutes only indicated that nursing staff would continue to monitor resident behavior to prevent altercations, without specifying any concrete plans of action or expected outcomes. Further review of the meeting minutes from July 2024 revealed a lack of detailed documentation on the number of altercations from April to July, and again, no specific plans of action were noted. The Administrator acknowledged that the QAPI minutes did not include specific plans to address the altercations, only mentioning behavior monitoring. The facility's Policy and Procedure on Quality Assessment & Assurance emphasized the need for structured processes to correct deficiencies and monitor the effects of action plans, which were not reflected in the QAPI minutes.
Failure to Monitor Resident on Psychotropic Medication
Penalty
Summary
The facility failed to adequately monitor a resident who was receiving Clozaril for auditory and visual hallucinations as ordered by the physician. The resident, who was admitted with diagnoses including schizophrenia and tobacco use, was supposed to be monitored every shift for hallucinations. However, the Medication Administration Record (MAR) showed that behavior monitoring was not documented on several night shifts. This lack of monitoring was confirmed by both a Licensed Vocational Nurse and the Director of Nursing, who acknowledged that the monitoring should have been completed and documented as ordered. The deficiency was highlighted when the resident, experiencing auditory hallucinations, hit another resident. The facility's policy on psychotherapeutic drug management required daily monitoring of psychotropic drug use and the use of non-pharmacological interventions when indicated. The failure to monitor the resident's condition as ordered prevented the facility from updating interventions to address the resident's specific behaviors, potentially leading to harm.
Failure to Prevent Resident Abuse and Update Care Plans
Penalty
Summary
The facility failed to protect residents from emotional and physical abuse, as evidenced by multiple incidents involving residents. On one occasion, two residents engaged in a physical altercation on the patio, resulting in one resident sustaining a superficial cut on the lip. The altercation was preceded by verbal aggression, and no staff was present to intervene when the fight began. The facility's policy mandates zero tolerance for abuse, yet the staff failed to prevent the altercation or provide adequate supervision. Another incident involved a resident who repeatedly exhibited aggressive behavior towards peers and staff. This resident's care plan was not updated despite multiple instances of aggression, including hitting other residents and staff members. The facility's policy requires care plans to be revised following any change in condition or behavior, but this was not adhered to, leaving other residents at risk of further incidents. Interviews with staff and residents revealed that the aggressive resident was known to be unpredictable and had a history of altercations. Despite this, the facility did not take appropriate measures to manage the resident's behavior or ensure the safety of others. The lack of timely updates to the care plan and insufficient staff intervention contributed to the ongoing risk of abuse within the facility.
Failure to Notify MD of Resident Altercation
Penalty
Summary
The facility failed to notify the Medical Doctor (MD) of a physical altercation between two residents, which occurred on 5/24/2024. Resident 6 punched Resident 5 in the left eye and forehead, but the incident was not reported to the MD, and a change of condition (COC) was not completed for either resident. This oversight was identified during interviews and record reviews, where it was noted that the incident was reported to the Administrator, Director of Nursing (DON), and the facility's Social Worker, but not to the MD. The facility's policy and procedure for Change of Condition Notification requires that physicians be informed of changes in residents' conditions in a timely manner, which was not adhered to in this case. Resident 5, who was admitted with diagnoses including schizoaffective disorder and insomnia, complained of a headache with a pain level of five out of ten following the altercation. Resident 6, diagnosed with schizophrenia and insomnia, was noted to have intact cognitive abilities. Despite the altercation and Resident 5's complaint of pain, no medical orders such as neurological checks or x-rays were obtained due to the failure to notify the MD. This lack of notification had the potential to result in serious injury to the residents involved.
Failure to Monitor Resident with Auditory Hallucinations
Penalty
Summary
The facility failed to adequately supervise and monitor a resident, identified as Resident 6, who was receiving Depakote for behavior problems related to auditory hallucinations. The facility did not monitor Resident 6's behavior on specific dates, despite having an MD order to do so every shift. Additionally, the facility did not provide one-to-one monitoring for Resident 6 on a day when it was ordered due to aggressive behavior towards others. These lapses in monitoring occurred even after Resident 6 had been involved in physical altercations with other residents, which were documented in nursing notes. Resident 6, who was admitted with diagnoses including schizophrenia and insomnia, had intact cognitive abilities according to a recent assessment. Despite this, the resident reported hearing voices that instructed them to harm others, leading to incidents where Resident 6 pushed and punched another resident. Interviews with staff confirmed that Resident 6's behavior was unpredictable and required close monitoring. The facility's failure to adhere to the MD's orders for monitoring and supervision posed a risk of further altercations and potential harm to Resident 6 and others.
Failure to Report Alleged Abuse Incident
Penalty
Summary
The facility failed to adhere to its Policy and Procedure on Abuse Reporting by not reporting an alleged physical abuse incident involving two residents to the California Department of Public Health (CDPH). Resident 9, who has a diagnosis of schizophrenia and intact cognitive abilities, hit Resident 5 on the left side of the face. This incident occurred in the hallway when Resident 5 was exiting their room. Despite Resident 5 reporting the incident to the charge nurse and expressing concerns about future altercations due to shared bathroom facilities, the incident was not reported to the appropriate authorities. Interviews with facility staff revealed a lack of communication and action regarding the incident. Certified Nursing Assistant 3 was aware of the incident but unsure if it was reported to CDPH, Police, or Ombudsman. The RN Supervisor did not report the incident to the Administrator, as there were no visible injuries on either resident, although it was considered alleged physical abuse. The Director of Nursing confirmed that the incident was not reported to the Administrator or themselves, acknowledging the risk of recurrence. The facility's policy mandates staff to report known or suspected abuse, which was not followed in this case.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, resulting in two incidents involving residents. In the first incident, Resident 1, who has schizophrenia, type 2 diabetes mellitus, and hyperlipidemia, was slapped on the back of the head by Resident 2 while sitting on the patio. Resident 1, who is moderately impaired in cognitive skills, expressed feeling afraid and unsafe after the incident. Resident 2, who also has schizophrenia and no cognitive impairment, had a history of aggressive behavior, including hitting female residents on consecutive days. The incident was witnessed by a Certified Nursing Assistant (CNA), who confirmed that Resident 2 slapped Resident 1 without provocation, causing Resident 1 to feel fearful and seek comfort from the CNA. In the second incident, Resident 3, who has schizophrenia, anxiety disorder, and major depressive disorder, was kicked on the left elbow by Resident 4 while lying on the hallway floor. Resident 3, who has no cognitive impairment, was unable to explain why Resident 4 kicked him. Resident 4, who has schizophrenia, type 2 diabetes mellitus, and hyperlipidemia, admitted to kicking Resident 3 intentionally and has a history of aggressive behavior towards both staff and residents. This incident was also witnessed by a CNA, who observed Resident 4 walking up to Resident 3 and kicking him without provocation. The facility's policy on abuse prevention and prohibition, which emphasizes zero tolerance for abuse, neglect, and mistreatment, was not effectively implemented in these cases. Both incidents highlight the facility's failure to protect residents from physical abuse, resulting in feelings of fear and insecurity among the affected residents. The facility's documentation and staff interviews corroborate the occurrences of these unprovoked attacks, indicating a lapse in ensuring a safe environment for all residents.
Failure to Follow MD Orders for Neurological Checks
Penalty
Summary
The facility failed to follow a Medical Doctor's (MD) order for neurological checks (neuro-checks) for Resident 3 after the resident sustained a hit to the head from a physical altercation with another resident. The MD's order, dated 3/27/2024 at 9:59 PM, required neuro-checks every four hours for 24 hours, then every shift for two days. However, the neuro-checks were not completed as ordered. The Director of Nurses (DON) confirmed that the neuro-checks should have continued until the evening of 3/30/2024 but were not properly carried out, with gaps in the assessments noted on 3/28/2024. Resident 3, who was admitted with diagnoses including anxiety, insomnia, and stimulant abuse, reported being hit on the left side of the face by another resident during a medication pass. The resident developed a headache following the incident. Licensed Vocational Nurse (LVN) 1 confirmed the incident and the subsequent MD order for neuro-checks and Tylenol. The failure to complete the neuro-checks as ordered was acknowledged by the DON, who stated that this placed the resident at risk of not properly assessing their neurological functions. The facility's policy and procedure for physician orders, dated 10/1/2023, indicated that licensed nurses are responsible for documenting and implementing MD orders, which was not followed in this case.
Failure to Prevent Resident Elopement Due to Improper Gate Management
Penalty
Summary
The facility failed to prevent the elopement of a resident by not ensuring that locked gates were opened one at a time. The Director of Staff Development (DSD) and another staff member simultaneously opened two locked gates, allowing Resident 4 to push past them and leave the facility. This resulted in Resident 4 being missing for four days, with the potential for injury and harm. Resident 4 had been admitted with diagnoses including anxiety, psychosis, and schizoaffective disorder. The resident was on absent without leave (AWOL) precautions, and staff were instructed to ensure the resident was not on the patio and to perform one-to-one therapy to monitor AWOL behavior. Despite these precautions, the resident was able to elope when both gates were opened simultaneously by staff members who did not see each other. Interviews with various staff members, including the DSD, Licensed Vocational Nurse (LVN), and other staff members, revealed that the facility's policy required one gate to be locked before opening the next. Staff members admitted that they did not follow this protocol, leading to the resident's elopement. The Director of Nursing (DON) confirmed that staff did not adhere to the facility's policies and procedures, which contributed to the incident.
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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 El Monte
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Eastland Subacute And Rehabilitation Center | 0.3 mi | ★★★★★ | 4 | 0 |
| Madera Post Acute Center | 0.6 mi | ★★★★★ | 26 | 0 |
| The Gardens Of El Monte | 1.3 mi | ★★★★★ | 23 | 0 |
| Fidelity Health Care | 1.3 mi | ★★★★★ | 3 | 0 |
| Valley View Post Acute | 1.9 mi | ★★★★★ | 3 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.