Below 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 Rinaldi Convalescent Hospital during CMS and state inspections, most recent first.
Failure to Notify Physician of Cloudy Catheter Urine and Sediment: A resident with paraplegia, neurogenic bladder, and an indwelling catheter was observed with cloudy yellow urine and whitish and pink-tinged sediment in the tubing and drainage bag. The care plan directed staff to monitor for increased sediment or cloudiness and notify the physician if symptoms persisted, but the Tx nurse stated the physician was not notified. The DON confirmed physician notification was important per the care plan and facility policy.
Failure to document refusal of ordered wound care. A resident with paraplegia, bladder dysfunction, and mild cognitive impairment had a right lower leg wound ordered for cleansing, Vaseline, non-adherent dressing, and Kerlix. The Tx Nurse completed part of the treatment but did not apply Kerlix because the resident refused, and the refusal was not documented in the Nurse’s Progress Notes as required by the wound care P&P; the DON confirmed the refusal should have been recorded.
A resident with paraplegia and a high Braden score was observed in bed without heel protectors on either heel, despite a physician order and care plan intervention requiring them for PU/PI prevention. Staff stated the resident should have been wearing the devices, and a CNA reported they may have been removed on night shift and not reapplied; the DON confirmed heel protectors are required per physician orders.
Failure to Maintain Resident Dignity and Privacy: A CNA was observed sitting in a resident’s room with personal belongings on the resident’s bedside table while waiting for the end of the shift, another CNA was observed standing over a resident during feeding instead of sitting at eye level, and a staff member failed to knock before entering a resident’s room. The residents involved had significant cognitive and physical care needs, including dysphagia and impaired cognition, and the facility’s dignity and resident rights policies required residents’ private space and personal dignity to be respected.
Failure to Inform Residents of Medication Names and Indications: An LVN administered multiple medications to three residents without telling them the names of the drugs or why they were being given, and without asking for consent before administration. The residents had documented ability or capacity to understand and participate in care, and the facility’s Resident Rights policy stated residents must be informed of and participate in their care and treatment.
Incomplete care planning affected two residents. One resident with CVA, dysphagia, and weakness had a constipation care plan with a 3-day BM goal, but records showed no BM for several days and staff did not escalate the issue as described by the ADON. Another resident with ESRD and dialysis had an order for a Liberal Renal, NAS diet, but the DN confirmed there was no specific care plan for the renal diet.
Call Light Not Within Reach: A resident with metabolic encephalopathy, muscle weakness, dysphagia, and failure to thrive was observed in bed with the call light tucked between the mattress and pillow and not within reach. The resident had moderately impaired cognition and required substantial to maximal assistance with eating and personal hygiene, and was dependent on staff for oral care and toileting hygiene. An RNCM later placed the call light next to the resident's hand and stated it should always be next to the resident so the resident can call for assistance.
Failure to Provide Written AD Information: A resident with dementia, dysphagia, and a hip fracture had severely impaired decision-making and was dependent on staff for most ADLs. The resident’s AD acknowledgement form showed no AD, but it did not document whether the resident or representative wanted more information, and the Social Service review stated that written AD information and assistance with formulating an AD were not provided; the SSA and DON confirmed the form was incomplete and the required information and assistance were not documented.
Torn Window Screen in Resident Room: A torn sliding door screen was observed in the room shared by two residents, and the DON confirmed the damage during interview. One resident had muscle weakness and HTN and required assistance with ADLs, while the other had a history of falls and HTN and also required substantial/maximal assistance with ADLs. The torn screen was noted as not being in good repair.
Failure to update fall care plan after a resident fall. A resident with dementia, dysphagia, and a prior hip fracture had an unwitnessed fall and was found on the floor beside the bed. The IDT and MD ordered bilateral landing pads, but the fall-related care plans were not reviewed or revised to include that intervention, and the ADON and DON stated licensed staff did not update the care plan after the COC.
Failure to maintain nail care for a resident with severely impaired cognition and dependence for personal hygiene. The resident’s fingernails were observed to be long, untrimmed, and unkempt, and the DN stated they were long and unclean and should be kept trimmed and clean. The DSDA stated CNAs are responsible for keeping residents’ nails clean and trimmed, and the facility policy called for daily cleaning and regular trimming of nails.
Heel Protectors Not Applied as Ordered: A resident with a stage 3 pressure ulcer, dysphagia following CVA, and impaired decision-making was ordered bilateral heel protectors for pressure injury prevention. During observation, the resident was found in bed without the devices, CNA was unaware of the order, and the LPN could not locate any heel protectors in the room even though the TAR documented them as in use.
A resident with dementia and contractures had an order for an inflatable therapy Carrot orthosis to be applied to the right hand daily for 7 hours, and the care plan included the same restorative intervention. During multiple observations, the resident was in bed without the orthosis on the hand, with the device left on the bedside table. The DN said the orthosis had not been applied, and the assigned RNA stated he had not applied it despite being responsible for the task.
Failure to implement ordered fall and elopement precautions for two residents. One resident with dementia, a femur fracture, and dysphagia had an unwitnessed fall, and although the MD ordered bilateral landing pads after the fall, none were present at the bedside during observation. Another resident with DM2, PVD, and impaired decision-making was care planned for WMS use with each-shift monitoring, but MAR review showed the WMS placement/function checks stopped even though the resident remained at risk for wandering and elopement.
A resident with a Foley catheter was observed with tubing forming a dependent loop and urine pooling in the tubing instead of draining freely to the collection bag. Another resident with an indwelling catheter had orders and a care plan for catheter care and monitoring, but the TAR/MAR lacked documented evidence that licensed staff implemented the required catheter-related monitoring and care. The ADON and DON confirmed the missing documentation and lack of implemented interventions.
Enteral feeding rate not transcribed on formula bottle. A resident with a G-tube was observed with an Isosource 1.5 feeding hanging on the pump, but the bottle label did not include the ordered infusion rate. An LVN stated the nurse hanging the formula should have written the rate on the label to match the MD order and avoid inaccurate delivery of the prescribed enteral nutrition.
A resident received oxygen without a physician order, and the oxygen tubing was left unlabeled with the date and time it was last changed. In a separate event, another resident with an order for continuous oxygen was observed with the NC in the mouth instead of the nostrils, and the RNCM corrected the placement. The DON and ADON confirmed that oxygen requires a physician order and that the NC must be properly placed to deliver the ordered oxygen.
Failure to monitor a resident for bleeding while receiving enoxaparin. A resident with UTI, dysphagia, and obstructive/reflux uropathy was ordered enoxaparin for DVT prophylaxis, and the MAR showed doses were administered, but there was no documentation of monitoring for bleeding or bruising. The ADON stated no MD order was obtained for side-effect monitoring, and the DON confirmed residents on anticoagulants should be monitored for bleeding per the facility’s anticoagulation protocol.
A resident with CVA, dysphagia, and HTN had an order for a weekly clonidine patch with instructions to alternate the site, but the MAR showed the patch was reapplied to the same arm on multiple occasions instead of being rotated. An LVN and the ADON both confirmed the site should have been rotated, and the manufacturer’s instructions stated the new patch should be placed on a different site after one week.
A medication room refrigerator had missing temperature documentation on multiple shifts. An LVN confirmed the refrigerator should be checked and recorded twice daily, and the ADON stated this is important to maintain medication integrity, especially for refrigerated medications. The facility policy required medications and biologicals to be stored under proper temperature controls in the medication room.
A resident’s medical record did not include anxiety disorder on the current diagnoses list, even though the chart contained a clonazepam order for anxiety, a care plan for anxiety related to anxiety disorder, and psychiatric notes documenting generalized anxiety disorder. The MDS also did not list the diagnosis, despite showing anti-anxiety medication use and significant functional dependence. The ADON and DON stated the record should include all current diagnoses.
A resident with metabolic encephalopathy, muscle weakness, dysphagia, and failure to thrive had moderately impaired cognition and needed extensive help with ADLs, but the facility could not locate a hospice H&P and had no documented evidence that the hospice physician evaluated the resident. Staff also reported that the hospice agency did not provide the in-service training required by contract, and the DON and ADM acknowledged the missing hospice documentation and training.
A LVN failed to perform hand hygiene before and after administering medications to two residents, including residents with HTN and CKD, and stated she forgot because she was tense and stressed. In a separate event, a CNA placed her personal purse and cell phone on a resident’s bedside table while the resident slept, and later stated personal items should never be brought into resident rooms to prevent the spread of germs and infections.
Bedroom Space Requirement Not Met: The facility failed to provide at least 80 sq. ft. per resident in multiple-occupancy rooms. Rooms 101, 102, 104, 105, and 107 did not meet the required space per resident, with two-bed rooms at 74.8 sq. ft. per resident and three-bed rooms at 73.3 sq. ft. per resident. The ADM submitted a waiver request, and observations noted residents had ample space and staff reported no concerns, but the rooms still fell below the facility’s stated bedroom space standard.
The facility failed to follow its Abuse, Neglect, Exploitation, and Misappropriation Prevention Program and Hiring policies by not properly completing and documenting pre-employment reference and background checks for a CNA. The CNA’s personnel file contained an incomplete Pre-Employment Reference Check List, including a reference from a staff member in a non-qualifying role and missing dates and verification details for prior employment. The DON and ADM acknowledged that pre-employment checks are intended to identify any history of abuse or related disciplinary actions and that it was unclear whether appropriate checks had been performed for this CNA, despite policy requirements to conduct such background investigations.
A resident with a G-tube and indwelling catheter did not have weekly weights obtained as ordered, and staff failed to monitor and document intake and output according to facility policy and professional standards. The resident, who was dependent on staff and had multiple complex medical conditions, did not receive required I/O monitoring from admission through hospitalization, and the omission was confirmed by interviews with nursing staff and leadership.
A resident with severe cognitive impairment and multiple complex medical conditions experienced significant unplanned weight loss and developed new and worsening pressure ulcers. Despite these major changes in health status, the facility failed to complete a required Significant Change in Status Assessment (SCSA) MDS, instead performing only a quarterly assessment, contrary to facility policy and staff acknowledgment.
A resident with severe cognitive impairment and multiple medical conditions did not receive physician-ordered lab tests, including CBC, CMP, and magnesium, due to staff failing to process the requisition and notify the physician of the missed tests.
Improper Handling of Wound Care Supplies: An RN/TN returned opened disposable wound care supplies to the treatment cart and did not disinfect a reusable plastic container after completing wound care for a resident with cellulitis and DM-related left lower leg ulcer. The DON and TN stated the disposable supplies should have been discarded and the container disinfected before being returned to the cart, consistent with the facility's infection control and wound care policies.
A resident with hypertension and congestive heart failure, who was cognitively intact, exhibited a sudden change in behavior by refusing care, screaming, laughing inappropriately, and kicking a staff member. Despite staff involvement and facility policy requiring physician notification for such changes, the physician was not informed of the incident.
Two residents did not receive their prescribed medications on time, and staff failed to notify the physician prior to administering the late doses. In both cases, medications scheduled for the morning were given several hours late without prior physician input, and documentation of physician notification or assessment for adverse effects was lacking. Nursing staff and the DON confirmed that the required process for physician notification was not followed.
A nurse failed to ensure that a resident with multiple medical conditions received medications according to physician orders, including not providing required food or fluids with certain medications, not instructing the resident to rinse her mouth after inhaler use, and allowing self-administration without a physician's order or proper supervision.
A resident did not receive multiple scheduled morning medications within the required timeframe, with doses administered over three hours late and subsequent doses given in close succession. Nursing staff did not notify the physician of the missed doses or document any monitoring for adverse reactions, resulting in a failure to follow medication administration protocols.
A nurse failed to sign the treatment administration record for a resident's wound care and pleural catheter treatments, leaving uncertainty about whether care was provided. In a separate case, a nurse documented that a resident's morning medications were given before actual administration, which occurred later in the day after the resident initially refused. These actions resulted in incomplete and inaccurate medication and treatment records, as confirmed by staff interviews and policy review.
A resident with severe cognitive impairment was found with pillows placed on both sides of their body, restricting movement, without a physician's order for restraints. A CNA admitted to placing the pillows and forgetting to remove them, despite being aware that this could be considered a restraint. The LVN and DON confirmed that such use of pillows is not permitted without proper authorization, and facility policy prohibits restraints for staff convenience or fall prevention.
Surveyors found that a resident with COVID-19 did not have the required droplet precaution signage posted, another resident receiving IV antibiotics lacked enhanced barrier precaution signage and supplies, and two nurses failed to perform hand hygiene before administering medications, with one also not wearing gloves for eye drop administration. These actions were inconsistent with the facility's infection control policies.
A bottle of Pepto-Bismol was found at the bedside of a resident without a physician's order or proper labeling. The medication, brought in by the resident's family, was not listed on the Medication Administration Record and had not been assessed for self-administration. Facility staff confirmed that medications should not be left at the bedside without following required procedures.
Expired blood glucose (BG) control solutions were found in a medication cart and had been used for quality control checks after their expiration date. An LVN confirmed the solutions should have been replaced, and the DON acknowledged the risk of inaccurate readings. Facility policy required outdated medications to be returned or destroyed, but this was not followed.
The facility did not include required performance evaluations in the personnel files of four CNAs, as confirmed by record review and staff interviews. Facility policy mandates evaluations after probation and annually, but these were missing, resulting in incomplete personnel records.
Several CNAs and LVNs did not have required health exam documentation in their personnel files, including exams prior to or shortly after hire and annual health exams thereafter. The DSD and DON confirmed the lack of medical clearance for these staff, and facility policies requiring such documentation were not followed.
The facility did not provide or document required behavioral health in-service training for two CNAs, despite having residents with psychiatric and mood disorders and a scheduled training on the in-service calendar. Interviews confirmed that the CNAs had not received formal training, and the Director of Staff Development acknowledged the training was not conducted as scheduled. Facility policies require annual behavioral health training for all staff, but no evidence of such training was found in the CNAs' personnel files.
The facility failed to develop comprehensive care plans for two residents, one with severe cognitive impairment and another with a history of falls. The absence of care plans for a Restorative Nursing Assistant exercise program and a floor mat intervention led to potential inadequate care and risk of injury. Staff interviews confirmed the lack of person-centered care plans, despite facility policies emphasizing their importance.
The facility failed to update care plans for residents after changes in medication and ADL needs. A resident's anticoagulation therapy care plan was not revised after medication changes, another resident's care plan lacked specific ADL interventions, and a third resident's care plan inaccurately reflected discontinued anti-anxiety medication. These deficiencies were identified during interviews and record reviews, highlighting a lack of adherence to facility policies on care plan updates.
Two residents in an LTC facility did not receive appropriate pain management due to failures in assessing pain and documenting medication administration. Tramadol and Percocet were administered without prior pain assessment or entries in the MAR, violating facility policies. This lack of documentation hindered effective pain management and risked unmanaged pain for the residents.
Two residents in an LTC facility did not have their controlled medications properly documented in the MAR, despite being removed from the blister pack as per the CDR. This failure to document involved Xanax and Tramadol for one resident and Percocet for another, leading to potential medication errors and drug diversion. The facility's policy requires immediate documentation in both the CDR and MAR, which was not followed.
A LTC facility failed to administer Morphine Sulfate Contin to a resident as ordered, potentially increasing their pain. Additionally, two residents received midodrine despite having systolic blood pressure readings above the physician-ordered threshold, risking elevated blood pressure. The facility's medication administration policy was not followed.
The facility failed to maintain sanitary food storage practices when a scoop was left inside a bin of thickener powder used for pureed diets. This was observed during an inspection with the Dietary Supervisor, who confirmed that the scoop should not have been left in the bin to avoid contamination. This practice risked exposing five residents on pureed diets to foodborne illnesses.
A long-term care facility failed to implement proper infection control measures, including the absence of trash cans for PPE disposal, improper use of isolation gowns by an LVN, and unlabeled urinals, leading to potential cross-contamination. Additionally, personal belongings were found in a medication room, violating infection control policies.
A facility failed to ensure staff knocked and requested permission before entering the rooms of two residents, violating their rights to dignity and privacy. Both residents had intact cognitive skills and required assistance with personal care. A CNA entered their rooms without knocking, which was against the facility's policy on dignity.
A facility failed to maintain a current copy of a resident's advance directive in their medical record, as required by policy. The resident, who had severe cognitive impairment and was dependent on staff for daily activities, was admitted with conditions including hemiplegia and encephalopathy. The absence of the advance directive in the chart was confirmed by the DSS and DON, posing a risk of not honoring the resident's medical decisions.
Failure to Notify Physician of Cloudy Catheter Urine and Sediment
Penalty
Summary
The facility failed to ensure the physician was notified when Resident 1’s indwelling catheter was observed to have cloudy urine with sediment, consistent with the resident’s care plan and facility policy for reporting changes in condition. Resident 1 was admitted with diagnoses including paraplegia, neuromuscular dysfunction of the bladder, and benign prostatic hyperplasia with lower urinary tract symptoms. The resident’s MDS indicated mild cognitive impairment for daily decision making and dependence on several activities of daily living, and the order summary included an indwelling catheter for neurogenic bladder. The care plan identified Resident 1 as at risk for urinary retention related to neuromuscular dysfunction of the bladder and directed staff to closely monitor for increased sediment or cloudiness and notify the physician if symptoms persisted. During observation, the resident’s catheter was draining cloudy yellow urine with whitish and pink-tinged sediment throughout the tubing and drainage bag. The treatment nurse stated the physician should have been notified of the cloudy urine and sediment, and the DON stated it was important to notify the physician of cloudy urine and sediment in accordance with the care plan. The facility policy stated the nurse will notify the attending physician or physician on call for a significant change in condition or when there is a specific instruction to notify the physician of changes in the resident’s condition.
Failure to Document Refusal of Ordered Wound Treatment
Penalty
Summary
The facility failed to document a resident’s refusal of a physician-ordered wound treatment for one of three sampled residents. Resident 1 was admitted with diagnoses including paraplegia, neuromuscular dysfunction of the bladder, and benign prostatic hyperplasia with lower urinary tract symptoms. The resident’s MDS indicated mild cognitive impairment for daily decision making and dependence on several activities of daily living, including toileting hygiene, bathing, lower body dressing, and footwear. The admission/readmission skin review documented skin scabbing, plaque with red borders, white abnormalities, and lesions to the front right lower leg and front right thigh. A physician order dated 5/1/2026 directed the right lower leg wound to be cleansed with NS, patted dry, treated with Vaseline, and covered with a non-adherent dressing and Kerlix daily for 14 days. During observation, the Tx Nurse cleansed the wound, applied Vaseline and a dressing, and used a two by two dressing with adhesive sides, but did not apply Kerlix. The Tx Nurse stated Kerlix was not applied because the resident refused, and that the refusal should have been documented in the Nurse’s Progress Notes. The DON also stated the refusal should have been documented, and the facility’s wound care P&P required that if a resident refused treatment, the refusal and reason(s) must be recorded in the medical record.
Heel Protectors Not Applied as Ordered
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not met when a resident with paraplegia, neuromuscular dysfunction of the bladder, and benign prostatic hyperplasia was observed lying flat in bed without heel protectors on either heel, despite a physician order to apply heel protectors to both heels for pressure injury prevention and management. The resident’s MDS indicated mild cognitive impairment for daily decision making and dependence on toileting hygiene, bathing, lower body dressing, and footwear, and the Braden Scale score of 12 identified the resident as high risk for PU/PI development. The resident’s care plan identified the resident as at risk for unavoidable PU/PI and included the intervention to apply heel protectors to bilateral heels to maintain intact skin free from redness, blisters, or discoloration. During interviews, the Tx Nurse stated the resident should have been wearing heel protectors while in bed and that they are important to reduce pressure and prevent PU/PI. A CNA stated the heel protectors were not on because night shift staff may have removed them and failed to reapply them, and the DON stated heel protectors are required to be applied in accordance with physician orders. The facility policy on prevention of pressure injuries also directed staff to review the care plan and provide support devices.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to maintain resident dignity and privacy in multiple observed situations involving three residents. One resident with dysphagia and schizophrenia was observed lying in bed while a CNA sat in the resident’s room between the bed and the door with the CNA’s personal purse and cell phone placed on the resident’s bedside table. The CNA stated she was waiting in the room for her shift to end, had not asked permission to sit there, and acknowledged the resident was confused and likely unable to consent or deny her presence. The ADON stated staff may not bring personal items into resident rooms or use resident rooms for breaks, and the facility’s dignity and resident rights policies required residents’ private space and property to be respected. A second resident with metabolic encephalopathy, muscle weakness, dysphagia, and failure to thrive was observed during feeding while a CNA stood over and hovered over the resident. A folding chair was next to the CNA during the observation. The desk nurse stated the CNA should have been sitting down and at eye level while feeding the resident so the resident could be properly observed while eating and so dignity and respect could be maintained. The CNA stated she fed the resident and wiped her mouth before sitting down, and said she could not sit because the rolling bedside table did not roll under the bed. The DSD stated staff should sit on a chair and be at eye level with residents during meals to make meals pleasant and to facilitate observation of chewing and swallowing. The report also states that during resident screening, a staff member failed to knock prior to entering a resident’s room. The facility’s dignity policy stated each resident must be cared for in a manner that promotes well-being, satisfaction with life, self-worth, and self-esteem, and the resident rights policy stated employees must treat all residents with kindness, respect, and dignity.
Failure to Inform Residents of Medication Names and Indications
Penalty
Summary
The facility failed to ensure that residents were fully informed of and able to participate in their medication treatment for three residents observed during medication administration. During an observation of one resident with diagnoses including hypertension and chronic kidney disease, an LVN administered docusate sodium and amlodipine orally without being observed telling the resident the names of the medications or their indications. The resident’s MDS indicated the resident could make self-understood and understand others, and the OSR showed the medications were ordered for bowel management and hypertension. During an observation and interview with another resident who had been admitted with muscle weakness and chronic kidney disease, an LVN administered gabapentin and furosemide orally without informing the resident of the medication names or why they were being given. The resident’s H&P indicated the resident had decision-making capacity at admission. When interviewed, the LVN stated she forgot to inform the resident of the medication names and indications and to ask for consent before administration. During a concurrent observation and interview with a third resident admitted with hypertension and muscle weakness, an LVN administered metoclopramide, omeprazole, and Creon orally without being observed informing the resident of the names and indications of the medications. The LVN stated she did not inform the resident of the medication names and indications and asked for consent prior to administration. The facility’s Resident Rights policy stated residents shall be informed of and participate in their care planning and treatment.
Incomplete care planning for constipation and renal diet
Penalty
Summary
Resident 40 was admitted with diagnoses including intercerebral hemorrhage (CVA/stroke), dysphagia, and muscle weakness. The resident’s MDS indicated he could make himself understood and understand others, required partial assistance with oral and personal hygiene, and was dependent on staff for toileting, showering, lower body dressing, and putting on/off footwear. During a concurrent observation and interview, the resident was sitting up in bed with a family member present, and the family member stated the resident had not had a BM for several days and that this happened often. The resident stated he was constipated, felt uncomfortable, and had told staff in the past but could not remember who he told. The resident’s constipation care plan had a goal to pass soft formed stool at the preferred frequency of every three days and included interventions to administer medications and treatments as ordered and for CNAs to record BM pattern each day, but the BM task showed no BM on 3/19/2026. The ADON reviewed the care plan, BM task, and MAR and stated it was unacceptable for the resident to be constipated for more than six days without CNAs notifying the charge nurse so the doctor could be called or a PRN constipation medication given, and that the goal of not going more than 3 days without a BM was not met by licensed staff. Resident 5 was readmitted with diagnoses including ESRD and dependence on renal dialysis. The resident’s MDS indicated moderately impaired cognition, supervision or touching assistance with eating and oral hygiene, partial/moderate assistance with personal hygiene, and substantial/maximal assistance with toileting. The order summary showed an order for a Liberal Renal, No Added Salt diet for ESRD. During interview and record review, the DN reviewed the resident’s care plans and stated there was no care plan created addressing the resident’s renal diet. The DN stated the resident should have a specific care plan for the renal diet because it would provide interventions specific to that diet, and stated all staff are responsible for initiating diet care plans and that care plans are important for communication among the interdisciplinary team.
Call Light Not Within Reach
Penalty
Summary
The facility failed to ensure that a call light was within reach for Resident 11. Resident 11 was admitted with diagnoses including metabolic encephalopathy, muscle weakness, dysphagia, and failure to thrive. The MDS dated 1/1/2026 indicated Resident 11 had moderately impaired cognition and required substantial to maximal assistance with eating and personal hygiene, and was dependent on staff for oral care and toileting hygiene. During an observation on 3/28/2026 at 8:30 a.m., Resident 11 was seen in bed with the call light tucked between the mattress and pillow and not within reach. During a concurrent observation and interview at 8:48 a.m. with the RN Case Manager, the call light was again observed in the same location. The RNCM placed the call light next to Resident 11's right hand and stated that the call light was not within reach and should always be next to the resident so the resident can call for assistance and for safety. The facility policy titled, Answering the Call Light, stated staff must ensure the call light is accessible to the resident when in bed.
Failure to Provide Written AD Information
Penalty
Summary
The facility failed to ensure that one of eight sampled residents, Resident 12, was provided written information about the right to refuse or accept medical or surgical treatment and to formulate an Advance Directive (AD). Resident 12 was admitted with diagnoses including unspecified dementia, nondisplaced fracture of the base of the neck of the femur, and dysphagia. The resident’s MDS dated 2/5/2026 indicated severely impaired cognitive skills for daily decision making, with the resident rarely or never making decisions, and the resident was dependent on staff for oral hygiene, toileting hygiene, showering/bathing, upper and lower body dressing, and personal hygiene. Review of Resident 12’s Advance Healthcare Directive Acknowledgement form dated 12/3/2025 showed the representative signed the form and that the resident did not have an AD, but the form did not indicate whether the resident or representative wished to receive additional information about ADs. A Social Service Review form dated 3/6/2026 stated that the resident had not issued an AD, that the resident and/or representative were not provided written information regarding AD, and that facility staff did not offer assistance in formulating an AD. During interviews, the SSA and DON stated the form was not completed thoroughly and confirmed the facility policy required written information and an offer of assistance to formulate an AD, but those steps were not documented for Resident 12.
Torn Window Screen in Resident Room
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for two residents by not ensuring the sliding door window screen in their shared room was in good repair. During observation, the screen was noted to have a tear measuring approximately 24 inches from top to bottom. The Director of Nursing confirmed the torn screen during a concurrent observation and interview and stated that the room must be sealed from the outside by a screen to prevent small insects from entering the room. Resident 15 was originally admitted on 7/01/2025 and readmitted on 12/17/2025 with diagnoses including muscle weakness and hypertension. The Minimum Data Set dated 3/02/2026 indicated the resident could make self-understood and understand others, and required partial/moderate assistance with oral hygiene and upper body dressing, and substantial/maximal assistance with toileting, showering, and personal hygiene. Resident 82 was originally admitted on 8/23/2023 with diagnoses including history of falling and hypertension. The MDS indicated the resident could sometimes make self-understood and sometimes understand others, and required substantial/maximal assistance with toileting hygiene, showering, upper and lower body dressing, and personal hygiene.
Failure to Update Fall Care Plan After Resident Fall
Penalty
Summary
The facility failed to review and revise a resident’s care plan after a change of condition following an unwitnessed fall. The resident was admitted with diagnoses including unspecified dementia, a nondisplaced fracture of the base of the neck of the femur, and dysphagia. The MDS dated 2/5/2026 indicated the resident’s cognitive skills for daily decision making were severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, showering/bathing, upper and lower body dressing, and personal hygiene. A Post Fall Review form dated 1/29/2026 documented that at 4:00 a.m. the resident was found lying on the floor on the left side of the bed after an unwitnessed fall and denied hitting his head. The IDT root cause review recommended bilateral landing pads at the bedside, and a physician order dated 1/29/2026 directed placement of landing pads on both sides of the bed. The resident’s fall risk assessment identified him as high risk for falls, with one to two falls within the last six months. The resident’s Safety and Fall Prevention care plan, initiated on 12/19/2025 and last revised on 2/12/2026, included interventions such as supervision as needed, removing tripping hazards, and encouraging use of the call light, but did not include bilateral landing pads. The Risk for Fall and Injuries Related to Limited Mobility care plan, initiated on 12/03/2025, was not reviewed or revised after the fall. During interview, the ADON stated licensed staff did not review and update the care plans following the fall, and the DON stated care plans are required to be reviewed and revised after a COC and as needed.
Failure to Maintain Resident Nail Care
Penalty
Summary
The facility failed to provide the necessary services to maintain good grooming and personal hygiene for one resident by not ensuring the resident’s fingernails were trimmed. Resident 65 was admitted and later readmitted to the facility with diagnoses including severe protein-calorie malnutrition, lack of coordination, and muscle weakness. The resident’s MDS dated 2/11/2026 indicated severely impaired cognition, independence with eating, partial/moderate assistance with oral hygiene, and substantial/maximal assistance with toileting and personal hygiene. During an observation on 3/28/2026, Resident 65’s fingernails were noted to be long, untrimmed, and unkempt. On 3/29/2026, the Desk Nurse observed the resident’s fingernails and stated they were long and unclean and should be kept trimmed and clean. The DSDA stated that CNAs are responsible for keeping residents’ nails clean and trimmed and that when CNAs see residents’ nails are long, it is their responsibility to trim them. The facility’s policy on fingernail and toenail care stated the purpose is to clean the nail bed, keep nails trimmed, and prevent infections, and that nail care includes daily cleaning and regular trimming.
Heel Protectors Not Applied as Ordered
Penalty
Summary
The facility failed to provide pressure ulcer prevention services for one sampled resident by not ensuring bilateral heel protectors were in place as ordered by the physician. Resident 36 was admitted and later readmitted with diagnoses including a stage 3 pressure ulcer of the right buttock, dysphagia following cerebral infarction, and a gastrostomy. The resident’s MDS indicated severely impaired cognitive skills for daily decision making, dependence on staff for several activities of daily living, and risk for pressure ulcers with pressure-reducing devices for both bed and chair. The physician’s order summary dated 3/27/2026 directed staff to apply bilateral heel protectors for pressure injury prevention and management during every shift. During observation on 3/28/2026, Resident 36 was lying in bed without heel protectors in place. CNA 1 stated the resident was not wearing heel protectors and was not aware of the order. LVN 3 also observed that the resident was not wearing heel protectors and could not locate any at the bedside or in the closet. Review of the TAR showed licensed staff documented the resident as wearing heel protectors on 3/27/2026 and 3/28/2026, but LVN 3 stated the devices were not present. The DON stated licensed staff are responsible for implementing physician orders and confirmed the resident was not wearing the ordered heel protectors.
Failure to Apply Ordered Hand Orthosis
Penalty
Summary
The facility failed to provide ordered restorative nursing treatment to maintain joint range of motion for one resident with dementia, lack of coordination, and contractures at multiple sites. The resident’s record showed an order for RNA to apply an inflatable therapy Carrot orthosis to the right hand every day, seven days a week, for seven hours daily as tolerated, and the care plan included the same intervention to prevent further finger flexion contracture. During observations on the same day, the resident was seen in bed without the orthosis on the right hand, and the device was observed on the bedside table instead. During a concurrent interview and observation, the Desk Nurse stated the orthosis had not been applied and that RNAs were responsible for applying it. RNA 1 stated he was assigned to the resident that day but had not applied the orthosis and did not respond when asked why. On follow-up, the Desk Nurse stated the resident should have had the orthosis applied because it was a physician’s order and said it was important to apply it to prevent further decline and worsening of contractures in the resident’s right hand.
Failure to Implement Fall and Elopement Safety Measures
Penalty
Summary
The facility failed to provide an environment free from accident hazards for two residents. For one resident with unspecified dementia, a nondisplaced femur fracture, and dysphagia, the record showed an unwitnessed fall on 1/29/2026 at 4:00 a.m. The interdisciplinary review summary from the post-fall review recommended bilateral landing pads at the bedside, and the physician order summary on the same date directed staff to apply landing pads on both sides of the bed. However, during observation on 3/28/2026, no landing pads were present at the bedside, and RN and ADON interviews confirmed that the ordered landing pads had not been placed. For another resident admitted with diagnoses including DM type 2 and peripheral vascular disease, the history and physical stated the resident could make needs known but could not make medical decisions. The resident’s care plan for elopement risk required the resident to wear a wander management system (WMS) and for staff to monitor placement and function every shift. The March 2026 MAR also directed staff to monitor WMS placement and function each shift, but the monitoring was not completed from 3/5/2026 through 3/29/2026. During an interview and record review, the ADON stated the WMS monitoring should have been ongoing and not ended on 3/5/2026. The ADON also stated the resident could become confused and had a prior elopement attempt, and that the WMS was important to help prevent future elopement attempts. The facility policy on wandering and elopement stated the facility would identify residents at risk for unsafe wandering and strive to prevent harm while maintaining the least restrictive environment.
Catheter Care and Monitoring Deficiencies
Penalty
Summary
Resident 2 had diagnoses including muscle weakness, UTI, and obstructive uropathy, and was ordered to have a Foley catheter to bedside drainage. During an observation, the resident was lying in bed with the catheter tubing visible below the side of the mattress and forming a U-shaped dependent loop. Light yellow urine was pooling in the loop and was not draining into the urine collection bag. The LVN stated that the tubing should not form a loop because urine can pool and potentially flow back to the bladder, which can cause UTI. Resident 99 was admitted with diagnoses including UTI, dysphagia, and obstructive and reflux uropathy. The resident’s physician orders included indwelling catheter care with washing using soap and water and patting dry during every shift, and changing the Foley catheter and bag if leaking, plugged, obstructed, excessively sedimented, or if the closed system was compromised. The resident’s care plan identified risk for infection due to the indwelling catheter and included interventions to position the catheter bag and tubing below bladder level, check for kinks, monitor and document pain or discomfort, and monitor and report signs and symptoms of UTI. Review of Resident 99’s TAR and MAR for March 2026 did not show documented evidence that licensed staff provided the monitoring required by the care plan. During interview, the ADON stated there was no documented evidence in the MAR or TAR that licensed staff or CNAs implemented the catheter-related interventions and provided monitoring for the resident. The DON stated licensed staff are required to implement care plan interventions, monitor residents with indwelling catheters for signs and symptoms of infection, provide catheter care, and document the monitoring and care in the medical record, and stated that these interventions were not implemented for Resident 99.
Enteral feeding rate not transcribed on formula bottle
Penalty
Summary
The facility failed to ensure the enteral feeding rate was transcribed on the enteral feeding formula bottle for one sampled resident, Resident 43. Resident 43 was admitted with diagnoses including muscle weakness and encounter for attention to gastrostomy, and the Minimum Data Set indicated the resident could make self-understood and understand others, while requiring substantial to maximal assistance from staff for oral hygiene, toileting hygiene, upper body dressing, lower body dressing, and personal hygiene. During an observation, Resident 43 was found sleeping in the room with the G-tube feeding pump turned off and an Isosource 1.5 formula bottle hanging on the G-tube pole with no written tube feeding order on the label. In a concurrent observation and interview, LVN 7 stated the nurse who hung the feeding formula bottle should have transcribed the physician’s ordered infusion rate on the label to ensure the order was accurately reflected, and that without the feeding rate on the label the resident could receive an inaccurate amount of formula. The physician’s order specified Isosource 1.5 via G-tube at 50 mL/hr for 20 hours, off at 8 a.m. and on at 12 noon or until dose is met to provide 1000 mL volume/1500 kcal. The facility policy required checking the enteral nutrition label against the order before administration, including the rate of administration.
Oxygen Orders and Delivery Not Properly Followed
Penalty
Summary
The facility failed to obtain a physician order before administering oxygen to a resident with COPD, dysphagia, and lack of coordination who was admitted on 3/25/2026 and later documented as lacking capacity for medical decision making. During observation, the resident was seen receiving oxygen at 2 LPM via nasal cannula, and RN 1 confirmed there was no physician order for oxygen administration. The DON also reviewed the orders and confirmed that no order existed for oxygen, while stating that a physician order is required before oxygen is administered. The facility also failed to ensure the resident’s oxygen tubing was labeled with the date and time it was last changed. During observation, the resident’s oxygen tubing was noted to be unlabeled. RN 1 stated the tubing should be changed weekly on Saturdays and as needed, and that it must be labeled with the date it was last changed. The DON confirmed that staff are required to change and label the oxygen tubing and stated that not changing and labeling the tubing increases the risk of infection. The facility further failed to ensure another resident received continuous oxygen as ordered. That resident had diagnoses including metabolic encephalopathy, muscle weakness, dysphagia, and failure to thrive, and the MDS showed moderately impaired cognition with substantial to maximal assistance needed for eating and personal hygiene and dependence for oral care and toileting hygiene. The order summary directed oxygen at 2 LPM via nasal cannula continuously to keep oxygen saturation above 90%, but the resident was observed with the nasal cannula in the mouth rather than in the nostrils. The RNCM corrected the placement and stated the cannula was not in place and should be in the nostrils, and the ADON stated proper placement is needed to ensure the resident receives oxygen per policy and order.
Failure to Monitor Bleeding With Anticoagulant Therapy
Penalty
Summary
The facility failed to ensure that Resident 99’s drug regimen was free from unnecessary medications by not monitoring the resident for signs and symptoms of bleeding while enoxaparin sodium was being administered. Resident 99 was admitted with diagnoses including UTI, dysphagia, and obstructive and reflux uropathy, and the H&P stated the resident did not have the capacity for medical decision making. The physician order summary showed enoxaparin sodium 40 mg/0.4 mL subcutaneously every 24 hours for DVT prophylaxis, and the MAR showed doses were given on 3/26/2026 and 3/27/2026. The MAR contained no documentation of monitoring for bleeding or bruising related to enoxaparin use. During interview and record review, the ADON stated there was no physician order for monitoring the side effects of enoxaparin and that licensed staff did not obtain such an order. The ADON also stated staff were required to obtain a physician order to monitor residents on anticoagulants for side effects and acknowledged the potential outcome could be bleeding. The DON stated residents receiving anticoagulants should be monitored for bleeding, and the facility’s Anticoagulation-Clinical Protocol required assessment for adverse drug reactions and monitoring for possible complications, including discussion with the physician if excessive bruising, hematuria, or other evidence of bleeding occurred.
Failure to Rotate Clonidine Patch Site
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when it did not rotate the administration site for a clonidine transdermal patch as ordered. Resident 40 was admitted with diagnoses including intercerebral hemorrhage, dysphagia, and hypertension. The resident’s MDS showed the resident could make himself understood and understand others, required partial assistance with oral and personal hygiene, and was dependent on staff for toileting, showering, lower body dressing, and putting on and taking off footwear. Resident 40 had an order for a weekly clonidine transdermal patch with instructions to alternate or rotate the site. Review of the MAR showed the patch was removed and reapplied to the right arm on 2/14/2026 and 3/14/2026, and removed and reapplied to the left arm on 2/21/2026. During interview and record review, LVN 4 stated the patch should have been rotated on those dates and was not. The ADON also stated clonidine patches must be rotated to avoid harm to the skin. The manufacturer’s instructions reviewed by the facility stated that after one week the old patch should be removed and discarded and a new patch placed on a different site.
Missed Documentation of Medication Refrigerator Temperatures
Penalty
Summary
The facility failed to ensure temperatures were checked and documented for one of two refrigerators in the medication room. During a concurrent observation, interview, and record review in the medication room, Refrigerator 1's temperature log was reviewed with LVN 3, who stated there were no documented temperatures for 3/8/2026 at 7:00 a.m., 3/8/2026 at 11:00 p.m., and 3/15/2026 at 7:00 a.m. LVN 3 stated the medication refrigerator must be checked and documented twice a day, once on day shift and once on night shift, to make sure the medications are the correct temperature and safe to give to residents. The ADON stated correct temperature is very important to the integrity of medication, especially those that require refrigeration, and that licensed nurses must check and record the temperature of each refrigerator twice a day. The facility's Medication Labeling and Storage policy stated medications and biologicals must be stored in locked compartments under proper temperature, humidity, and light controls, and that medications requiring refrigeration are to be stored in a refrigerator located in the medication room.
Incomplete Diagnosis Documentation in Resident Record
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one sampled resident by not including the resident’s anxiety disorder on the current diagnoses list. The resident had been admitted and later readmitted with diagnoses that included encounter for attention to gastrostomy, pressure ulcer of the right buttock stage three, and dysphagia following cerebral infarction, but the admission record did not list anxiety disorder as a diagnosis. The resident’s MDS dated 12/23/2025 showed severely impaired cognitive skills for daily decision making and dependence on staff for showering/bathing, toileting hygiene, and lower body dressing, with substantial to maximum assistance needed for oral hygiene, personal hygiene, and upper body dressing. The MDS did not identify anxiety disorder, although it did indicate the resident was taking anti-anxiety medication. A psychoactive and sedative/hypnotic assessment dated 8/27/2025 documented a physician order for clonazepam 0.5 mg via G-tube twice daily for anxiety manifested by restlessness with episodes of pulling out the G-tube. The resident’s care plan, initiated on 10/09/2025, addressed anxiety related to anxiety disorder and included interventions to administer anti-anxiety medications and monitor side effects and effectiveness. Psychiatric notes completed by NP 1 on 11/04/2025 and 1/12/2026 both documented generalized anxiety disorder, and the physician order summary report dated 3/27/2026 continued to list clonazepam for anxiety manifested by restlessness with episodes of pulling out the G-tube. During interview, the ADON and DON stated the resident’s record should include all current diagnoses, but the current diagnoses list did not include anxiety disorder.
Hospice Services Not Fully Arranged for Resident
Penalty
Summary
The facility failed to ensure hospice services were arranged for one sampled resident by not ensuring the hospice attending physician completed a history and physical and by not ensuring the hospice agency provided staff training required by the contract. Resident 11 was admitted with diagnoses including metabolic encephalopathy, muscle weakness, dysphagia, and failure to thrive. The resident’s MDS showed moderately impaired cognition and dependence on staff for oral care and toileting hygiene, with substantial to maximal assistance needed for eating and personal hygiene. During record review and interviews, the ADON and MRA were unable to locate a hospice H&P for Resident 11. The ADON reviewed hospice sign-in sheets from 12/23/2025 through 3/27/2026 and stated there was no documented evidence that the hospice physician was in the facility to evaluate Resident 11. The DON stated Resident 11 should have a hospice H&P because hospice is another level of care and that the H&P would reflect the resident’s current level and assist staff in formulating a comfort-focused plan of care. Staff interviews also showed the hospice agency had not provided in-service training to facility staff. LVN 5 and RN 2 both stated they had not received education or in-service training from the hospice agency. The DSD stated the hospice agency had not provided in-service training to facility staff, and the ADM reviewed the hospice contract and stated the agency should have provided in-service training per the contract. The contract required hospice to provide orientation, training, competency assessment, and in-service education related to comfort, pain control, symptom management, death and dying, patient rights, forms, and record keeping.
Hand Hygiene and Personal Item Storage Lapses
Penalty
Summary
The facility failed to ensure medications were administered in a safe manner when a LVN did not perform hand hygiene before preparing medications or after administering them to two residents. One resident was admitted with hypertension and chronic kidney disease and required substantial to total assistance with several activities of daily living. The resident’s medication orders included docusate sodium and amlodipine besylate. During observation, the LVN prepared and administered the medications without washing hands before or after the process. A second resident was admitted with muscle weakness and chronic kidney disease and had decision-making capacity at admission. The resident’s medication orders included gabapentin and furosemide. During a concurrent observation and interview, the same LVN again prepared and administered medications without performing hand hygiene before or after the medication pass. The LVN stated she was tense and stressed and forgot to wash her hands, and stated she should have washed her hands before and after administering medications to prevent cross contamination and for infection prevention. The facility also failed to prevent personal items from being placed on a resident’s bedside table. A CNA was observed sitting in a resident’s room with her personal fuzzy purse and personal cell phone placed on the resident’s bedside table while the resident lay asleep in bed. The resident required substantial assistance with oral hygiene, upper body dressing, and personal hygiene, and was dependent on staff for toileting, showering, lower body dressing, and footwear. The CNA stated the purse and phone belonged to her and that she was using her phone because she had finished charting; she also stated she should never bring personal items into resident rooms to prevent the spread of germs and infections.
Bedroom Space Requirement Not Met
Penalty
Summary
The facility failed to provide at least 80 square feet per resident in multiple resident bedrooms for five of 36 resident rooms, specifically Rooms 101, 102, 104, 105, and 107. These rooms had two beds in each room in Rooms 101 and 102, and three beds in each room in Rooms 104, 105, and 107. A review of the Request for Room Size Waiver letter dated 3/29/2026 showed that the Administrator submitted the request because these rooms did not meet the federal square footage requirement per resident. The room size review listed Rooms 101 and 102 at 149.6 square feet each with 74.8 square feet per resident, and Rooms 104, 105, and 107 at 220 square feet each with 73.3 square feet per resident. The facility’s policy stated that bedrooms must provide at least 80 square feet per resident in double rooms and at least 100 square feet in single rooms. During the Resident Council meeting, no concerns were raised about room size, and during observation the residents had ample space to move freely, with sufficient space for beds, side tables, and resident care equipment. Staff interviewed also reported no concerns regarding the size of Rooms 101, 102, 103, 104, and 105.
Failure to Complete and Document Pre-Employment Screening for CNA
Penalty
Summary
The deficiency involves the facility’s failure to implement its Abuse, Neglect, Exploitation, and Misappropriation Prevention Program and Hiring policies by not conducting and documenting required pre-employment screening for a certified nursing assistant (CNA 1). Review of CNA 1’s personnel file, including the Personnel Action Form, showed prior employment at another skilled nursing facility. The Pre-Employment Reference Check List (PERCL) for CNA 1 contained only a name of a former employee as the first reference, with no title documented, and a second reference listing only the prior facility’s company name and the current Director of Staff Development’s (DSD) name, without an interview date, employment verification dates, or other required information. The DSD confirmed CNA 1’s date of hire and that the PERCL lacked complete documentation. During interviews, the DON stated that pre-employment reference checks are part of ensuring safety, confirming qualifications, and determining whether an applicant has any history of resident abuse, and clarified that RNA or CNA staff are not permitted to provide professional employment references or verify employment history. The DON further stated that the reference from the restorative nursing assistant appeared to be a personal reference and that the former DSD had not completed CNA 1’s PERCL prior to hire. In a separate interview, the Administrator acknowledged that the purpose of pre-employment checks is to identify any negative history and that it was difficult to determine whether such checks had been completed for CNA 1. Review of the facility’s Abuse, Neglect, Exploitation, and Misappropriation Prevention Program policy showed a requirement to conduct employee background checks and not knowingly employ individuals with disciplinary actions related to abuse or misappropriation, and the Hiring policy allowed for background investigations for applicants and current employees, which were not properly carried out or documented for CNA 1.
Failure to Monitor Weekly Weights and Intake/Output for Resident with G-Tube and Catheter
Penalty
Summary
The facility failed to obtain weekly weights as ordered for one resident who had significant medical needs, including a gastrostomy tube (G-tube) and an indwelling catheter. The resident was admitted with diagnoses such as traumatic subarachnoid hemorrhage, type 2 diabetes mellitus, and neuromuscular dysfunction of the bladder, and was dependent on staff for most activities of daily living. Physician's orders specified weekly weights for four weeks, but documentation showed that the weight for the third week was not obtained or recorded. Staff interviews confirmed that the weekly weight was missed, and facility policy required monitoring weights to detect undesirable or unintended weight loss or gain. Additionally, the facility did not ensure that staff monitored and documented the resident's intake and output (I/O) in accordance with professional standards and facility policy. Despite the resident having a G-tube and an indwelling catheter, there was no documented evidence of I/O monitoring from admission through the resident's most recent hospitalization. Staff interviews revealed that I/O monitoring was not included in the admission orders, and as a result, staff did not perform or document I/O in the Medication Administration Record. Facility policy required I/O monitoring for at least one month for residents with a G-tube and/or indwelling catheter, but this was not done for the resident in question. Interviews with nursing staff and facility leadership confirmed that the omission of I/O monitoring was due to a failure to include it in the admission orders and a lack of subsequent identification of this omission by clinical staff. The Director of Nursing stated that I/O monitoring should have been initiated upon admission and continued for the first four weeks, especially given the resident's history of pulling out the G-tube. Facility policies reviewed indicated that I/O monitoring is required for residents with urinary catheters and should be documented and evaluated weekly, but these procedures were not followed in this case.
Failure to Complete Timely SCSA MDS for Resident with Significant Decline
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) within the required timeframe for one resident who experienced notable changes in health status. The resident, who had diagnoses including traumatic subarachnoid hemorrhage, G-tube dependence, mood disorder, and neuromuscular bladder dysfunction, was readmitted and subsequently experienced severe cognitive impairment. Despite these complex medical needs, the facility only completed a quarterly MDS assessment rather than the required comprehensive SCSA. Record reviews revealed that the resident underwent significant, unplanned weight loss over a short period, losing 57 pounds (29.4%) in 92 days. Additionally, the resident developed new and worsening pressure ulcers, including an unstageable ulcer on the sacrococcyx and a stage II pressure ulcer on the right foot. These changes represented a major decline in more than one area of the resident's health status, meeting the criteria for a significant change that would require a comprehensive reassessment and potential revision of the care plan by the interdisciplinary team (IDT). Interviews with facility staff, including the MDS Coordinator and the Director of Nursing, confirmed that a SCSA should have been completed in response to the resident's significant weight loss and the development and worsening of pressure ulcers. The facility's own policy also indicated that a SCSA is required when there is a major decline or improvement in a resident's status affecting multiple health areas and requiring IDT review. However, the facility did not complete the SCSA as required, instead performing only a quarterly assessment.
Failure to Complete Ordered Laboratory Tests for Resident
Penalty
Summary
The facility failed to follow a physician's order dated 8/26/2025 to obtain laboratory tests for one resident. The resident, who had a history of traumatic subarachnoid hemorrhage with loss of consciousness, a gastrostomy tube, and neuromuscular dysfunction of the bladder, was severely cognitively impaired and dependent on staff for most activities of daily living. The physician's order required a Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), and magnesium level to be performed. However, review of records and interviews with staff confirmed that these laboratory tests were not completed as ordered. Further investigation revealed that the requisition slip for the lab tests was folded, indicating that the phlebotomist did not collect the required blood samples. Staff interviews confirmed that the missed laboratory tests were not communicated to the physician. The facility's policy required staff to process test requisitions and arrange for tests as ordered by the physician, but this protocol was not followed in this instance.
Improper Handling of Wound Care Supplies
Penalty
Summary
Infection control practices were not implemented when Treatment Nurse 1 completed wound care for one resident with cellulitis of the left lower leg and diabetes mellitus. The resident was admitted with impaired lower body dressing, toilet transfer, and bed mobility, and had an order to cleanse the left lower leg diabetic ulcer with normal saline, pat dry, apply honey fiber, and cover with a sterilized adhesive dressing daily. During observation, the nurse returned a plastic container holding opened packs of 4x4 gauze, paper tape, and four disposable medicine cups to the bedside table while providing wound treatment and did not disinfect the reusable plastic container before returning it to the treatment cart. During interview, the DON and Treatment Nurse 1 stated that the disposable supplies should not have been returned to the treatment cart and that the plastic container should have been disinfected before being returned. The DON stated the nurse should have had enough disposable supplies at bedside before starting the wound treatment to avoid going back and forth from the resident room to the treatment cart, and the nurse stated the leftover disposable supplies should be discarded to prevent cross contamination. The facility policy on infection control stated that its practices are intended to maintain a safe, sanitary, and comfortable environment and help prevent and manage transmission of disease and infections, and the wound care policy stated that only necessary disposable supplies should be taken into the room and disposable supplies cannot be returned to the cart.
Failure to Notify Physician of Resident's Sudden Behavioral Change
Penalty
Summary
The facility failed to notify the attending physician of a sudden and marked change in a patient's behavior, as required by regulation. Patient 4, who had diagnoses of hypertension and congestive heart failure and was cognitively intact, refused a shower and began screaming when staff attempted to change her soiled incontinence briefs. The situation escalated to the point where the patient was yelling, laughing inappropriately, and ultimately kicked a staff member. Multiple staff, including the Administrator and Director of Social Services, were present and attempted to address the situation, but the physician was not notified of this significant behavioral change. Interviews with staff, including the CNA, Administrator, Director of Staff Development, LVN, and Director of Nursing, confirmed that the physician should have been informed of the change in the patient's condition. The facility's own policy also required prompt notification of the physician and resident representative in the event of a change in the resident's medical or mental condition. The failure to report this incident represented a lapse in following both regulatory and facility policy requirements.
Plan Of Correction
A) IMMEDIATE CORRECTIVE ACTION: On 10/7/2025, the RN supervisor assessed Patient 4 for any signs of adverse outcome regarding refusals to showers/bed bath. Upon explanation and discussing the importance of showers, Patient 4 was still not convinced to allow the CNA to continue with the hygienic and care procedure. CNA was relieved from her care and another CNA was assigned immediately with no further issues. Change of Condition was initiated and completed by the Charge Nurse to reflect Patient 4's behavior. MD and responsible party (RP) were made aware of patient 4's refusals. Patient 4's care plan was updated by the MDS nurse to signify her behavior change. Patient 4 will be monitored for 72-hours for any other changes. On 10/7/2025, the Director of Nursing Services (DON) and Director of Staff Development (DSD) completed an in-service to nursing staff on how to handle patient refusals of showers and notification requirements and processes for changes of condition. A policy and procedure titled, "CHANGE of CONDITION," was reviewed and discussed followed by question-and-answer evaluation. B) HOW FACILITY WILL IDENTIFY OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE DEFICIENT PRACTICE: On 10/7/2025, DSD interviewed all CNAs on shift to identify additional patients with episodes of care needs refusals, included them on a "Special Care Needs" list to ensure proper monitoring and appropriate interventions as individualized as possible. C) MEASURES PUT IN PLACE TO ENSURE THAT THE DEFICIENT PRACTICE DOES NOT OCCUR: On 10/28/2025, DON held an in-service with all licensed nurses on P/P: Change of Condition, with an emphasis on MD/RP notification. On 10/29/2025, two additional systematic changes were implemented: 1. "Resident Special Care Needs" worksheet was modified to include patients with episodes of refusals of care needs. The list will be generally updated weekly and as changes occur by the Desk Nurse, to be shared on both nursing units. 2. "Huddle" every shift to review patients with special needs such as giving detailed attention to the patients who would tend to refuse care. Discussed with the team huddle the importance of reporting any incident of refusals to immediately implement interventions as needed. D) HOW THE FACILITY PLANS TO MONITOR ITS PERFORMANCE TO MAKE SURE THAT SOLUTIONS ARE SUSTAINED: Weekly audits on refusals based on Change of Condition reports will be reviewed by the DON/Designee. The DON/Designee will present any findings to the QAPI/QAA Committee monthly for three months for recommendations, if any. E) COMPLETION DATE: 10/31/2025
Failure to Notify Physician of Late Medication Administration
Penalty
Summary
The facility failed to notify the attending physician when medications were not administered on a timely basis as prescribed for two patients. For one patient, who had diagnoses including muscle weakness, GERD, depression, and cerebral infarction, multiple scheduled morning medications were not administered at the prescribed time. The medications, which included pregabalin, duloxetine, famotidine, fenofibrate, and several supplements, were given three and a half hours late without prior notification to the physician. The patient confirmed not receiving the medications on time, and the nurse acknowledged that the physician was not notified of the missed doses or the late administration. The subsequent dose was administered only a few hours after the late dose, again without physician input, and there was no documentation of assessment for adverse reactions due to the close timing of doses. For the second patient, who had paraplegia and was cognitively intact, the morning medications were not administered at the scheduled time due to the patient's refusal, except for pain medication. The nurse waited for the patient to request the medications and eventually administered them several hours late. The physician was only notified about the late administration after the survey team inquired, and not before the medications were given. The nurse stated that the physician should be notified in such situations to avoid potential double dosing, especially for medications scheduled twice daily. The facility's policy required contacting the physician if a dose was believed to be inappropriate or excessive, but this was not followed prior to the late administration. Interviews with nursing staff and the Director of Nursing confirmed that the facility did not have a specific policy for late medication administration, but acknowledged the importance of notifying the physician before giving late doses. The staff recognized that failing to notify the physician and document instructions could lead to inappropriate medication timing and potential adverse effects. The deficiency was identified through interviews, record reviews, and direct observation, showing a lack of timely physician notification and documentation when medications were not administered as ordered.
Plan Of Correction
C 0875 - NURSING SERVICE - GENERAL Medication Administration IMMEDIATE CORRECTIVE ACTION: 1. The RN supervisor assessed Patient 10 on any signs of adverse outcome regarding medications that were not administered on time per MD orders. Vital signs were taken and recorded as follows: BP =124/74, P = 76, R = 19, O2 Sat = 96% and Pain level = 2/10. Patient 10 was deemed stable with no issues and remained verbally responsive, alert and oriented x 4 with no apparent complaint at this time. 2. The RN supervisor assessed Patient 5 for any abnormality of vital signs: BP = 131/74, P = 80, R = 18, O2 Sat = 96% & Pain level = 0/10. Patient 5 was stable with no signs of distress and remained alert/oriented x 4, able to verbalize needs with no problem. 3. A one-on-one in-service was initiated and completed with LVN 2 and LVN 4 respectively to discuss the P/P on timely medication administration. The emphasis was to be very careful in following the guidelines for patients' health and well-being under their care. Discussed also the potential of unwanted effects from medications being administered too close of the time of the next ordered dose to be given. Reiterated in the discussion on the importance for the patients' MD be notified of circumstances that may lead to the delayed medication administration. Any MD orders will be written and carried out; a 72-hour monitoring would be done to ensure patient safety, followed by accurate timely documentation. An in-service was done by the DON on 10/28/2025 on all nursing staff on how to handle patients with medications that are delayed in administration. A policy and procedure titled, "Medication Administration" was reviewed and discussed. B) HOW FACILITY WILL IDENTIFY OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE DEFICIENT PRACTICE: All alert/oriented patients are with the potential to have set ways of taking their medications, these identified patients must be properly assessed by the RN supervisor as to the need of time adjustments on their medications to be administered. Patients with special requests or needs must be communicated to their respective MDs for proper orders to ensure ultimate safety, health and well-being of identified patients. The Medical Records Department will continue to do daily audits on both eMARs and eTARs to ensure proper charting and documentation as required. Any deviations must be reported to the DON/Designee for immediate resolutions/corrections. C) MEASURES PUT IN PLACE TO ENSURE THAT THE DEFICIENT PRACTICE DOES NOT OCCUR: The facility had implemented a Weekly Medication Pass Audit by the DON, ADON and DSD to monitor improved performance of Charge Nurses on proper and accurate medication administration. Any noted deviations must be corrected immediately, and continued mentoring with performance improvement must be done with the specific charge nurses. D) HOW THE FACILITY PLANS TO MONITOR ITS PERFORMANCE TO MAKE SURE THAT SOLUTIONS ARE SUSTAINED: The DON/Designee will report and discuss with the QAPI/QAA committee the outcomes of Weekly Medication Administration audits including issues observed during medication pass and immediate actions done to prevent deficient practice from occurring. This will be reviewed for 3 months. E) COMPLETION DATE: 10/31/2025
Failure to Administer Medications as Prescribed
Penalty
Summary
A deficiency occurred when a nurse failed to administer medications to a patient as prescribed by the physician. The patient, who had diagnoses including dysphagia, asthma, chronic respiratory failure with hypoxia, COPD, and lack of coordination, required specific administration instructions for several medications. During a medication pass, the nurse prepared and provided the medications to the patient but did not ensure that the medications were taken according to the physician's orders. Specifically, the patient did not take Metoprolol with food, did not take Potassium Chloride with the prescribed four to six ounces of water, and did not rinse her mouth after using the Pulmicort inhaler. The nurse also did not provide instructions or directions for the use of these medications and left the room before confirming that the patient had followed the required steps. The patient's care plan included interventions for swallowing problems, asthma/COPD, and nutritional risk, all of which required staff to monitor and assist with medication administration and hydration. Despite these documented needs, the nurse allowed the patient to self-administer medications without a physician's order for self-administration and without providing the necessary assistance or supervision. The nurse also failed to notify the physician when medications were not administered as prescribed, such as when Metoprolol was given more than two hours after the scheduled time and without food. Facility policy required medications to be administered as prescribed, within the appropriate time frame, and with adherence to any special instructions, such as taking medications with food or fluids and rinsing the mouth after inhaler use. The policy also specified that self-administration of medications must be authorized by the physician and documented in the care plan. In this case, the nurse did not follow these policies, resulting in the patient not receiving medications in accordance with physician orders.
Plan Of Correction
C 0900 - Nursing Service - Administration of Medication A) IMMEDIATE CORRECTIVE ACTION: 1. On 10/7/2025 the RN supervisor immediately assessed patient 9 for any signs of adverse outcome regarding medications that were not administered per MD orders. Vital signs were taken and recorded as follows: BP=139/76, P=68, R=16, O2 Sat=96% and Pain level=0/10. Patient 9 was deemed stable with no issues and remained verbally responsive, alert and oriented x 4 with no apparent complaint at this time. MD and responsible party were notified. RN supervisor provided patient 9 with education on proper method of taking her medication. Patient verbalized understanding. 2. On 10/7/2025 DON initiated and completed a one-on-one in-service with LVN 4 respectively to discuss the policy and procedure (P/P) on medication administration. The emphasis was on accurately following MD orders for specific medications as per MD order and/or pharmaceutical recommendation (i.e. with food with sufficient fluids, rinsing mouth between medications, etc.) DON also discussed the potential of unwanted effects from medications being administered incorrection. DON reiterated the importance of "pour, pass, and sign" medication administration procedure. B) HOW FACILITY WILL IDENTIFY OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE DEFICIENT PRACTICE: On 10/7/2025 upon identification of deficient practice, DON, ADON, and RN Supervisor immediately completed a facility round to observe all other charge nurses during medication pass to ensure residents' medications are being administered as ordered. No additional residents were affected by the deficient practice. C) MEASURES PUT IN PLACE TO ENSURE THAT THE DEFICIENT PRACTICE DOES NOT OCCUR: On 10/28/2025 DON completed an in-service for all nursing staff on "Medication Administration" P/P, how to handle patients with medication refusals, importance of "pour, pass, sign," and MD/RP notification prior to administration of any additional doses. The discussion was followed by question-and-answer evaluation. On 10/30/2025 facility implemented a medication pass audit that will be completed weekly at random selection by the DON, ADON and/or designee to monitor Charge Nurses' medication administration performance on proper and accurate medication administration. Any noted deviations will be corrected immediately and continued mentoring and performance improvement plans will be implemented as needed. D) HOW THE FACILITY PLANS TO MONITOR ITS PERFORMANCE TO MAKE SURE THAT SOLUTIONS ARE SUSTAINED: The DON/Designee will report weekly audit findings to the QAPI/QAA committee monthly for three months for recommendations, if any. E) COMPLETION DATE: 10/31/2025 C0900
Failure to Administer Medications on Time and Notify Physician
Penalty
Summary
A deficiency occurred when a resident did not receive their scheduled 9 a.m. medications within the required timeframe. The medications, which included Pregabalin, Duloxetine, Famotidine, Fenofibrate, and several others, were not administered within one hour of the prescribed time as required by regulation and facility policy. The delay was confirmed during a medication area inspection and through interviews with nursing staff, who acknowledged that the medications were not given as ordered and that there was no documentation of administration on the Medication Administration Record (MAR) within the required window. Further review revealed that the resident had not received any of their scheduled morning medications by the time of the inspection, and the medications were ultimately administered at 12:29 p.m., more than three hours after the scheduled time. The resident confirmed in an interview that she had not received her morning medications and stated that she does not refuse medication when woken up. Nursing staff also confirmed that the physician was not notified of the missed doses, and no reason for the omission was documented in the resident's records. Additionally, the administration of the next scheduled doses occurred at 4:10 p.m., resulting in two sets of medications being given in close succession. There was no documentation that the resident was monitored or assessed for adverse reactions following the late administration of multiple medications, including anti-constipation and seizure medications. The facility's policy requires medications to be administered within one hour of the prescribed time, and the failure to do so, along with the lack of physician notification and monitoring, constituted the deficiency.
Plan Of Correction
C 0945 - Nursing Service - Administration of Medication A) IMMEDIATE CORRECTIVE ACTION: 1. On 10/7/2025, the RN supervisor immediately assessed Patient 10 for any signs of adverse outcome regarding medications that were not administered on time per MD orders. Vital signs were taken and recorded as follows: BP=124/74, P=76, R=19, O2 Sat=96%, and Pain level=2/10. Patient 10 was deemed stable with no issues and remained verbally responsive, alert, and oriented x 4 with no apparent complaint at this time. MD and responsible party were notified. 2. On 10/7/2025, DON completed a one-on-one in-service with LVN 2 to discuss the P/P on timely medication administration. The emphasis was to be very careful in following the guidelines for patients' health and well-being under their care. DON also discussed the importance of "pour, pass, sign." DON reiterated that MD be notified of circumstances that lead to the delayed medication administration. Any MD orders will be written and carried out; a 72-hour monitoring would be done to ensure patient safety, followed by accurate timely documentation. C) HOW FACILITY WILL IDENTIFY OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE DEFICIENT PRACTICE: On 10/7/2025, upon identification of deficient practice, DON, ADON, and RN Supervisor immediately interviewed all other charge nurses regarding any other medication administration delays that took place that day. No additional delays were identified, and no other residents were identified as being affected. MEASURES PUT IN PLACE TO ENSURE THAT THE DEFICIENT PRACTICE DOES NOT OCCUR: An in-service was completed by the DON on 10/28/2025 for all nursing staff on "Medication Administration" policy and procedures. The facility had implemented a Medication Pass audit that will be completed weekly at random by the DON, ADON, and/or designee to monitor improved performance of Charge Nurses on proper and accurate medication administration. Any noted deviations will be corrected immediately, and performance improvement plans will be implemented as needed. D) HOW THE FACILITY PLANS TO MONITOR ITS PERFORMANCE TO MAKE SURE THAT SOLUTIONS ARE SUSTAINED: The DON/Designee will report weekly audit findings to the QAPI/QAA committee monthly for three months for recommendations, if any. E) COMPLETION DATE: 10/31/2025 C 0965 - Nursing Service - Administration of Medication A) IMMEDIATE CORRECTIVE ACTION: 4. On 10/07/2025, RN Supervisor immediately assessed patient 2 for any change of condition or abnormality of wounds - no redness, no discharge observed from affected sights (right thigh scab, right pleur x site, and spine suture site). MD was notified. LVN 4, who
Failure to Document and Administer Medications and Treatments as Ordered
Penalty
Summary
The facility failed to ensure proper documentation and administration of medications and treatments for two patients, resulting in deficiencies related to medication and treatment records. For one patient with chronic respiratory failure, asthma, and pleural effusion, the treatment nurse did not sign the electronic Treatment Administration Record (eTAR) for three ordered treatments on a specific date. The treatments included care for a right thigh scab, a right Pleur X catheter, and a post-surgical spine site. The eTAR was left blank for these treatments, while other dates were properly signed, indicating a lapse in documentation and uncertainty about whether the treatments were administered as ordered. In another instance, a cognitively intact patient with paraplegia and multiple medication orders did not receive their scheduled morning medications at the prescribed time due to refusal. The nurse documented the medications as given before actually administering them, which did not occur until later in the afternoon. This premature documentation could have led to confusion for the oncoming shift and the risk of medications being administered too close together. The nurse acknowledged documenting before administration and recognized the potential for confusion and medication errors. Both deficiencies were confirmed through interviews with nursing staff and review of facility policies, which require that medications and treatments be documented immediately after administration. The facility's policies also emphasize the importance of accurate and timely documentation to ensure continuity of care and adherence to physician orders. The failure to follow these procedures resulted in incomplete records and the potential for missed or improperly timed treatments and medications.
Plan Of Correction
Completed patient 2's treatment on 10/04/2025, immediately completed late entry documentation. On 10/07/2025, the RN supervisor immediately assessed Patient 5 for any change of condition or abnormality of vital signs: BP = 131/74, P = 80, R = 18, O2 Sat = 96%, and Pain level = 0/10. Patient 5 was stable with no signs of distress and remained alert/oriented x 4, able to verbalize needs with no problem. MD was notified. On 10/7/2025, the DON initiated and completed a one-on-one in-service with LVN 4 to discuss the policy and procedure (P/P) on charting and documentation and timely medication administration. The emphasis was on signing eTAR immediately upon completion of treatment. DON also discussed the potential of unwanted effects from medications being administered too close to the time of the next ordered dose to be given. DON reiterated the importance of notifying the patient's MD of circumstances that lead to the delayed medication administration. Any MD orders will be written and carried out; a 72-hour monitoring period would be done to ensure patient safety, followed by accurate timely documentation. **B) HOW FACILITY WILL IDENTIFY OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE DEFICIENT PRACTICE:** 1. On 10/7/2025, upon identification of deficient practice, DON, ADON, and Treatment Nurse immediately reviewed all eTARS for the last 30 days to ensure that no additional gaps in documentation were identified. No additional residents were affected by the deficient practice. 2. On 10/7/2025, DON, ADON, and RN Supervisor immediately interviewed all the licensed nurses on shift to identify any other delayed medication administration. No further residents were identified to be affected by the deficient practice. 3. The Medical Records Department will continue to do daily treatment audits to ensure that any potential deficient practice does not occur by notifying the DON/Designee immediately. Further, the DON has in-services scheduled for licensed nurses for continuous education and training. **C) MEASURES PUT IN PLACE TO ENSURE THAT THE DEFICIENT PRACTICE DOES NOT OCCUR:** 1. On 10/28/2025, DON completed an in-service for all nursing staff on "Charting and Documentation" policies and procedures. The discussion was followed by a question-and-answer evaluation. On 10/30/2025, the facility implemented a weekly eTAR audit to be completed by the Medical Records Department to ensure accuracy and completion of treatment documentation. Audit findings will be provided to DON and/or Designee. 2. On 10/30/2025, the facility implemented a medication pass audit that will be completed weekly at random by the DON, ADON, and/or designee to monitor Charge Nurses' medication administration performance on proper and accurate medication administration. Any noted deviations will be corrected immediately, and continued mentoring and performance improvement plans will be implemented as needed. **D) HOW THE FACILITY PLANS TO MONITOR ITS PERFORMANCE TO MAKE SURE THAT SOLUTIONS ARE SUSTAINED:** The DON/Designee will report weekly findings for eTAR audits and medication pass audits to the QAPI/QAA committee monthly for three months for recommendations. **E) COMPLETION DATE:** 10/31/2025
Improper Use of Physical Restraints Without Physician Order
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment and a history of dementia and failure to thrive was found with pillows placed on both sides of their body, restricting their movement. The resident was dependent on staff for activities of daily living and lacked the capacity to make decisions. During an observation, a CNA admitted to placing the pillows during breakfast and forgetting to remove them, acknowledging awareness that such use of pillows could constitute a restraint. Further interviews revealed that the LVN had previously instructed the CNA not to use pillows in this manner to restrict the resident's movement, and confirmed that there were no physician orders for restraints for this resident. The DON also stated that pillows placed in a way that restricts movement and cannot be removed by the resident are considered restraints. Review of facility policy confirmed that restraints should only be used with a physician's order and not for staff convenience or fall prevention, and that any material restricting movement and not easily removed by the resident is considered a physical restraint.
Plan Of Correction
C 1130-Nursing Service - Restraints and Postural Support A) IMMEDIATE CORRECTIVE ACTION: 7. On 10/06/2025, CNA #2 immediately removed patient 4's bilateral pillows. RN Supervisor immediately assessed patient 4 for any change of condition (COC) or adverse effects that may have been caused by the bilateral pillows. No COC noted. MD and RP were notified. 8. On 10/06/2025, DSD completed a one-on-one in-service with CNA 2 on facility's restraint-free environment policies and procedures. B) HOW FACILITY WILL IDENTIFY OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE DEFICIENT PRACTICE: 4. On 10/6/2025, upon identification of deficient practice, DON, ADON, and DSD immediately rounded the facility to ensure that no additional residents have pillows by their sides that may be used as restraints. No further residents were identified to be affected by the deficient practice. 5. The Medical Records Department continues to do daily audits on Change of Condition that reflects any incident requiring the use of restraints. At this time, no resident was identified and observed to have any form of restraint at all. C) MEASURES PUT IN PLACE TO ENSURE THAT THE DEFICIENT PRACTICE DOES NOT OCCUR: 3. On 10/28/2025, DON completed an in-service for all nursing staff on a P/P: "Restraint Usage." The discussion was followed by question-and-answer evaluation with all participants. On 10/30/2025, Social Services Director and DSD completed additional in-services on a "Restraint Free Environment." The discussion was followed by question-and-answer evaluation. 4. On 10/29/2025, Administrator updated the form "Resident Centered Care Room Rounds Report" to include "Does resident have any objects that may be a restraint?" question on daily rounds to be completed daily by assigned ambassadors and/or Manager on Duty (MOD). Any noted deviations will be corrected immediately, and surveillance tools will be submitted to the DON and/or Designee for monitoring. D) HOW THE FACILITY PLANS TO MONITOR ITS PERFORMANCE TO MAKE SURE THAT SOLUTIONS ARE SUSTAINED: Time, no resident was identified and observed to have any form of restraint at all.
Infection Control Lapses in Signage, Precautions, and Hand Hygiene
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's infection control practices. In one instance, a patient with a confirmed diagnosis of COVID-19 was not properly identified with a droplet transmission-based precaution sign outside her room. Although the patient's care plan required standard, contact, and droplet isolation with eye protection and a closed door, only an enhanced barrier precaution sign was posted. The Assistant Director of Nursing and the Infection Preventionist both acknowledged that the correct signage was not in place, which could have led to unintentional exposure of staff, visitors, and other patients to COVID-19. Another deficiency was observed with a patient who had a surgical site infection and was receiving intravenous antibiotics. Despite facility policy requiring enhanced barrier precautions for residents with indwelling medical devices or wounds, there was no EBP sign or PPE supply cart outside the patient's room. Both the Director of Staff Development and the Director of Nursing confirmed that the appropriate signage and precautions were not implemented, contrary to facility policy and infection control standards. Additional lapses in infection control were noted during medication administration. Two nurses failed to perform hand hygiene before administering medications to two patients, and one nurse did not wear gloves while administering eye drops. The soap dispenser in one patient's room was also found to be empty. These actions were inconsistent with the facility's policies on hand hygiene, medication administration, and the instillation of eye drops, as confirmed by the Director of Nursing and review of facility procedures.
Plan Of Correction
The DON/Designee will report daily findings of Room Rounds to the QAPI/QAA committee monthly for three months for recommendations, if any. E) COMPLETION DATE: 10/31/2025 C 1270- Nursing Service - Patients with Infectious Disease A) IMMEDIATE CORRECTIVE ACTION: 1. On 10/06/2025, facility Infection Preventionist (IP) immediately replaced the door signage with the appropriate Droplet Precautions signage on patient 1's door to reflect the appropriate isolation precautions. All assigned staff who worked in patient 1's room were tested with a Rapid Antigen Test - all results were negative, and staff were notified to test again on days 3 and 5 and monitor themselves for any signs or symptoms of possible Covid-19. To date, no additional staff have tested positive for Covid-19, and the facility outbreak has been closed. 2. On 10/6/2025, upon identification of deficient practice, CNA 6 immediately donned the correct PPE, and IP immediately placed an EBP sign on the door of patient 6. CNA was immediately provided with a one-on-one in-service by the DSD on Enhanced Barrier Precautions. RN Supervisor immediately assessed patient 6 for any change of condition (COC) or adverse reactions that may have been caused by the deficient practice. No COC noted. MD and RP were notified. 3. On 10/7/2025, LVN 5 immediately completed the required hand hygiene protocols upon the identification of deficient practice. RN Supervisor immediately assessed patient 11 for any change of condition (COC) or adverse reactions that may have been caused by the deficient practice. No COC noted. MD and RP were notified. DON immediately completed a one-on-one in-service with LVN 5 on the importance of hand hygiene and hand hygiene protocols during medication administration. 4. On 10/7/2025, LVN 4 immediately completed the required hand hygiene protocols upon the identification of deficient practice. RN Supervisor immediately assessed patient 9 for any change of condition (COC) or adverse reactions that may have been caused by the deficient practice. No COC noted. MD and RP were notified. DON immediately completed a one-on-one in-service with LVN 4 on the importance of hand hygiene and hand hygiene protocols during medication administration. B) HOW FACILITY WILL IDENTIFY OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE DEFICIENT PRACTICE: 1. On 10/6/2025, upon identification of deficient practice, DON, ADON, and DSD immediately rounded the facility to ensure that all other isolation signage has been posted appropriately and corresponded with the ordered isolation precautions. No additional deficient practices were identified. 2. On 10/6/2025, upon identification of deficient practice, DON, ADON, and DSD immediately rounded the facility to ensure that all other staff providing care to residents on EBP were donning appropriate PPE when providing care. No additional deficient practices were identified. 3. & 4. On 10/7/2025, upon identification of deficient practice, DON, ADON, and IP immediately rounded the facility to ensure that all other charge nurses are completing hand hygiene timely and appropriately during medication administration. No additional deficient practices were identified. C) MEASURES PUT IN PLACE TO ENSURE THAT THE DEFICIENT PRACTICE DOES NOT OCCUR: 1. On 10/14/2025, clinical resource consultant completed a one-on-one in-service for the IP on Standard, Enhanced, and Transmission-based Precautions, hand hygiene, PPE use, L.A. County DPH - IPCP Guidelines for SNFs, EBP program, and assessment of all residents for EBP eligibility. 2.-4. On 10/20/2025, DSD completed an in-service for all nursing staff on infection control and types of isolations, EBP, donning and doffing PPE, and hand hygiene. On 10/28/2025, DON completed an in-service for all nursing staff on infection control and types of isolations and signage, EBP, and hand hygiene during medication administration. The discussion was followed by a question-and-answer evaluation. 3. Effective 10/30/2025, IP and/or designee will monitor EBP and other isolation signage during daily facility rounds and document performance on surveillance checklist. 4. Effective 10/30/2025, facility implemented a medication pass audit that will be completed weekly at random by the DON, ADON, and/or designee to monitor charge nurses' medication administration performance on proper and accurate medication administration and hand hygiene. Any noted deviations will be corrected immediately, and continued mentoring and performance improvement plans will be implemented as needed. D) HOW THE FACILITY PLANS TO MONITOR ITS PERFORMANCE TO MAKE SURE THAT SOLUTIONS ARE SUSTAINED: The IP/Designee will report Infection Control Surveillance results to the QAPI/QAA committee monthly for three months for recommendations, if any. DON/Designee will report weekly medication pass audits to the QAPI/QAA committee monthly for three months for recommendations, if any. E) COMPLETION DATE: 10/31/2025
Unlabeled Nonlegend Medication Found at Bedside Without Physician Order
Penalty
Summary
A deficiency was identified when a bottle of Pepto-Bismol, a nonlegend medication, was found at the bedside of a patient without a physician's order. The medication was observed on the patient's nightstand, unopened and without a label. The patient stated that her daughter had brought the medication for her to use if needed, and that it had been on her nightstand for some time. Review of the patient's records showed no order for Pepto-Bismol, and the medication was not listed on the Medication Administration Record. The patient had multiple diagnoses, including end stage renal disease, type 2 diabetes mellitus, and congestive heart failure, and required moderate assistance with activities of daily living. During interviews, facility staff, including a Licensed Vocational Nurse and the Assistant Director of Nursing, confirmed that medications should not be left at the bedside without a physician's order and an assessment for self-administration. The facility's policy requires that any medication brought in by family must be given to licensed staff for labeling, verification of an order, and assessment before being left at the bedside. The presence of the medication at the bedside without following these procedures constituted a failure to prevent unauthorized access to medication and to ensure proper medication management as required by facility policy and regulation.
Plan Of Correction
C2000 - Pharmaceutical Services - Labeling & Storage A) IMMEDIATE CORRECTIVE ACTION: On 10/06/2025, the Charge Nurse immediately removed the Pepto-Bismol from the resident's bedside. RN supervisor immediately assessed Patient 7, who is alert and oriented x 4, for any changes of condition and/or adverse effects of having non-prescribed medications at bedside. None were noted. When the RN asked the patient about the medication, she indicated that her daughter brought it for her to use when she needs it. MD and RP were notified. The Charge Nurse obtained an order from the MD for the medication to be given as needed, medication secured in the medication cart, and the RN supervisor explained to the patient about no medications being allowed at bedside until a proper assessment is accomplished. The resident agreed to have the medication stored in the medication cart and to ask the Charge Nurse for it if she ever needed it. The DON completed a one-on-one in-service with LVN 2 regarding policies and procedures for self-administration of medications. B) HOW FACILITY WILL IDENTIFY OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE DEFICIENT PRACTICE: On 10/6/2025, DON, ADON, and DSD immediately rounded the facility to identify any additional medications at residents' bedsides. No additional medications were noted at bedsides. Ongoing daily rounds by the RN supervisor, ADON, DON, and Ambassadors will continue to focus on the presence of medications at bedside. Any presence of medications will be dealt with accordingly. C) MEASURES PUT IN PLACE TO ENSURE THAT THE DEFICIENT PRACTICE DOES NOT OCCUR: Effective 10/29/2025, the Administrator updated the Resident Centered Care Room Rounds Report to ensure room ambassadors are checking resident bedsides for any OTC and/or prescription medications. D) HOW THE FACILITY PLANS TO MONITOR ITS PERFORMANCE TO MAKE SURE THAT SOLUTIONS ARE SUSTAINED: Room ambassadors will provide Room Rounds Reports to DON/Designee upon completion, and audit results will be presented and discussed with the QAPI/QAA committee for the next three months to ensure compliance.
Expired Blood Glucose Control Solutions Used for Quality Control
Penalty
Summary
A package containing two bottles of expired blood glucose (BG) control solutions was found stored inside one of the facility's medication carts. The bottles were labeled with a handwritten open date, and according to the manufacturer's instructions, the solutions expired 90 days after opening. Despite this, the expired solutions remained in the cart and were documented as being used for quality control checks after their expiration date. The Licensed Vocational Nurse (LVN) confirmed that the solutions should have been replaced once expired. The Director of Nursing (DON) acknowledged that expired blood sugar control solutions could result in inaccurate blood sugar readings. Facility policy required that discontinued, outdated, or deteriorated medications be returned or destroyed per pharmacy instructions, but this procedure was not followed in this instance. The expired solutions were available for use and had been used for quality control checks beyond their expiration date.
Plan Of Correction
C2030 COMPLETION DATE: 10/31/2025 C2030-Pharmaceutical Services - Labeling & Storage A) IMMEDIATE CORRECTIVE ACTION: On 10/07/2025, the Charge Nurse immediately removed the expired Control Solution from Medication Cart 1. The DON immediately completed a one-on-one in-service with LVN 2 regarding p/p regarding viability of expired medications and biologicals, with an emphasis on the importance of possible effects on patient's safety and well-being. B) HOW FACILITY WILL IDENTIFY OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE DEFICIENT PRACTICE: On 10/7/2025, upon identification of the expired Assure Dose Control Solution, DON, ADON, and RN Supervisor checked all medication carts and medication rooms for any additional expired medications and/or biologicals. No other expired products were identified. Ongoing random monitoring of medication cart reviews are done weekly by the RN supervisor, ADON, and DON while medication pass is in progress to ensure that no biologicals are present in medication cart. C) MEASURES PUT IN PLACE TO ENSURE THAT THE DEFICIENT PRACTICE DOES NOT OCCUR: Effective 10/30/2025, weekly random medication cart audits will be initiated and completed by the ADON and RN supervisor. Any observed issue will be corrected immediately, and findings will be reported to DON/Designee. D) HOW THE FACILITY PLANS TO MONITOR ITS PERFORMANCE TO MAKE SURE THAT SOLUTIONS ARE SUSTAINED: The DON/Designee will report to the QAPI/QAA committee and discuss findings of random weekly medication cart audits. These audits will be reviewed for the next three months to ensure compliance. E) COMPLETION DATE: 10/31/2025
Missing Performance Evaluations in CNA Personnel Files
Penalty
Summary
The facility failed to maintain current, complete, and accurate personnel records by not including required performance evaluations for four of eight Certified Nursing Assistants (CNAs). During a review of employee records and interviews with the Director of Staff Development (DSD) and the Director of Nursing (DON), it was confirmed that there was no documentation of current performance evaluations for these CNAs. The DSD, responsible for completing CNA evaluations, stated that the evaluations were not done and could not provide a reason, noting that the evaluations were due before her employment at the facility. The DON confirmed that performance evaluations are typically conducted after the probationary period and annually, and that these evaluations are essential for identifying staff training and education needs. A review of the facility's policies and procedures indicated that performance evaluations are required at the end of the 90-day probationary period, annually, and after promotions or transfers. The policies also specify that personnel files must include performance appraisals or evaluations. The absence of these evaluations in the personnel files for the identified CNAs was verified through record review and staff interviews, demonstrating noncompliance with both regulatory requirements and the facility's own policies.
Plan Of Correction
C4860-Employee Personnel Records A) IMMEDIATE CORRECTIVE ACTION: On 10/08/2025, DSD immediately completed performance evaluations for CNA 1, CNA 2, CNA 3, and CNA 4. B) HOW FACILITY WILL IDENTIFY OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE DEFICIENT PRACTICE: On 10/8/2025, DSD and Assistant DSD reviewed all current CNA files to ensure the presence of an evaluation within the last 12 months. C) MEASURES PUT IN PLACE TO ENSURE THAT THE DEFICIENT PRACTICE DOES NOT OCCUR: Effective 10/30/2025, DSD will review all CNA anniversary dates monthly to ensure annual evaluations are completed timely and as per facility protocol. D) HOW THE FACILITY PLANS TO MONITOR ITS PERFORMANCE TO MAKE SURE THAT SOLUTIONS ARE SUSTAINED: The DSD/Designee will present monthly evaluation completion reports to the QAPI/QAA committee monthly. These audits will be reviewed for the next three months to ensure compliance. E) COMPLETION DATE: 10/31/2025 C4905-Employee Personnel Records
Missing Staff Health Exam Documentation
Penalty
Summary
The facility failed to ensure that the personnel files for several certified nursing assistants (CNAs) and licensed vocational nurses (LVNs) contained documentation of required health examinations either 90 days prior to or within seven days after hire, as well as annual health exams thereafter. Specifically, the records for five CNAs and two LVNs did not include evidence of a health exam completed within the required timeframe upon hire. Additionally, the files for two LVNs lacked documentation of annual health exams after their initial employment. During interviews, both the Director of Staff Development (DSD) and the Director of Nursing (DON) acknowledged the absence of medical clearance for these staff members. The DSD confirmed that it is now her practice to ensure compliance with health exam requirements for new hires and annual reviews. The facility's policies and procedures require maintenance of personnel records in accordance with state and federal regulations, including documentation of the ability to perform essential job functions, but these were not followed in the cited cases.
Plan Of Correction
A) IMMEDIATE CORRECTIVE ACTION: On 10/09/2025, DSD immediately contacted CNA 1, CNA 2, CNA 3, CNA 4, CNA 5, LVN 1, and LVN 2 to notify them that they may not return to work until a physical exam is completed. She referred them to a clinic that completed their physicals and provided the facility with their clearance and ability to work. Staff were returned to work upon providing their physical exams to the DSD and/or Administrator. B) HOW FACILITY WILL IDENTIFY OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE DEFICIENT PRACTICE: On 10/8/2025, DSD and Assistant DSD reviewed all other CNA and LVN files to ensure the presence of a health exam within the last 12 months. C) MEASURES PUT IN PLACE TO ENSURE THAT THE DEFICIENT PRACTICE DOES NOT OCCUR: Effective 10/30/2025, DSD will review all CNA and LVN anniversary dates monthly to ensure annual health exams are completed timely and as per facility protocol. D) HOW THE FACILITY PLANS TO MONITOR ITS PERFORMANCE TO MAKE SURE THAT SOLUTIONS ARE SUSTAINED: The DSD/Designee will present monthly health exam completion reports to the QAPI/QAA committee monthly. These audits will be reviewed for the next three months to ensure compliance. E) COMPLETION DATE: 10/31/2025
Failure to Provide Required Behavioral Health Training to CNAs
Penalty
Summary
The facility failed to provide required in-service training on behavioral health for Certified Nursing Assistants (CNAs), as indicated by the facility's own in-service calendar and policies. A review of the facility assessment showed that residents commonly have psychiatric and mood disorders, including psychosis, impaired cognition, depression, bipolar disorder, schizophrenia, PTSD, anxiety disorder, and other mental health conditions. The facility's annual in-service calendar scheduled behavioral health training for March, covering care of residents with dementia, mental and psychosocial disorders, substance abuse, PTSD, trauma, and trigger management for all staff. Interviews with two CNAs revealed that neither had received formal in-service or training on behavior management, and one CNA expressed a desire for such education to better handle residents' behaviors. The Director of Staff Development (DSD), who started employment in March, confirmed that the scheduled behavioral health training was not provided and was unsure if the previous DSD had conducted it. Review of personnel files for the two CNAs showed no documented evidence of behavioral health training. Facility policies require annual in-service training for nurse aides and all staff on behavioral health, with training to be completed prior to providing services, annually, and as necessary based on the facility assessment. The policies also specify that training curricula should include learning objectives, performance standards, and evaluation criteria, and that competency may be demonstrated through written exams or consistent application of interventions. Despite these requirements, the facility did not provide or document the required behavioral health training for the sampled CNAs.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, leading to potential inadequate care and risk of injury. For Resident 27, who was admitted with conditions including dysphasia, dementia, seizures, severe protein-calorie malnutrition, and repeated falls, the facility did not create a care plan addressing the resident's Restorative Nursing Assistant (RNA) exercise program. Despite the resident's severe cognitive impairment and need for substantial assistance in daily activities, the care plan lacked specific interventions and goals for the RNA program, which was crucial for maintaining the resident's function and joint mobility. Similarly, the facility did not develop a comprehensive care plan for Resident 12, who was admitted with dementia, lack of coordination, a subtrochanteric fracture of the right femur, and a history of falls. The resident required maximal assistance for daily activities and had a floor mat placed next to the bed to prevent injury from falls. However, there was no documented evidence of a care plan addressing the use of the floor mat, which was necessary for consistent staff intervention and monitoring of its effectiveness in preventing falls. Interviews with facility staff, including the MDS Coordinator and the Director of Nursing, confirmed the absence of person-centered care plans for both residents. The facility's policies and procedures emphasized the importance of developing comprehensive care plans based on thorough assessments, yet these were not followed, resulting in a lack of structured care and monitoring for the residents' specific needs.
Failure to Update Care Plans for Medication Changes and ADL Needs
Penalty
Summary
The facility failed to update and revise the care plan for a resident undergoing anticoagulation therapy after changes were made to the prescribed medications. Resident 29, who was readmitted to the facility with diagnoses including end-stage renal disease and paroxysmal atrial fibrillation, had their anticoagulant medications changed from Plavix and Aspirin to Eliquis. Despite this change, the care plan was not updated to reflect the new medication regimen, which was confirmed during interviews with the MDS Coordinator and the Director of Nursing. The facility's policy requires care plans to be updated with current medications, but this was not adhered to, resulting in an inaccurate medical record. Another deficiency was identified in the care plan for a resident with severe cognitive impairment and total dependence on staff for activities of daily living (ADLs). Resident 70's care plan lacked specific interventions for grooming, oral hygiene, toileting, showering, and personal hygiene needs. During a review, the MDS Coordinator acknowledged that the care plan should have included specific interventions to ensure the resident's ADL care was tailored to their needs. The absence of detailed interventions in the care plan could lead to inadequate care provision. Additionally, the facility did not update the care plan for a resident who had been prescribed anti-anxiety medication. Resident 12, who had a history of dementia and a recent femur fracture, was prescribed Xanax for anxiety, which was later discontinued. However, the care plan continued to reflect the use of Xanax, leading to potential confusion among staff. The Assistant Director of Nursing confirmed that the care plan was not updated to reflect the discontinuation of the medication, which is contrary to the facility's policy requiring accurate and complete documentation in the medical record.
Inadequate Pain Management Due to Documentation Failures
Penalty
Summary
The facility failed to provide appropriate pain management for two residents, Resident 22 and Resident 10, by not assessing their pain before and after administering controlled medications. For Resident 22, tramadol was administered on February 9, 2025, without prior pain assessment or documentation in the Medication Administration Record (MAR). The Licensed Vocational Nurse (LVN) responsible for administering the medication did not sign the MAR, which is crucial for tracking medication administration and ensuring proper pain management. The Assistant Director of Nurses confirmed the lack of documentation and emphasized the importance of signing both the Controlled Drug Record (CDR) and MAR to prevent medication errors and ensure effective pain management. Resident 10 experienced a similar issue with the administration of oxycodone with acetaminophen (Percocet) on multiple occasions. The medication was removed from the blister pack and administered without prior pain assessment or documentation in the MAR. The Director of Nurses and LVN involved confirmed the absence of corresponding entries in the MAR, which is necessary for tracking medication administration and assessing the effectiveness of pain interventions. The facility's policy requires immediate documentation of controlled medication administration, including date, time, and nurse's signature, to ensure accurate medical records and effective pain management. The facility's failure to adhere to its policies and procedures for controlled medication administration resulted in inadequate pain management for both residents. The lack of documentation in the MAR and CDR prevented proper tracking of medication administration and pain assessment, potentially leading to unmanaged pain and diminished quality of life for the residents. The facility's policies emphasize the importance of accurate documentation to prevent medication errors and ensure effective pain relief, which was not followed in these cases.
Failure to Document Medication Administration
Penalty
Summary
The facility failed to maintain accurate clinical records for two residents, leading to a deficiency in medication administration documentation. Resident 22, who was admitted with diagnoses including repeated falls, depression, and anxiety disorder, had orders for Xanax and Tramadol. On a specific date, these medications were removed from the blister pack, as indicated in the Controlled Drug Record (CDR), but were not documented in the Medication Administration Record (MAR). This omission was confirmed by the Director of Staff Development and the Assistant Director of Nurses, who noted the importance of signing both the CDR and MAR to prevent medication errors and ensure proper reassessment of the medications' effectiveness. Similarly, Resident 10, who was admitted with chronic pain syndrome, had orders for Percocet. The CDR showed that Percocet was removed on three separate occasions, but these administrations were not recorded in the MAR. This discrepancy was confirmed during a medication cart observation and record review with a Licensed Vocational Nurse and the Director of Nurses. The failure to document in the MAR could lead to issues such as medication errors and drug diversion, as the MAR is crucial for tracking medication administration and assessing pain relief. The facility's policy and procedure for controlled medications require that the licensed nurse immediately document the administration details in both the CDR and MAR. However, in these cases, the nurses failed to follow this protocol, resulting in incomplete records. The lack of documentation in the MAR for both residents' medications highlights a significant lapse in the facility's adherence to its own policies, potentially compromising resident care and safety.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to administer Morphine Sulfate Contin to Resident 72 as ordered by the physician on February 1, 2025. Resident 72, who was admitted with diagnoses including infection and inflammatory reaction to prosthetic devices, acute hematogenous osteomyelitis, cellulitis, and chronic pain syndrome, did not receive the prescribed 30 mg dose of Morphine Sulfate Contin. The Minimum Data Set Nurse confirmed that the medication was not administered, and the Licensed Vocational Nurse assigned to Resident 72 on that day was unavailable for comment. The Director of Nursing acknowledged that the failure to administer the medication as ordered placed Resident 72 at risk for increased pain. The facility also failed to adhere to physician orders regarding the administration of midodrine for Residents 70 and 83. Resident 83, who was admitted with hypertension and heart failure, was given midodrine despite having systolic blood pressure readings above the physician-ordered threshold of 120 mm Hg on multiple occasions in January and February 2025. Licensed Vocational Nurses 3 and 4 confirmed that they signed off on administering the medication even when the blood pressure parameters were not met, potentially putting Resident 83 at risk for elevated blood pressure and complications. Similarly, Resident 70, who was admitted with hypertension and hypotension, received midodrine when their systolic blood pressure exceeded 120 mm Hg on several occasions in January 2025. The Director of Nursing confirmed that the medication should not have been administered under these conditions, as it could lead to elevated blood pressure and associated complications. The facility's policy on medication administration, which requires adherence to physician orders, was not followed in these instances.
Improper Food Storage Practices in Kitchen
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and preparation practices in the kitchen. During an observation and interview with the Dietary Supervisor, a container bin with a transparent cover containing a whitish powder, identified as a thickener used for pureed diets, was found with a stainless steel scoop inside. The handle of the scoop was buried in the thickener powder, which is against the facility's policy. The Dietary Supervisor acknowledged that the scoop should not have been left inside the bin to prevent contamination of the thickener powder. This practice had the potential to place five residents on pureed diets at risk for foodborne illnesses.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement proper infection control measures, as evidenced by several deficiencies observed during the survey. In one instance, a resident's room lacked a trash can for disposing of used Personal Protective Equipment (PPE), which is crucial for maintaining transmission-based precautions. This oversight was acknowledged by the Assistant Director of Nursing, who confirmed that the absence of a trash can could lead to the spread of infection to other residents. Another deficiency was observed when a Licensed Vocational Nurse (LVN) exited a resident's room while still wearing an isolation gown, which is against the facility's Enhanced Barrier Precautions (EBP) policy. The LVN's failure to remove the gown before leaving the room resulted in potential contamination of the medication cart. The Infection Preventionist confirmed that the LVN should have removed the gown to prevent the spread of infection, as per the facility's guidelines. Additionally, the facility did not ensure that urinals were properly labeled with resident identifiers, which could lead to cross-contamination. Two residents had unlabeled urinals, one of which was improperly hung on a trash bin. The Director of Nursing acknowledged that this practice could result in the inadvertent use of urinals by other residents, increasing the risk of infection. Furthermore, a medication room was found to contain personal belongings, which is against infection control policies, as confirmed by the Assistant Director of Nursing and the LVN involved.
Failure to Respect Resident Privacy and Dignity
Penalty
Summary
The facility failed to ensure that staff knocked and requested permission before entering the rooms of two residents, which violated the residents' rights to dignity and privacy. Resident 40, who was admitted with diagnoses including hypertension and type 2 diabetes mellitus, had intact cognitive skills for daily decision-making and required partial assistance with personal care. During an observation, a Certified Nurse Assistant (CNA) entered Resident 40's room without knocking or asking for permission, which the CNA later acknowledged as disrespectful. Similarly, Resident 188, who was admitted with hypertension and depression, also had intact cognitive skills and required substantial assistance with personal care. The same CNA entered Resident 188's room without knocking or asking for permission. The facility's policy on dignity, which was last reviewed in January 2025, mandates that staff must knock and request permission before entering residents' rooms to promote their well-being and self-esteem. The Minimum Data Set Coordinator confirmed that this practice is essential to respect residents' rights and privacy.
Failure to Maintain Resident's Advance Directive in Medical Record
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding advance directives for one resident, identified as Resident 16. The deficiency was identified during a review of Resident 16's clinical records, which revealed that the facility did not maintain a current copy of the resident's advance directives in the resident's chart. This oversight was confirmed during interviews with the Director of Social Services (DSS) and the Director of Nursing (DON), both of whom acknowledged that the advance directive should have been included in the resident's medical record to guide staff in honoring the resident's medical decisions. Resident 16 was initially admitted to the facility with diagnoses including hemiplegia, hemiparesis, gastrostomy, and encephalopathy, and was noted to have severely impaired cognition and total dependence on staff for activities of daily living. The Minimum Data Set (MDS) and History and Physical (H&P) assessments indicated that Resident 16 lacked the capacity to understand and make decisions. Despite this, the facility's failure to maintain the advance directive in the resident's chart posed a risk of not honoring the resident's end-of-life treatment preferences, as outlined in the facility's revised policy on advance directives.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 3,439 citations issued within 25 miles in the last 12 months — including the 25 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Granada Hills
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Granada Hills Convalescent | 1.2 mi | ★★★★★ | 19 | 0 |
| Casitas Care Center | 1.2 mi | ★★★★★ | 19 | 0 |
| Providence Holy Cross Med Ctr D/p Snf | 1.7 mi | ★★★★★ | 17 | 2 |
| Ararat Nursing Facility | 1.7 mi | ★★★★★ | 25 | 1 |
| Magnolia Gardens Convalescent Hospital | 1.8 mi | ★★★★★ | 28 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.