Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pine Grove Healthcare & Wellness Centre, Lp during CMS and state inspections, most recent first.
Incomplete staff competency validation was identified for a CNA, an RNA, two LVNs, and an RN. The DSD and ADON confirmed that onboarding and annual competency checks were not properly completed or documented, including a CNA checklist signed without observing skills, an RNA orientation signed off without documented validation, and missing competency evaluations for licensed nurses upon hire and, for one LVN, annually. The facility's policy required competency validation based on job duties and assigned tasks.
Uncovered wheeled trash bins filled with nursing trash were observed in the parking lot next to dumpsters. The DS stated the bins should have been covered, and the ADON confirmed the facility’s Waste Management P&P required waste to be placed in large covered waste bins and not left outside exposing garbage.
A facility failed to document blood pressure laterality accurately for two residents receiving dialysis. One resident had an AV fistula in the left arm and multiple BP readings were charted as taken on that arm even though staff said they were actually taken on the right arm. Another resident had a right-arm AV fistula and BP readings were charted as taken on the right arm even though staff said they were actually taken on the left arm. Staff confirmed the charting errors and the facility policy required records to be complete and accurate.
Failure to Validate Water Management Program Controls: The facility did not perform water testing to initially validate its water management program control measures or confirm the water was free of waterborne pathogens such as Legionella. The PM, ADM, and IP stated there was no initial validation testing for the program controls, and the IP reported water testing had only been done initially in 2018 with no testing afterward. Facility policy stated the water management team would ensure the program was running as designed and effective, and CMS guidance reviewed by surveyors addressed testing protocols, acceptable ranges, and documentation of results.
A facility separated two married residents into different rooms without documented written notice or a recorded explanation for the change. The residents had significant physical and cognitive impairments, and the resident representative had repeatedly requested that they remain together because one resident was bedridden and depended on the other for help. Staff confirmed the room change was made to accommodate an isolation admission, but no room change notification or follow-up documentation was completed, and the couple remained apart despite an available room later becoming open.
Failure to Assess Bed and Wheelchair Alarms as Restraints: A resident with dementia, a hx of falls, and severe cognitive impairment was observed in a wheelchair with a wheelchair alarm in place. The resident had orders for bed and wheelchair alarms for safety, but RN and ADON interviews confirmed there was no documented restraint-physical evaluation before the alarms were used, despite facility policy stating restraints require an order and use in accordance with the resident’s assessment.
A resident with schizophrenia, DM2, and emphysema was prescribed Quetiapine for auditory hallucinations, but the MDS was inaccurate regarding antipsychotic use and the Antipsychotic Medication Review. The MDS Coordinator confirmed the assessment should have shown routine antipsychotic receipt and reflected the GDR completed for the resident, while the care plan addressed psychotropic medication use related to schizophrenia and behavior management.
Unpalatable Meal Tray: A resident with DM2 and protein-calorie malnutrition was on a CCHO standard portion diet with regular texture and thin liquids. The resident stated the facility food had no flavor and was not liked, and a food tray observation found the spinach bland; the DS also tasted it and agreed it needed more flavor. The dietary policy required meals to be attractive and of good quality.
A resident on hospice with aortic aneurysm, heart disease, and end stage heart failure had an incomplete care plan that did not include the hospice diagnosis or the ordered hospice visit frequencies. RN and MDS staff stated the hospice binder and EMR were inconsistent, and the DON confirmed the facility did not develop the resident’s hospice care plan as required by the hospice agreement and facility policy.
Call Light Left Out of Reach: A resident with CVA sequelae, generalized weakness, and cognitive impairment was observed in bed with the call light hanging off the side of the bed and on the floor, out of reach. The resident’s care plan identified inconsistent call light use, attempts to get out of bed without assistance, and a need for the call light to remain within reach at all times. The ADON confirmed the call light was out of reach, and facility policy stated the call alert device will be placed within the resident’s reach.
Multiple 3-bed rooms did not meet the required square footage per resident, with 13 of 35 rooms measuring below the minimum standard. Surveyors observed a resident using a walker in one room, and the ADM acknowledged the space deficiency while stating the facility was seeking a room waiver because the reduced room size did not affect resident health and safety.
The facility failed to prevent non-consensual sexual contact between two residents with severely impaired cognition who were seated side by side in wheelchairs in a hallway. A visitor observed a male resident’s hand inside the front of a female resident’s pants and reported this to an LVN, while video footage later reviewed by the ADM and DON showed the male resident attempting to place his hand under and in front of the female resident’s pants and the female resident swaying his hand away. Another staff member in housekeeping was told by the visitor that one resident was touching the other but, not fully understanding, did not report the concern to nursing or other staff. The ADM acknowledged that the facility was not able to prevent the sexually inappropriate touching, that residents did not have consent for such contact, and that everyone is a mandated reporter, while facility policy stated that no form of resident abuse is condoned.
A resident with dementia, legal blindness, severe cognitive impairment, and significant physical limitations was identified as a fall risk with restlessness while in bed, yet the care plan interventions to monitor and document sleep patterns, notify the physician of insomnia or anxiety, and provide individualized fall-prevention measures were not implemented. Staff confirmed there was no documented sleep monitoring, no related orders on the MAR, and no sedative orders in place despite ongoing nighttime restlessness, moaning, and screaming. The resident, who could not use a call light or verbalize needs, did not have a bed alarm, even though nurses and the ADON stated a bed alarm should have been ordered and could have alerted staff when the resident was no longer in a safe position. On a night when the resident was noted to be especially restless and constantly moving in bed, the resident was later found on the floor beside the bed with a forehead abrasion, and the IDT attributed the fall to severe cognitive impairment, restlessness, and physical limitations.
The facility did not complete required antibiotic time-outs (ATO) within 48 to 72 hours for two residents who were prescribed antibiotics for infections, as mandated by facility policy. Medical records and staff interviews confirmed that ATOs were not documented within the specified timeframe after antibiotic initiation, despite both residents receiving their prescribed antibiotics. Staff acknowledged the omission and confirmed that the ATOs should have been completed according to the facility's antibiotic stewardship protocols.
The facility failed to maintain room temperatures between 71 to 81 degrees Fahrenheit for three residents, causing discomfort and potential negative impacts on their quality of life. Despite complaints from the residents and confirmation from maintenance staff, the rooms remained excessively hot, with temperatures recorded as high as 92 degrees Fahrenheit. The facility's policies to ensure a comfortable environment were not adequately followed.
The facility was found deficient in maintaining sanitary food handling and storage practices. A rusted can opener, uncovered non-stick spray oil, and improperly sealed and unlabeled cheese were observed in the kitchen. The dietary consultant and DON confirmed these practices were against the facility's policies, which require proper labeling, sealing, and sanitization to prevent contamination.
The facility failed to ensure dumpsters were closed and not overflowing, as required by its Waste Management Policy. Observations revealed dumpsters overflowing with PPE and kitchen trash, which the Dietary Supervisor acknowledged could attract pests and pose an infection control concern. The Administrator confirmed non-compliance with policies designed to reduce contamination risk.
The facility failed to maintain an effective water management program to prevent Legionnaire's disease, as they did not conduct initial or ongoing testing for legionella. Interviews with the Maintenance Supervisor and Infection Preventionist revealed a lack of testing, despite facility policies and national guidelines emphasizing the importance of environmental testing to validate control measures. This oversight placed residents at risk for severe respiratory infections.
The facility failed to ensure a safe and sanitary environment by not properly insulating bed control wires for two residents and allowing trash cans in three rooms to overflow with waste and PPE. Staff confirmed these issues, which could lead to safety and infection control problems.
A resident with multiple health conditions was unable to go outside for over a month due to the lack of a suitable wheelchair. The available wheelchair was too snug, ripped, old, and dusty, leading to the resident feeling sad and starting to get depressed. Despite staff acknowledgment of the issue, no appropriate wheelchair was provided, highlighting a deficiency in accommodating the resident's needs.
Two residents with language barriers were not provided with communication boards as required by their care plans. One resident, with dementia and muscle weakness, and another with a spinal fracture and muscle weakness, both lacked the necessary communication aids to express their needs. Observations confirmed the absence of communication boards, and staff interviews corroborated this deficiency, which contravened the facility's policy on accommodating residents' communication needs.
Two residents in the facility, both dependent on staff for personal hygiene due to severe cognitive impairments and physical limitations, were observed with dirty and crusted fingernails. Despite facility policies requiring hand cleaning to prevent infection, these residents did not receive adequate grooming services, as confirmed by staff observations and interviews.
A resident with severe cognitive impairment and multiple health conditions did not receive their prescribed medications, amlodipine and Vitamin C, at the scheduled time due to a delay caused by the attending LVN. The medications were administered 1 hour and 18 minutes late, exceeding the facility's policy of a one-hour window for medication administration.
A facility failed to maintain a medication error rate below 5%, resulting in a 7.69% error rate during a med pass. A resident with cardiomegaly, heart failure, and diabetes received Amlodipine and Vitamin C 1 hour and 18 minutes late due to an LVN attending a call light. This was against the facility's policy of administering meds within one hour of the scheduled time.
An expired bottle of Osmolite 1.5 Cal was found in a medication room at nurse station 2, posing a risk to residents if administered. The DSD and DON acknowledged that licensed staff should ensure medications are not expired, as per facility policy, which requires immediate removal and disposal of outdated items.
A facility failed to coordinate care with hospice staff for a resident with a terminal prognosis, resulting in an inaccurate medical record. The resident's hospice binder lacked documentation of visits by hospice staff, including an RN and Spiritual Counselor, from December to February. This failure could potentially impact the resident's receipt of necessary hospice care.
The facility failed to ensure call lights were within reach for two residents, both with significant cognitive and physical impairments. One resident's call light was found hanging on the wall behind their bed, while another's was wrapped around a bed rail, both out of reach. This oversight could delay assistance and increase fall risk, contrary to facility policy.
The facility did not post accurate and complete nurse staffing information in a prominent location accessible to all residents and visitors. On one occasion, the information was only visible in the red zone for COVID-19 positive residents, and on another, the posted information was outdated. The administrator confirmed these deficiencies, which violated the facility's policy requiring daily, accurate postings.
The facility failed to meet the square footage requirement of 80 sq. ft. per resident in 13 rooms. Despite this, CNAs and residents reported no issues with space for care and mobility. A room waiver was recommended by the Department.
A resident with cognitive impairment and medical conditions was improperly restrained by a CNA using a white sheet as an abdominal binder to prevent self-scratching and pulling out a G-tube. This action violated the facility's policy, which requires restraints to be used only for medical necessity with proper authorization. Staff interviews confirmed the inappropriate use of the restraint.
A resident with cognitive impairment was subjected to physical restraint by a CNA, who wrapped a sheet around the resident's stomach to prevent access to their abdominal area. The incident was reported by an LVN to an RN, but the RN failed to inform the Administrator, delaying the required reporting to authorities. This breach of protocol violated the facility's policy on timely reporting of abuse and restraint incidents.
Incomplete Staff Competency Validation
Penalty
Summary
The facility failed to ensure that competency and skills validations were completed for five of five sampled nursing staff in accordance with the facility assessment and the facility's Staff Competency Validation policy. During record review and interviews with the Director of Staff Development and the Assistant Director of Nursing, CNA 1's onboarding skills checklist was signed off without an actual observation of skills, with the DSD stating she only verbally discussed the skills before signing the form. RNA 1's 16-hour clinical orientation was also signed off as complete without documentation showing how the skills were validated. The licensed nurse records reviewed showed that LVN 1 did not have documented evidence of a completed skills competency evaluation upon hire or annually thereafter, LVN 2 did not have documented evidence of a completed skills competency evaluation upon hire, and RN 1 did not have documented evidence of a completed skills competency evaluation upon hire. The DSD and ADON stated that competency evaluations were required upon hire and annually for licensed nurses, and that the evaluations were used to confirm staff were competent in assigned duties such as medication documentation and dialysis care.
Uncovered Trash Bins Left Exposing Waste
Penalty
Summary
The facility failed to ensure garbage was properly disposed of in accordance with its Waste Management policy and procedure. During observation in the facility parking lot, two lidless, uncovered trash bins on wheels were found filled with bags of trash and placed next to three dumpsters. The Dietary Supervisor stated the two trash bins contained nursing trash and should have been covered. During interview and record review, the Assistant Director of Nursing reviewed the facility’s Waste Management policy dated 4/21/2022, which directed staff to dispose of all regulated or potentially regulated waste, close and dispose of regulated waste according to state and federal regulations, and place bags into large, covered waste bins. The ADON stated all trash should be transferred from the wheeled trash bins into the dumpsters and that the uncovered trash bin was not supposed to be left outside exposing the garbage inside.
Inaccurate Blood Pressure Laterality Documentation for Dialysis Residents
Penalty
Summary
The facility failed to ensure vital signs were documented accurately for two residents receiving dialysis. Resident 5 had ESRD, was dependent on hemodialysis, and had an AV fistula in the left upper arm. Her care plan and order summary indicated that blood pressure was not to be taken in the left arm. However, March 2026 blood pressure documentation repeatedly showed readings recorded as taken on the left arm on multiple days. During interview, an LVN stated the blood pressure was actually taken on the right upper arm and that the left-arm documentation was entered in error because the wrong site was selected in the charting system. The MDS Coordinator also stated the left-arm documentation was incorrect. Resident 82 was admitted with HTN and dependence on renal dialysis, had ESRD, and received hemodialysis three times weekly with a right upper extremity AV fistula. Her H&P, order summary, and care plan all indicated that blood pressure was not to be taken in the arm with the AV fistula. March 2026 vital sign documentation showed blood pressures recorded as taken on the right arm on multiple days. During interview, the ADON stated the resident’s AV fistula was in the right upper extremity and that the documented right-arm blood pressures were incorrect because the blood pressure had actually been taken from the left arm. The facility’s policy on completion and correction stated that medical records are to be complete, legible, descriptive, and accurate. Staff interviews confirmed that the documented laterality for both residents’ blood pressure readings did not match where the measurements were actually taken, and that the charted site was entered incorrectly in the vital sign record.
Failure to Validate Water Management Program Controls
Penalty
Summary
The facility failed to implement water testing samples to initially validate its water management program control measures and confirm that the facility’s water was free of waterborne pathogens such as Legionella. During a concurrent interview and record review on 3/17/2026, the Property Manager and Maintenance Supervisor reviewed CDC and ASHRAE guidance regarding validation of a water management program. The Property Manager stated he understood the concept of validation and stated the facility had no testing done for its water management program and had no initial validation for its controls. During interviews on 3/18/2026, the Administrator stated there was no initial validation test done for the controls for the water management program and later stated the importance of initially validating the controls was to ensure the program is working. The Infection Preventionist stated the facility had only had testing done initially in 2018 and did not do any water testing afterwards. The Infection Preventionist also stated the importance of validating controls on an ongoing basis is to prevent Legionella from happening in the facility. A review of the facility’s Water Management policy dated 12/22/2025 showed the facility intended to develop and utilize water management strategies to reduce the risk of growth and spread of Legionella and other opportunistic water-borne pathogens in facility water systems. The policy also stated the team would ensure the program was running as designed and effective. CMS guidance reviewed during the survey stated facilities should implement a water management program that considers ASHRAE and CDC guidance and includes control measures, testing protocols, acceptable ranges, and documentation of results and corrective actions when control limits are not maintained.
Failure to Provide Written Notice for Room Change and Separate Married Residents
Penalty
Summary
The facility failed to provide written notice and documented evidence explaining why a room change was required for two married residents, and it failed to accommodate their request to remain roomed together from 5/5/2025 through 7/21/2025. The deficiency involved Residents 43 and 44, who were initially admitted with significant physical and cognitive impairments. Resident 43 had paraplegia, generalized muscle weakness, and moderate impairment with cognitive skills for daily decision making, and was dependent for rolling in bed, dressing, footwear, hygiene, and eating. Resident 44 had osteoarthritis of the right knee, generalized muscle weakness, moderate cognitive impairment, and required substantial to maximal assistance with transfers and standing, along with assistance or supervision for other activities of daily living. During interviews, the resident representative stated that Residents 43 and 44 were married and had repeatedly expressed a preference for them to remain together because Resident 43 was bedridden and unable to call for help without Resident 44. The representative stated the facility had separated them at times over the prior year and that, during one period in 2025, they were assigned separate rooms for about 2 months. Resident 44 stated he was not notified before the room change or told why he had to be separated from Resident 43. The Assistant Director of Nursing stated that prior to a room change, notification should have been completed with the resident and/or responsible party, and that a room change notification and follow-up visit should have been documented for every room change. Record review showed Residents 43 and 44 were moved from the same room to different rooms on 5/5/2025 to accommodate a new resident admitted under isolation, and no room change notification documentation or progress note was found for that date. The Social Services Director stated she was aware of the request for the married residents to stay together, but no room change notification was documented because she was busy. The Administrator confirmed that an empty room was available on 5/27/2025 and stated the residents should have been moved back together then rather than waiting until July 2025. The facility policy titled Resident Rights stated that a resident has the right to share a room with a spouse if mutually agreeable and feasible, and the Room or Roommate Change policy required timely written notice to the resident and representative, including the reason for the change.
Failure to Assess Use of Bed and Wheelchair Alarms as Restraints
Penalty
Summary
The facility failed to ensure that one sampled resident was free from the use of physical restraints unless needed for medical treatment by not conducting an assessment before using a wheelchair alarm and bed alarm. Resident 34 was admitted to the facility on 3/9/2022 and later readmitted on [DATE]. The resident’s diagnoses included difficulty in waking, dementia, and a history of falling. The Minimum Data Set dated 2/25/2026 indicated severely impaired cognitive skills for daily decision making, partial/moderate assistance with eating and oral hygiene, and substantial/maximal assistance with toileting hygiene, showering, and upper and lower body dressing. The resident’s order summary dated 3/18/2026 showed orders for a bed pad alarm and a wheelchair alarm, both for safety and fall prevention, with monitoring each shift for proper function and placement. During observation on 3/16/2026, Resident 34 was seen sitting in a wheelchair with a wheelchair alarm in place. During interview and record review, RN 2 stated the resident should have had a restraint-physical evaluation before the alarms were used and that there was no documented evidence that such an assessment was completed from 3/15/2026 to 3/19/2026. ADON also stated that Resident 34 did not have a restraint-physical evaluation prior to the use of the bed and wheelchair alarm, and the facility policy stated restraints require a physician order and are used only when deemed necessary by the IDT and in accordance with the resident’s assessment.
Inaccurate MDS Antipsychotic Assessment
Penalty
Summary
The facility failed to ensure an accurate Minimum Data Set (MDS) assessment for one resident who was admitted with diagnoses including schizophrenia, type 2 diabetes mellitus, and emphysema. The physician order summary showed the resident was receiving Quetiapine Fumarate 25 mg, two tablets by mouth at bedtime for schizophrenia manifested by auditory hallucinations. However, the resident’s MDS dated [DATE] indicated the resident was taking an antipsychotic medication but also indicated the resident did not receive antipsychotics, which was inconsistent with the medication record. During a concurrent interview and record review, the MDS Coordinator stated the resident was taking an antipsychotic medication and that the MDS was not accurate. The MDS Coordinator stated the answer should have been documented as yes, antipsychotics were received on a routine basis only, and that the Antipsychotic Medication Review should have reflected the gradual dose reduction completed for the resident. The resident’s care plan, revised 2/13/2026, identified psychotropic medication use related to behavior management and schizophrenia and included interventions related to pharmacy and physician review, dosage reduction consideration, and review of behaviors and alternate therapies. The facility policy on the RAI Process stated resident assessments must accurately depict resident-specific issues and meet state and federal guidelines and data submission requirements.
Unpalatable Meal Tray
Penalty
Summary
The facility failed to provide one sampled resident with meal trays that were appetizing and palatable. The resident was admitted with diagnoses of type 2 diabetes mellitus with ketoacidosis and protein-calorie malnutrition. The resident’s MDS dated 2/25/2026 indicated cognitive intactness, dependence for chair/bed-to-chair transfers, standing, and footwear, substantial/maximal assistance with dressing, and supervision or touching assistance with personal hygiene and eating. The resident’s March 2026 order summary showed a consistent carbohydrate standard portion diet with regular texture and thin consistency. During interview, the resident stated the food received from the facility was bad, had no flavor, and was not liked. During a food test tray observation, the spinach on the tray was described as bland and lacking flavor. The Dietary Supervisor tasted the spinach and stated it was bland and needed more flavor, and also stated that older residents may have diminished taste and that medications can affect taste. The facility policy for the dietary department stated that meals should be nutritionally adequate, attractive, well-balanced, and consistent with physician orders, with standards for quality of food.
Incomplete Hospice Care Plan and Inconsistent Hospice Documentation
Penalty
Summary
The facility failed to follow its hospice agreement to coordinate care for one resident receiving hospice services by not developing an effective communication process for the resident’s plan of care, hospice visitation, and physician’s orders. The resident was admitted with diagnoses including aortic aneurysm, heart disease, and encounter for palliative care. The resident’s MDS dated 12/31/2025 indicated modified independence for daily decision making, setup or clean-up assistance with eating, partial/moderate assistance with oral hygiene, substantial/maximal assistance with upper body dressing and personal hygiene, and dependence with toileting hygiene, lower body dressing, and footwear. The resident’s POC summary dated 3/19/2026 showed a physician’s order to recertify the resident to Hospice 1 for symptom management and comfort-focused care for end stage heart failure. The resident’s care plan, revised 3/15/2026, included cooperation with the hospice team to meet the resident’s spiritual, emotional, intellectual, physical, and social needs, but it did not include the resident’s hospice diagnosis of end stage heart failure. RN 2 stated the resident had a hospice binder at Nursing Station 2, that hospice orders were transcribed into the facility’s electronic medical record, and that conflicting orders between the hospice binder and the electronic record could cause confusion and potentially inaccurate, incomplete, and unsafe hospice plan of care. RN 2 and the MDS assistant both stated that the resident’s hospice visit frequencies were not in the care plan and should have been included so the care team would know the specific care needed. The DON reviewed the hospice contract agreement and the hospice binder and stated the facility’s electronic medical records were inconsistent with the hospice binder records, that the facility did not develop the resident’s hospice care plan, and that the hospice care plan was incomplete. The hospice contract and facility policy both stated that hospice and facility staff would collaborate on the care plan and maintain hospice documentation in the resident’s medical record.
Call Light Left Out of Reach
Penalty
Summary
The facility failed to ensure that the call light for one sampled resident was within reach. Resident 83 was admitted with diagnoses of unspecified sequelae of cerebral infarction and generalized muscle weakness. The resident’s H&P documented mild cognitive impairment and that she was only able to make decisions for her basic needs. The admission assessment indicated moderate cognitive impairment with memory loss, no impairment in upper extremity range of motion, impairment on one side of the lower extremity range of motion, and that the resident was bedfast most or all of the time. Resident 83’s care plan identified that she was noncompliant, attempted to get out of bed without assistance, did not consistently use the call light, and had an increased risk for falls with injury. The care plan also stated that staff were to ensure the call light was within reach at all times and later indicated the call light would be secured by wrapping it around the grab bar to maintain accessibility. During observation, the resident was lying in bed with the call light hanging off the right side of the bed on the floor on top of the fall mat. During a concurrent observation and interview, the ADON observed the resident turned on her side with both legs attempting to come off the bed and touching the floor, while the call light remained on the floor out of reach. The ADON stated the call light was out of the resident’s reach, and later stated that if a call light is not within reach, there is a risk for delay in staff providing assistance. The facility policy stated the call alert device will be placed within the resident’s reach.
Insufficient Bedroom Square Footage in Multiple Resident Rooms
Penalty
Summary
The facility failed to provide a minimum of 80 square feet per resident in multiple resident bedrooms, affecting 13 of 35 resident rooms: Rooms 5, 7, 9, 11, 15, 16, 17, 18, 19, 20, 21, 22, and 23. During the facility tour, surveyors identified that these rooms did not meet the required square footage for multiple-resident bedrooms. The room waiver letter reviewed by surveyors showed that the affected rooms ranged from 216.26 to 226.9 square feet and were configured as 3-bed rooms, while the minimum square footage for a 3-bedroom was 240 square feet. During observation in one room, a resident was seen sitting on the edge of the bed preparing to stand and ambulate with a walker. The resident stated the room space was adequate and that the walker allowed movement without difficulty, and also stated staff had enough space to move around while providing care. The Administrator acknowledged that 13 rooms did not meet the 80 square feet per resident requirement and stated the facility was requesting a room waiver because the reduced square footage did not affect resident health and safety. Survey observations also noted adequate ventilation and lighting, bathroom and toilet facilities, privacy curtains, sufficient freedom of movement, enough space for staff to provide care, and enough storage for residents' belongings in the affected rooms.
Failure to Prevent and Report Non-Consensual Sexual Contact Between Residents
Penalty
Summary
The deficiency involves the facility’s failure to prevent sexual abuse between residents in a hallway. Resident 1, who had dementia and severely impaired cognitive skills for daily decision-making, required partial to moderate assistance for mobility and was not self-responsible, with a representative designated as responsible party. On the date of the incident, Resident 1 was seated in a wheelchair in the hallway next to Resident 2. An SBAR and Change in Condition Evaluation completed that afternoon documented that Resident 1 was at risk for emotional distress related to alleged inappropriate touching and that a witness had reported Resident 1 was being touched inappropriately by Resident 2 while seated in the hallway. Resident 2 was also not self-responsible and had severely impaired cognitive skills for daily decision-making, with diagnoses including muscle weakness, gait mobility issues, and dysphagia. Resident 2 required partial to moderate assistance for sit-to-stand and walking. An SBAR and Change in Condition Evaluation for Resident 2 on the same date documented an allegation of inappropriate sexual behavior toward Resident 1, manifested by inappropriate touching, and that Resident 2 was being monitored for inappropriate behavior manifested by touching Resident 1. The Administrator later stated that Residents 1 and 2 did not have consent to touch, especially in the private area or for any sexual interaction with another resident, and that if sexual inappropriate touching was not consensual, it was considered sexual abuse. The events leading to the deficiency were corroborated by witness interviews and video review. Visitor 1 reported seeing two wheelchairs side by side in the hallway, with Resident 1 closest to the wall and Resident 2 next to Resident 1, and observed Resident 2’s hand down the front inside of Resident 1’s pants, moving. Visitor 1 reported this to LVN 1 at the nurse’s station. The Administrator and DON reviewed surveillance footage from the hallway, which showed the two residents sitting side by side in wheelchairs, Resident 2 attempting to place a hand under and in front of Resident 1’s pants, and Resident 1 swaying Resident 2’s hand away; the exact hand location was not visible on the video. Housekeeping staff (HK1) stated that Visitor 1 told him something about Resident 2 touching Resident 1 and pointed toward the residents, but HK1 did not fully understand and did not report it to nursing or other staff. The Administrator acknowledged that the facility was not able to prevent Resident 2’s sexually inappropriate touching and stated that everyone is a mandated reporter required to report even alleged abuse. The facility’s abuse and neglect policy stated that the facility does not condone any form of resident abuse and that its purpose is to address the health, safety, welfare, dignity, and respect of residents.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate accident prevention interventions, including use of a bed alarm, monitoring and documentation of sleep patterns, and timely physician notification of insomnia or anxiety, for a resident assessed as at risk for falls. The resident was admitted with dementia, hypertension, and legal blindness, and was identified on a Fall Risk Evaluation as at risk for falls, with intermittent confusion, bedbound/incontinent status, and poor vision. The MDS documented severely impaired cognitive skills for daily decision making, bilateral upper extremity impairment, unilateral lower extremity impairment, and dependence or significant assistance needed for all ADLs, including rolling in bed. The care plan identified the resident as at risk for falls related to confusion, gait/balance problems, poor communication/comprehension, unawareness of safety needs, and restlessness while in bed, and also included a care plan for coronary artery disease with an intervention to monitor and document sleeping patterns, inform the physician of any insomnia or anxiety, and give sedatives as ordered. Despite these identified risks and care plan directives, the facility did not implement or document monitoring of the resident’s sleep pattern, and there was no sedative order in place. Multiple staff interviews, including with RN 1, LVN 2, and the ADON, confirmed there was no documented evidence that the resident’s sleep pattern had been monitored, even though it was listed as a care plan intervention. Staff also stated that if sleep monitoring was part of the care plan, it should have been ordered and reflected on the MAR so that licensed nurses could document hours of sleep. RN 1 acknowledged that the care plan was not resident-centered and that the intervention to monitor/document sleep pattern and notify the physician of insomnia or anxiety had not been carried out. The DON verified that the intervention to monitor and document sleep pattern was not implemented. The facility also failed to provide a bed alarm for this resident, despite the resident’s severe cognitive impairment, blindness, restlessness, and inability to use the call light or verbalize needs. LVN 1 stated the resident did not have a bed alarm and should have had an order for one to alert staff when the resident was no longer in a safe position in bed. LVN 2 and the ADON similarly stated that a bed alarm could have helped prevent a fall by alerting staff when pressure was off the bed. Staff interviews described the resident as usually restless at night, not sleeping like other residents, and moving or squirms frequently in bed. On the night of the incident, documentation and interviews indicated the resident was restless, screaming, moaning, and constantly moving in bed from around 1–2 AM, with repositioning and distraction attempts for comfort. At approximately 5:30 AM, the resident was found on the floor on the right side of the bed, face down between the bed and nightstand, with a 2 cm abrasion on the left forehead. The IDT progress notes identified the likely root causes of the fall as severe cognitive impairment, restlessness, and significant physical limitations, and the DON confirmed that the fall care plan did not include a specific intervention to address the resident’s restlessness while in bed and instead contained only a general directive to follow the facility fall protocol.
Failure to Complete Timely Antibiotic Time-Outs for Two Residents
Penalty
Summary
The facility failed to ensure that an antibiotic time-out (ATO), a structured process for reviewing and assessing the need for ongoing antibiotic therapy, was completed within 48 to 72 hours for two residents who were prescribed antibiotics. According to the facility's policy, an ATO should be performed within this timeframe to reassess the necessity of the antibiotic based on clinical and laboratory data, and to communicate findings with the prescribing physician. However, record reviews and interviews confirmed that ATOs were not completed for these residents within the required period after antibiotic initiation. One resident was admitted with chronic kidney disease, urinary tract infection, and enterocolitis due to Clostridium difficile, and was prescribed metronidazole. The medication administration records showed that the resident received the antibiotic as ordered, but there was no documentation of an ATO being completed within the 48 to 72-hour window. Another resident, admitted with heart failure, bacteremia, and end-stage renal disease, was prescribed ciprofloxacin following a surgical procedure. Similarly, the records indicated the antibiotic was administered as ordered, but an ATO was not documented within the required timeframe. Interviews with the Infection Preventionist, Registered Nurse Supervisor, and Director of Nursing confirmed that the ATOs for both residents were not completed as per facility protocol. The staff acknowledged that the ATOs should have been performed within 48 to 72 hours after starting the antibiotics, as outlined in the facility's policies on antibiotic stewardship and ATO procedures. The absence of timely ATOs was verified through both electronic medical chart reviews and staff statements.
Failure to Maintain Appropriate Room Temperatures
Penalty
Summary
The facility failed to maintain the room temperatures within the required range of 71 to 81 degrees Fahrenheit for three residents, leading to discomfort and potential negative impacts on their quality of life. Resident 126, who was in an isolation room, experienced excessive heat, causing her to sweat profusely and have difficulty sleeping. Despite her complaints about the room being too hot, the temperature was recorded at 92 degrees Fahrenheit by the maintenance staff. Resident 126 expressed that the heat exacerbated her insomnia, and she was unable to sleep due to the uncomfortable conditions. Resident 63 also reported discomfort due to the high temperature in his isolation room. He expressed that the room was too hot, which was confirmed by the maintenance staff who measured the temperature. Similarly, Resident 36, who had a history of polyneuropathy and other medical conditions, complained about the persistent heat in his room. Despite having the window partially open, he felt the room was excessively hot and had repeatedly informed various staff members, including the Maintenance Supervisor, about the issue without any resolution. The maintenance staff and Infection Control Nurse acknowledged the residents' complaints but failed to effectively address the temperature issues. The Maintenance Supervisor stated that he could control the thermostat remotely and was not notified of any extreme temperatures by the monitoring app. However, the residents continued to experience discomfort, and the facility's policies and procedures aimed at providing a comfortable environment were not adequately followed, resulting in the deficiency.
Deficiencies in Food Handling and Storage Practices
Penalty
Summary
The facility failed to maintain the food service area in a clean and sanitary manner, as observed during a survey. A can opener in the kitchen was found to be rusted, which was acknowledged by the dietary consultant (DC) as a potential source of cross-contamination. Additionally, a non-stick spray oil was observed without a lid, and cheese in the refrigerator was not properly sealed or labeled with an open or use-by date. These observations were confirmed by the DC, who noted the importance of sealing and labeling to prevent contamination. The Director of Nursing (DON) reviewed the facility's policies and procedures (P&P) and confirmed that the observed practices were not in compliance. The P&P required that all food items be labeled and dated, and that open products be stored in containers with tight-fitting lids. The can opener was also required to be sanitized between uses according to the manufacturer's guidelines. The DON emphasized that these measures are crucial to prevent food contamination and ensure resident safety.
Improper Waste Disposal and Overflowing Dumpsters
Penalty
Summary
The facility failed to ensure that three dumpsters in the parking lot were closed and not overflowing, as required by the facility's Waste Management Policy and Procedure. During observations and interviews conducted on two separate days, the dumpsters were found to be overflowing with personal protective equipment (PPE) and kitchen trash. The Dietary Supervisor acknowledged that the dumpsters should not be overflowing, as this could attract insects and rodents, posing an infection control concern. The facility's Administrator confirmed that the facility was not compliant with its Policies and Procedures, which were designed to reduce the risk of contamination from regulated waste. The policy indicated that biohazard containers should have closed lids and that food waste should be placed in covered garbage cans. The Administrator noted that when dumpsters are left open and overflowing with kitchen waste, it could lead to unpleasant odors and attract pests, further emphasizing the infection control issues.
Failure to Implement Effective Water Management Program for Legionella
Penalty
Summary
The facility failed to establish and maintain an effective water management program to prevent the development and transmission of Legionnaire's disease. During interviews, the Maintenance Supervisor (MS) admitted that the facility does not conduct any testing for legionella, neither initially nor on an ongoing basis, to confirm the effectiveness of their control measures. The Infection Preventionist (IP) also acknowledged the lack of testing for legionella or other waterborne pathogens, despite suggesting that testing would validate the effectiveness of the facility's control measures. A review of the facility's policy and procedure on Water Management indicated that the facility should develop and utilize water management strategies to reduce the risk of legionella and other water-borne pathogens. However, the facility did not follow through with environmental testing for pathogens as part of their verification and validation process. The CMS and CDC guidelines, as well as ASHRAE standards, emphasize the importance of environmental testing for legionella to validate the effectiveness of control measures, especially in healthcare facilities serving at-risk populations. The facility's failure to implement these testing protocols placed residents at risk for developing severe respiratory infections.
Deficiencies in Environmental Safety and Waste Management
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for two residents by not ensuring that the bedside control wires for their beds were properly insulated. The exposed wires were observed in the rooms of two residents, one of whom had severe cognitive impairment and a history of falling, while the other had moderate cognitive impairment and a history of falling and depression. The Director of Nursing confirmed the presence of exposed wires, which could pose a risk of fire, shocks, and accidents. Additionally, the facility did not manage waste disposal effectively, as observed in three rooms where trash cans were overflowing with trash and used personal protective equipment. This was confirmed by interviews with staff, including a certified nursing assistant, an infection preventionist, and a licensed vocational nurse, who acknowledged that overflowing trash cans could lead to infection control issues. The facility's policies and procedures required trash cans to be closed and waste bags to be removed when three-quarters full, but these guidelines were not followed, contributing to an unsanitary environment.
Failure to Provide Suitable Wheelchair for Resident
Penalty
Summary
The facility failed to provide reasonable accommodations for a resident's needs and preferences regarding a wheelchair that was comfortable for his size and in good condition. The resident, who was admitted with multiple diagnoses including polyneuropathy, type 2 diabetes with diabetic polyneuropathy, end-stage renal disease, anemia, and dysphagia, expressed his desire to go outside for fresh air and sunlight. However, he was unable to do so because the facility did not have a wheelchair that fit him properly, and the available wheelchair was described as too snug, ripped, old, and dusty. The resident reported feeling sad and starting to get depressed due to being confined to his bed for over a month. Despite his requests and the facility staff's acknowledgment of the issue, no suitable wheelchair was provided. Interviews with various staff members, including the Director of Nursing, Certified Nursing Assistant, Social Service Director, and Occupational Therapy staff, confirmed the lack of an appropriate wheelchair and the resident's inability to be transferred safely and comfortably. The facility's policies and procedures, including those related to maintenance, resident rights, and infection control, emphasize the importance of maintaining equipment in good condition and accommodating residents' needs. However, the failure to provide a suitable wheelchair for the resident highlights a deficiency in adhering to these policies, potentially impacting the resident's psychosocial well-being and safety.
Failure to Provide Communication Boards for Residents with Language Barriers
Penalty
Summary
The facility failed to provide communication boards to two residents, Residents 66 and 225, who had language barriers and were dependent on staff for communication. Resident 66, diagnosed with dementia and muscle weakness, was admitted to the facility and was noted to be dependent on staff for various activities of daily living. The care plan for Resident 66 indicated the need for adaptive equipment, such as a communication board, to address the language barrier. However, during multiple observations, no communication board was found in Resident 66's room, and staff confirmed the absence of such a device. Similarly, Resident 225, who had a wedge compression fracture and muscle weakness, was also identified as having a language barrier. The care plan for Resident 225 included the provision of a communication board or translator to facilitate communication. Observations revealed that no communication board was present in Resident 225's room, and the resident reported frequent misunderstandings with staff due to the lack of communication aids. Staff interviews confirmed the absence of communication boards for Resident 225. The facility's policy on accommodating residents' communication needs requires the provision of adaptive devices like communication boards for residents with language barriers. The Director of Nursing acknowledged that the absence of communication boards for these residents placed them at risk of being unable to express their needs effectively. This deficiency highlights the facility's failure to adhere to its own policy and ensure that necessary communication aids are readily accessible to residents with language barriers.
Failure to Provide Adequate Grooming Services
Penalty
Summary
The facility failed to provide adequate grooming services for two residents who were dependent on staff for activities of daily living (ADLs), specifically personal hygiene. Resident 53, who was admitted with diagnoses including sepsis, dysphagia, and muscle weakness, was observed with dirty and crusted fingernails. The resident's cognitive skills were severely impaired, and they were totally dependent on staff for personal hygiene, as indicated in their care plan. Despite these needs, observations revealed that the resident's nails were not maintained, which was confirmed by a licensed vocational nurse who noted the potential for bacteria harboring under the nails. Similarly, Resident 57, who had diagnoses including dysphagia, muscle weakness, and paraplegia, was also observed with unkempt fingernails. This resident required substantial assistance with eating and was dependent on staff for personal hygiene. During an observation, the resident's fingernails were noted to have a dry, crusted, yellowish-blackish substance. The facility's administrator acknowledged that it was unacceptable for residents to have dirty fingernails and that the facility's policy was to clean residents' hands when dirty, especially before and after meals, to prevent the spread of infection.
Medication Administration Delay for a Resident
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of Resident 64 by not administering medications as prescribed. Resident 64, who was admitted with diagnoses including cardiomegaly, heart failure, and diabetes, had a physician's order for amlodipine 5 mg and Vitamin C 250 mg to be administered at 9 AM. However, during a medication pass observation, it was noted that the medications were administered at 10:18 AM, which was 1 hour and 18 minutes after the scheduled time. The Licensed Vocational Nurse (LVN) responsible for administering the medications stated that the delay was due to attending to another resident's call light. The facility's policy allows for medications to be administered within one hour before or after the scheduled time, but the administration in this case exceeded that window. The facility's administrator confirmed that the medications should have been administered between 8 AM and 10 AM, indicating a failure to adhere to the facility's medication administration policy.
Medication Administration Timing Deficiency
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a rate of 7.69% during a medication administration observation. This deficiency was identified when two medication errors occurred out of 25 opportunities, specifically involving a resident who was administered medications outside the prescribed time frame. The medications, Amlodipine 5 mg and Vitamin C 500 mg, were given 1 hour and 18 minutes after the scheduled 9 AM administration time, which was beyond the facility's policy of administering medications within one hour before or after the scheduled time. The resident involved had significant medical conditions, including cardiomegaly, heart failure, and diabetes, which required careful management of their medication regimen. The Licensed Vocational Nurse (LVN) responsible for the medication pass attributed the delay to attending to a call light during the medication administration process. The facility's policy and procedures emphasized the importance of adhering to the scheduled administration times to ensure compliance with dose guidelines, but this was not followed in this instance, leading to the identified deficiency.
Expired Osmolite 1.5 Cal Found in Medication Room
Penalty
Summary
The facility failed to remove expired Osmolite 1.5 Cal, a therapeutic nutrition product, from one of its medication rooms, specifically at nurse station 2. During an observation with the Director of Staff Development (DSD), a bottle of Osmolite 1.5 Cal was found with an expiration date that had already passed. The DSD acknowledged that expired enteral feeding bottles should not be present in the medication room, as their administration could lead to residents becoming ill and potentially requiring hospitalization. The Director of Nursing (DON) confirmed that licensed staff are responsible for checking expiration dates before administering any medication or enteral feeding bottles to residents. The facility's policy on medication storage mandates the immediate removal and proper disposal of expired, contaminated, or deteriorated medications. However, the presence of the expired Osmolite 1.5 Cal in the medication room indicates a lapse in adherence to this policy, posing a risk to resident health.
Lack of Coordination and Documentation in Hospice Care
Penalty
Summary
The facility failed to ensure proper coordination of care between the facility and hospice staff for a resident, resulting in an inaccurate medical record. The resident, who was admitted with a terminal prognosis and under hospice care, did not have hospice staff visit progress notes maintained in their medical record. Additionally, hospice staff did not sign in on their flow sheet in the resident's hospice binder, which is considered part of the medical record. This lack of documentation could potentially lead to the resident not receiving the necessary hospice care and services. The resident, identified as having severe cognitive impairment and being dependent on assistance for daily activities, was admitted to the facility with serious health conditions, including a dissection of the ascending aorta and type 1 diabetes. Despite the care plan indicating the need for cooperation with the hospice team to meet the resident's needs, the hospice binder lacked documentation of visits by the hospice RN and Spiritual Counselor from December 2024 to February 2025. The Director of Nursing confirmed the absence of required documentation, which was against the facility's policy and procedure for hospice care of residents.
Inaccessible Call Lights for Residents
Penalty
Summary
The facility failed to ensure that the call light system was within reach for two residents, leading to a potential delay in receiving assistance. Resident 8, who was admitted with type 2 diabetes and dementia, was observed with their call light hanging on the wall behind the head of their bed, out of reach. This resident was noted to have severe cognitive impairment and was dependent on staff for daily activities, making the accessibility of the call light crucial for their safety and communication needs. Certified Nursing Assistant 1 confirmed the call light's placement was not within the resident's reach. Similarly, Resident 44, diagnosed with metabolic encephalopathy and multiple sclerosis, was found with their call light wrapped around the back part of their bed's side rail, also out of reach. This resident's care plan specifically indicated the need for the call light to be within reach due to their risk of falls and dependency on staff for assistance. Licensed Vocational Nurse 2 acknowledged the call light's improper placement and its importance for resident communication. The Director of Nursing emphasized the risk posed by inaccessible call lights, as residents might attempt to move independently, increasing the risk of falls or unmet needs. The facility's policy mandates that call lights be placed within residents' reach, which was not adhered to in these cases.
Failure to Post Accurate Nurse Staffing Information
Penalty
Summary
The facility failed to post accurate and complete nurse staffing information in a prominent location accessible to residents and visitors, as required by their policy and procedure. On February 4, 2025, the nurse staffing information was only posted in the red zone, which is designated for residents who tested positive for COVID-19, and was not visible to other residents or visitors outside this area. This oversight was confirmed during an observation at the facility's entrance and lobby, where the staffing information was not accessible to those in the yellow and green zones. Additionally, on February 5, 2025, the Daily Nurse Staffing form posted in the lobby was found to be outdated, displaying the previous day's date, thus rendering it inaccurate. The facility's administrator acknowledged that the staffing information was not updated and confirmed that the posting did not comply with the facility's policy, which mandates that the information be accessible to all staff, residents, and visitors, and must be accurate. The facility's policy, revised in July 2018, requires daily posting of the facility name, current date, and total number of actual hours worked by licensed and unlicensed nursing staff per shift in a clear, readable format in a prominent location.
Room Size Deficiency in Multiple Resident Rooms
Penalty
Summary
The facility failed to ensure that 13 of 35 resident rooms met the square footage requirement of 80 square feet per resident in multiple resident rooms. During an initial observation, it was noted that rooms 5, 7, 8, 11, 15, 16, 17, 18, 19, 20, 21, 22, and 23 did not meet this requirement. Despite this, residents were able to ambulate and move around in their wheelchairs freely, and nursing staff had enough space to provide safe quality care. The facility had a room waiver indicating that the rooms with three beds were in accordance with the needs of the residents and did not adversely affect their health and safety. Interviews with Certified Nursing Assistants (CNAs) and residents revealed that there were no concerns regarding the room sizes. CNAs stated that there was enough room to provide proper and safe care to the residents. Additionally, residents did not express any concerns about the size of their rooms. The Department recommended the room waiver for the specified rooms as requested by the facility.
Improper Use of Physical Restraints on a Resident
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints, as required by their policy. A Certified Nurse Assistant (CNA) wrapped the resident's torso with a white sheet, using it as an abdominal binder, which restricted the resident's normal access to their body. This action was taken to prevent the resident from self-scratching and pulling out their gastrostomy tube (G-tube) or incontinent brief. The resident, who was cognitively impaired and required substantial assistance for daily activities, was unable to understand or make decisions due to their medical conditions, including hemiplegia and dementia. The facility's policy mandates that restraints should only be used when necessary for medical treatment and require a physician's order, assessment, and consent. The CNA's action was not in compliance with this policy, as it was done for convenience rather than medical necessity. Interviews with the staff, including a Licensed Vocational Nurse (LVN) and a Registered Nurse (RN), confirmed that the use of the sheet as a restraint was inappropriate and not authorized. The facility administrator also emphasized that restraints should only be used as a last resort and in accordance with the resident's assessment and plan of care.
Failure to Timely Report Suspected Abuse and Restraint
Penalty
Summary
The facility failed to report a suspected case of abuse and physical restraint involving a resident to the appropriate authorities within the required timeframe. The incident involved a resident who was cognitively impaired and required substantial assistance for daily activities. The resident was found with a white sheet wrapped around their stomach, which was used by a CNA to prevent the resident from accessing their abdominal area. This action was reported by an LVN to an RN, but the RN failed to report the incident to the facility's Administrator as required by the facility's policy. The Administrator was only informed of the incident during a staff meeting several days later, which delayed the reporting to the State Survey Agency, Law Enforcement, and the LTC Ombudsman. The facility's policy mandates that such incidents be reported within two hours, but this was not adhered to, potentially placing the resident at risk for further abuse and delaying the investigation. The facility's policies on restraint and abuse prevention clearly outline the procedures for reporting such incidents, which were not followed in this case.
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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 San Gabriel
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Broadway Healthcare Center | 0.7 mi | ★★★★★ | 18 | 0 |
| Mission Care Center | 0.9 mi | ★★★★★ | 25 | 0 |
| Ivy Creek Healthcare & Wellness Centre | 1.1 mi | ★★★★★ | 13 | 0 |
| San Gabriel Valley Medical Ctr D/p Snf | 1.1 mi | ★★★★★ | 17 | 0 |
| Live Oak Rehab Center | 1.2 mi | ★★★★★ | 38 | 1 |
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