Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 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 Rio Hondo Subacute & Nursing Center during CMS and state inspections, most recent first.
Failure to Provide Safe Repositioning and Investigate a Witnessed Fall: A resident who was non-verbal, cognitively impaired, and dependent for care was repositioned alone on a low air loss mattress despite a care plan requiring two-person assistance. During brief care, the resident slid out of bed, struck the head on a nightstand, and was placed back in bed by the CNA without immediate nurse notification or assessment. The resident was later found with worsening eye swelling and bruising and was transferred for hospital evaluation, where jaw dislocation and orbital bruising were documented. The DON stated the CNA witness was not interviewed during the investigation.
Delayed Reconciliation of Admission Antibiotic Order: A resident admitted from a GACH had an antibiotic order for vancomycin omitted from the initial admission reconciliation. The DON and RN stated the admitting nurse was responsible for reconciling hospital orders, but the vancomycin oral suspension was not entered until the next day, with the first dose given later that evening; the medication was not stocked in the ADC.
Inadequate Pain Assessment and Management After Fall Injury: A nonverbal resident with dementia and multiple neurologic deficits fell from bed, struck her head on a nightstand, and was later found with bleeding, bruising, swelling, and agitation. Staff used a numerical pain scale instead of PAINAD, left non-verbal pain indicators unaddressed, and did not give ordered PRN analgesia despite the resident’s inability to report pain and later-confirmed facial and jaw injuries.
A resident with COPD, dysphasia following cerebral infarction, and severe cognitive impairment had a vancomycin order for C. diff via G-tube every 6 hours after readmission. The DON confirmed the facility delayed obtaining and entering the order, resulting in about 29 hours between doses and 4 missed doses, with no documentation of admission med reconciliation or reason for the delay.
A resident with CHF, type 2 DM, gait abnormalities, toe amputations, and moderately impaired cognition, who required supervision for transfers and ambulation and was known to walk the halls and sit at the nurse’s station at night, was admitted without completion of a required Leave of Absence without Notice (LAWN) elopement risk assessment or an elopement care plan. One night, after sitting in a wheelchair at the nurse’s station with no staff present, the resident stood, walked to the front entrance, followed an unidentified woman, and exited through a front door that was propped open and programmed so its alarm only sounded if held open for at least one minute. The resident left the building unnoticed, leaving the wheelchair at the front door, walked away, and remained missing for several hours until found at a nearby bus stop, while staff later confirmed that the admission elopement assessment had not been completed as required by facility policy.
A resident with quadriplegia and intact cognition reported missing personal belongings from a van parked on facility property and stated he had spoken with multiple staff, but his concerns were not addressed. The grievance was not documented in the facility’s grievance binder, and the ADM acknowledged there was no follow-up or documented resolution, despite the van remaining on-site. The SSA reported discussing the van with the resident and offering a grievance but could not recall documenting any communication or details of the belongings, while also noting that grievances are typically resolved within a short timeframe. Review of the facility’s grievance policy showed that staff were required to initiate and log grievances and that leadership and social services were responsible for investigation and follow-up, which did not occur in this case.
Incomplete informed consent for psychotropic medications: Facility records showed that several residents receiving antipsychotic, antidepressant, and anti-anxiety medications did not have complete consent documentation before administration. One resident had missing consent for some medications and an incomplete Ativan form, another non-verbal resident lacked responsible-party consent for quetiapine, and other residents had psychotropic disclosures missing resident/representative signatures, physician signatures, dates, or required medication details. Staff interviews confirmed the consent gaps and that some residents lacked capacity to consent on their own.
Call Lights Not Kept Accessible for Two Dependent Residents: Two residents with severe mobility limitations and dependence for care were observed with call systems out of reach while in bed. One resident with quadriplegia and a tracheostomy needed the call light pad placed next to his cheek to request help and suctioning, but it was clipped to the bed linen away from reach. Another resident with hemiplegia, contractures, and impaired upper-extremity function could not press or reach the call light, which was stuck between the side rail. Staff confirmed both residents needed accessible call systems to summon assistance, and the DON acknowledged the facility was not following its policy.
Advance directive forms were not readily accessible in the chart for four residents. One resident had an Advance Health Care Directive noted, but staff could not produce the document in the record and the POLST did not match. Three other residents had no ADA form in the hard copy chart or EHR, and the SSD said the forms were still kept in an office binder instead of the medical record. The residents had varied conditions including fractures, ESRD, asthma, acute respiratory failure, dysphagia, spinal stenosis, anemia, and MI, with cognition ranging from intact to severely impaired.
Medications were left unsecured on medication carts and discarded pills were observed on waste container lids, making them accessible to residents and visitors. An LPN left a resident’s nitroglycerine, midodrine, and Depakote on top of a hallway med cart while unattended, and two med carts had pills and a capsule sitting on waste container lids. The facility also had multiple opened house supply and resident medications on carts without opened-date labels, including docusate sodium, multivitamin with minerals, senna, diclofenac gel, and valproic acid oral solution.
Unsafe Food Storage, Labeling, and Cooling Practices: Surveyors found multiple refrigerated foods stored past their use-by dates, along with unlabeled or improperly dated items such as tomatoes and opened applesauce. A CDM stated foods without proper labels or with incorrect dates were unsafe for resident consumption. Surveyors also found cooked beans with a blank cooling log, and the cook and CDM acknowledged temperatures were not consistently recorded or verified as required by the log instructions and facility policy.
An LPN documented telephone orders to delay a morning med pass for two residents without confirming the orders with the MD, and the orders lacked specific medication and timing details. In a separate issue, staff backdated and wrote another nurse’s and DON’s names on psychotropic consent forms for a resident with impaired cognition, while the RP had not been properly informed or consented and the PMHNP stated he did not know the resident lacked capacity or who the RP was.
The facility failed to keep infection control policies and the reportable disease list readily available, and staff did not know where to find them. During an influenza outbreak, the IPN did not follow county guidance for close contacts of confirmed cases, did not test or monitor several exposed residents, did not document offering Tamiflu to two residents, and used the wrong influenza test kits, making results invalid. Staff also failed to follow EBP/PPE requirements for residents with G-tubes, including not wearing isolation gowns during G-tube care and not changing gowns between residents.
Failure to Provide Bed-Hold Notice and Documentation: A resident with type II DM and hyperlipidemia was transferred to a GACH after a fall, but the record lacked a transfer order, bed-hold order, and documented evidence that written bed-hold notice was provided. The facility’s bed-hold form was incomplete, with no dates or signatures, despite policy requiring written information about bed-hold rights and returns.
Baseline Care Plan Not Initiated Within Required Timeframe: A resident admitted with DM, a foot ulcer, HTN, and HLD did not have a baseline care plan initiated within 48 hours of admission. The plan was created several days later and did not specify the resident’s needs, treatments, diagnoses, or medications. The admitting LVN stated she forgot to start it and assumed the next shift would complete missing assessments, and the DON confirmed the baseline care plan should have been initiated on admission.
A resident with dementia, depression, and anxiety did not have a comprehensive care plan addressing dementia or separate plans for Ativan, trazodone HCL, and divalproex. Another resident assessed at risk for PI did not have a comprehensive prevention plan despite Braden risk and turning/repositioning documentation, and skin redness was observed at the sacrococcyx. A Cantonese-speaking resident had a communication care plan with interpreter services, but no bilingual communication board was in the room and the resident reported staff rarely had a Chinese interpreter and that he felt very sad because nobody understood him.
Failure to Provide Grooming Assistance: Three residents with varying ADL needs did not receive needed haircut services, leaving one resident to arrange and pay for an outside haircut, another to ask a friend for transportation and payment, and a third to trim his own hair with blunt children's scissors because he could not reach the top and back of his head. The SSD stated the prior haircut provider resigned and no replacement had been found, and she did not inform the residents or their RP about transportation or financial assistance options. Facility policies required care that promotes dignity, self-worth, and good grooming.
Failure to Reconcile Hospital Diabetes Medications on Admission: A resident with DM2 and a foot ulcer was admitted with hospital discharge instructions for Alogliptin, Glipizide, and Insulin Lispro, but the admitting nurse reviewed only the hospital active med list and did not obtain or transcribe the discharge orders. As a result, the resident’s admission orders omitted the oral DM meds and insulin coverage, even though BG readings ranged from 112 to 280 and the resident reported his usual DM meds were not being given. The RN, NP, and DON confirmed the discharge orders were not properly reviewed or communicated.
Failure to assist a dependent resident with ordered transfers and mobility. A resident with post-laminectomy syndrome and spinal stenosis was assessed as dependent for bed mobility and chair/bed-to-chair transfers, with care plan and MD orders for transfer to a chair for 2 hours as tolerated with a pressure relieving cushion. However, the ADL flowchart was left blank or marked not applicable across shifts, the resident was observed in bed, and the resident stated he had not been helped out of bed for about a month. A CNA and an LVN both stated the resident had not been assisted out of bed, and the DSD stated staff should know assignments and document refusal rather than not applicable.
A resident with a suprapubic catheter had the drainage bag left on top of the bed next to his leg instead of below bladder level. The AMDSN confirmed the bag was not draining properly, the TN said she forgot to place it correctly after changing it, and the DON stated the bag must be kept below the bladder to allow urine to drain. The resident’s care plan and the facility’s CAUTI policy both required proper catheter placement and unobstructed urine flow.
A resident with ESRD, CHF, and ongoing HD had repeated gaps in the post-HD section of the Hemodialysis Communication Record, with no documented post-treatment vital signs or nurse signature after multiple dialysis sessions. The LVN and DON both confirmed that staff were expected to complete the post-dialysis assessment and documentation when the resident returned from dialysis.
A resident admitted with paraplegia, acute kidney failure, and a T5-T6 compression fracture did not receive required face-to-face attending physician visits once every 30 days during the first 90 days after admission. The H&P showed the DNP saw the resident only at admission and again later, and the DON and ADM confirmed there was no documented evidence that the attending physician had assessed or evaluated the resident since admission.
An LVN prepared an incorrect dose of Levetiracetam for a resident with epilepsy, dementia, dysphagia, and severely impaired cognition, pouring more than the ordered 5 mL into a medicine cup while holding it in the air. During the same med pass, the LVN did not follow the ordered G-tube flushing protocol and failed to flush before administration and between multiple medications, including Amlodipine, Cholecalciferol, Lisinopril, Multivitamin liquid, and a probiotic capsule. The surveyor intervened before the incorrect Levetiracetam dose was given.
A resident with dementia, depression, anxiety, and severe cognitive impairment had MRR findings that were not acted on by facility staff. The consultant pharmacist recommended adding food/meals instructions to the carvedilol order, but the MAR and order summary did not include that direction. The MRR also identified that informed consents for trazodone and Ativan should be current; the Ativan consent was incomplete and the chart did not contain a trazodone consent. Interviews with the PC and DON confirmed the recommendations and consent requirements were not followed.
A resident admitted without pressure ulcers and with paraplegia and severe mobility limitations did not receive a completed Braden Scale risk assessment, and no pressure ulcer prevention care plan or specific interventions such as repositioning or a low air loss mattress were implemented. Over several days, staff documented no skin breakdown, and the IDT did not address pressure ulcer risk, while the resident remained on a regular mattress and required maximal assistance for turning and hygiene. A family member later discovered redness and open skin on the buttocks during an incontinent brief change, after an earlier refused change and unknown duration of soiling. An LVN subsequently documented a DTI on the buttock and a Stage 3 sacrococcygeal ulcer but did not measure the wound, did not timely enter or implement treatment orders, and no wound care was documented for the first two days after identification. Later assessment documented a 5 x 7 x 0.2 cm Stage 3 sacrococcygeal ulcer requiring surgical debridement, and leadership confirmed failures in admission risk assessment, care planning, wound measurement, and timely treatment, which the report states placed the resident at risk for infection, discomfort, and pain.
A cognitively intact resident with sepsis and type 2 DM, who required assistance with ADLs and had a care plan emphasizing her preference for meaningful daily routines and choice of bathing method, did not receive a shower on her regular shower day. Documentation for that day showed no bath type provided, and the resident reported that staff often failed to help her shower despite repeated requests, causing her to feel depressed and useless. The assigned CNA stated she initially offered a shower, which the resident declined at that moment due to pain, but then did not return to re-offer the shower, did not arrange for another staff member to assist, and did not notify anyone that the shower was missed, explaining she was too busy and forgot, contrary to the DON’s expectation that missed showers be reported so they can be completed.
A cognitively intact resident with a history of substance abuse and prior overdose had an active care plan requiring monitoring for signs of substance use, but staff did not document such monitoring despite repeated episodes involving contraband and substance use. Over time, staff observed the resident with vape devices, pills, and marijuana-like smoke in the room, and later saw the resident smoking an unknown substance outside with a family member, yet the care plan was not meaningfully revised and no consistent monitoring was documented. The same family member later admitted giving the resident alcohol after the resident was found vomiting with alcohol odor and was hospitalized for alcohol intoxication, but the facility still allowed this visitor and others to continue unsupervised, unrestricted visitation, and did not inform the MD of earlier incidents or instruct staff on specific behaviors to monitor, contrary to the facility’s own visitation and substance use policies.
A resident with sepsis and type 2 DM, who was cognitively intact, reported to a dialysis social worker that facility staff failed to respond to requests for assistance and behaved unprofessionally, including cursing while at work. The dialysis social worker twice contacted the facility SSD about these concerns, and the SSD initially stated she would follow up with the resident, but there was no documentation of the grievance in the grievance log or progress notes and no written resolution provided. In interviews, the resident and the dialysis social worker reported that no one from the facility had addressed the concerns, and the SSD acknowledged she does not document verbal concerns or initiate grievance forms unless specifically requested, resulting in no recorded grievance or resolution for this resident.
A cognitively intact resident with hemiplegia reported that a CNA handled him roughly during incontinence care, causing pain and prompting him to scream, which was corroborated by his roommate and reported by a family member to an LVN and an RN. The facility’s abuse policy required immediate identification of possible abuse, removal of the alleged perpetrator from duty, initiation of an investigation within two hours, protection of the resident during the investigation, and timely reporting to appropriate agencies, but staff did not recognize or process the complaint as an abuse allegation. Although the CNA was briefly reassigned that shift, the CNA was placed back on assignment with the same resident on a later shift, the Administrator/abuse coordinator was not notified, and no timely investigation or mandated protective measures were implemented, resulting in noncompliance with the facility’s abuse prohibition procedures.
A resident with hemiplegia and intact cognition and the resident’s family member reported to an LVN that a CNA was rough during incontinence care and caused pain, and the family member requested that the CNA not be assigned to the resident again. The facility’s abuse policy required reporting alleged abuse to CDPH, law enforcement, the Ombudsman, and other agencies within two hours, initiating an investigation, and protecting residents from further harm, but the LVN did not notify the ADM or DON and no required external reports were made. Staffing records later showed the same CNA was reassigned to the resident on a subsequent night shift, after which the family member found the resident in a soaking wet brief and the resident reported that no one had checked on him during the night.
A resident with a history of substance abuse and paraplegia was not adequately assessed, monitored, or supervised despite multiple documented episodes of suspected and confirmed substance use. Staff noted a frequent visitor staying overnight with suspicious behavior, observed the resident vaping what smelled like marijuana in his room, and found vape pens and non‑prescribed erectile enhancement pills in his belongings, but there was no thorough investigation, consistent monitoring, or timely physician notification. The resident, who was under the legal smoking age and assessed as unable to safely hold a cigarette, was later seen outside with a visitor placing an unknown smoking material in his mouth, and no sustained reassessment or structured supervision of visits followed. On a subsequent visit, staff found the room smelling of smoke, marijuana, and alcohol, and the resident was vomiting and foaming at the mouth; the visitor admitted providing alcohol, and the resident was diagnosed with acute alcohol intoxication. Despite these events, the same visitor continued to have unsupervised and unrestricted access, and staff reported they were not directed to monitor for substance use behaviors or to control contraband brought in by visitors.
A paraplegic resident with intact cognition and a history of substance use disorder had a physician order for an electric wheelchair to address mobility needs, but the facility did not follow through on obtaining the device. The Social Services policy required provision of medically related social services, including ambulation equipment, yet there was no documented follow-up by the case manager after the order. An IDT later decided against providing the electric wheelchair due to concerns about the resident’s prior fentanyl use and recent contraband incidents, despite the resident relying on a manual wheelchair that he could not safely self-propel, as confirmed by PT. The resident and family reported ongoing requests for the electric wheelchair, feelings of isolation, and restricted freedom of movement, while facility leadership gave conflicting accounts of Social Services’ responsibility for arranging DME for custodial residents.
A resident who was cognitively intact and fully dependent on staff due to quadriplegia was subjected to derogatory and inappropriate comments by two CNAs during a fecal disimpaction procedure. The CNAs engaged in personal conversation and made offensive remarks in the resident's presence, causing the resident to feel uncomfortable and upset. Facility policy required staff to treat residents with dignity and respect at all times, and the incident was confirmed by staff interviews.
A resident with Parkinson's Disease and a history of falls did not have required bolster pillows attached to the bed as outlined in the care plan, despite being dependent on staff for mobility and having frequent involuntary movements. Multiple staff confirmed the absence of bolsters, and observations showed the intervention was not implemented after room transfer, leading to continued risk of falls.
A resident with severe cognitive impairment and a stage 4 pressure ulcer was not adequately represented in care planning, as the responsible party was not included in interdisciplinary care conferences and was only given limited information after meetings. Staff did not provide regular or detailed updates about the wound's stage or treatment, leaving the responsible party unaware of the wound's severity and progression, in violation of facility policy.
A resident with multiple medical conditions did not receive prescribed nystatin cream, Zoryve foam, and normal saline flushes as ordered, with facility records showing missed administrations and blank documentation. Nursing staff confirmed these treatments were not given or documented, and the resident reported not receiving his medications, contrary to facility policy requiring timely administration and documentation.
A resident with severe cognitive impairment and a stage four pressure ulcer did not have consistent documentation of required turning and repositioning every two hours, as ordered by the physician. Facility staff, including CNAs and nurses, failed to record care in accordance with policy, resulting in multiple gaps in the medical record over several days.
Pest Infestation in Resident Room: The facility failed to maintain an effective pest control program for a resident's room. The resident, who had paraplegia, generalized muscle weakness, and was dependent on staff for several ADLs, had a care plan noting risk for pest issues related to hoarding and excessive personal items. Staff observed multiple small black pests flying and crawling on the resident's food tray and around the room, along with food containers, utensils, and a urinal with odors that attracted insects. The resident said flies had been in the room for a while, CNA reported the issue had been brought to the charge nurse and supervisor multiple times, and the DON stated no interventions beyond education had been completed.
The facility did not post accurate and current nurse staffing data as required, instead displaying outdated and projected staffing hours rather than actual hours worked for each shift. This occurred after the staff member responsible for updating the postings went on leave, and no other staff was assigned to maintain the daily updates.
Two residents experienced deficiencies in dignity and respect when one waited at least 19 minutes for staff response after activating a call light, despite staff presence at the Nurses' Station, and another was subjected to derogatory language by a CNA and subsequently felt neglected. Both incidents were confirmed through interviews, observations, and record reviews, showing a failure to follow facility policies on timely response and respectful communication.
A resident with cognitive impairment and a history of inappropriate physical contact did not have a comprehensive, person-centered care plan that clearly defined behaviors to monitor or provided specific interventions for one-to-one supervision. Facility staff failed to consistently implement the required supervision, and the care plan lacked sufficient detail to guide staff actions, resulting in lapses in monitoring after reported incidents.
A resident with a right ankle fracture experienced ongoing pain and refused to ambulate, but staff failed to consistently assess, document, and communicate the pain to the NP or physician. Despite policy requirements, pain assessments and reassessments were incomplete, and pain interventions were not always evaluated for effectiveness, leading to poor pain control and decreased mobility.
Menu Item Substituted Without RD Approval: A dietary service failed to follow the planned lunch menu when roasted cauliflower was unavailable and was replaced with steamed cauliflower and then steamed sliced carrots for 21 residents without RD approval. The DS stated the change was unexpected and residents were not informed beforehand; residents reported they were served different vegetables than listed and one resident said he did not eat the carrots he received.
Catheter Monitoring and Drainage Bag Positioning Failures: The facility failed to consistently monitor urine sediment in several residents with indwelling catheters and did not keep suprapubic catheter drainage bags below bladder level for two residents. Observations found sediment in catheter tubing and drainage bags, incomplete TAR documentation for catheter checks, and drainage bags hanging from bed frames above waist level. Staff and the DON acknowledged that sediment can signal a UTI and that drainage bags should be positioned below the bladder to prevent backflow.
Failure to Implement Pharmacist MRR Recommendations: The DON, licensed nursing staff, and physician did not follow multiple consultant pharmacist MRR recommendations for four residents. Issues included missing behavior monitoring for escitalopram, lack of orthostatic BP monitoring for residents receiving Risperdal, failure to document proper mixing instructions for gabapentin and Protonix via G-tube, and failure to change cholecalciferol from daily to weekly dosing. MARs, BP summaries, and care plans did not reflect the pharmacist’s instructions, and the DON confirmed the recommendations were not implemented.
Improper food storage and labeling were observed in the kitchen. A bin of onions stored under the food prep desk had fruit flies, and two onions showed mold. A ton of vanilla ice cream in the walk-in freezer was also found without a date opened or use-by date. The DS stated dietary staff were responsible for inspecting produce and that the staff who opened the ice cream were responsible for labeling it.
Missing Informed Consent for Psychotropic Medications: The facility failed to obtain valid informed consent before giving psychotropic meds to two residents. One resident with hemiplegia, hemiparesis, and cognitive impairment received Mirtazapine via g-tube for depression, but the disclosure form was incomplete and lacked the physician signature and consent date. Another resident with depression, anxiety, and severely impaired decision-making capacity received Ativan before hemodialysis, but the disclosure lacked the resident representative signature and required nurse counter signature. The DON confirmed the missing documentation.
Call Light Not Within Resident’s Reach: A resident with type 2 DM, a prior cerebral infarction affecting the left side, severely impaired cognition, and dependence for multiple ADLs had the call light observed behind the bed while in bed. CNA confirmed it was not within reach and stated the resident needed it accessible to call for help, while the DON reviewed the facility policy stating call lights must be in reach when residents are in bed.
Failure to notify the MD of a resident’s change in condition. A resident with Type 2 DM, Fournier Gangrene, urethral fistula, ESRD, and an indwelling catheter was observed with bilateral lower extremity edema and sediment in catheter urine. Staff did not complete a CoC evaluation, the treatment nurse was unaware of the swelling, an LVN had not assessed the feet or notified the MD, and the DON stated the MD was not notified until the issue was brought to the facility’s attention.
A resident with acute kidney failure, HTN, and fluctuating decision-making capacity had an incomplete personal property inventory that listed only a hospital nightgown. Staff and the resident's family reported that hearing aids were present at admission, later went missing, and were not reflected on the inventory list even after replacement hearing aids were kept at the bedside. An LVN stated SSD was responsible for updating inventories, and SSA confirmed the list had not been updated to reflect the resident's current belongings.
Failure to Provide Safe Repositioning and Investigate a Witnessed Fall
Penalty
Summary
The facility failed to ensure a resident who was totally dependent for activities of daily living, non-verbal, cognitively impaired, and had a left knee contracture and abnormal posture was protected from a fall and injury while being repositioned on a low air loss mattress. The resident’s care plan required two-person physical assistance for transfers and bed mobility, and the facility’s repositioning and low air loss mattress procedures required staff to check the care plan and use the number of staff needed for safe repositioning. Despite this, a CNA changed the resident’s brief alone during overnight care while the resident was on the low air loss mattress. During the repositioning, the CNA stated the mattress was slippery and the resident’s contracted right leg caused the resident to be pulled downward. The resident slid out of bed and fell to the floor, landing on the bottom and striking the head on a nightstand beside the bed. The CNA stated the resident did not respond when asked if okay, wiped blood from the right eye area, and then moved the resident back into bed alone without asking for staff assistance. The CNA also stated the incident was not reported to the licensed nurse at the time because other residents needed attention. The resident was later found with bleeding and a scratch above the right eye, and the injury worsened over the next day with swelling and bruising around the orbital area. The resident was transferred to the hospital for further evaluation, where records documented bilateral anterior jaw dislocation and right orbit ecchymosis. The facility’s investigation was incomplete because the DON stated the CNA who witnessed the fall was not interviewed, and the care plan was not updated to reflect new interventions after the fall.
Delayed Reconciliation of Admission Antibiotic Order
Penalty
Summary
The facility failed to ensure continuity of care for a resident admitted from a general acute care hospital by not reconciling the admission orders to include vancomycin. The resident had diagnoses including COPD, dysphasia following cerebral infarction, and need for assistance with personal care. The MDS dated 3/2/2026 indicated the resident had no speech, was rarely or never able to express ideas and wants or understand others, had short- and long-term memory problems, severely impaired cognitive skills for daily decision making, and was dependent on others for self-care and mobility. The resident was readmitted to the facility on 4/24/2026 at 6:12 PM. During interview and record review, the DON stated the physician’s order for vancomycin oral suspension 50 mg/ml, 2.5 ml via G-tube every 6 hours was entered on 4/25/2026 at 2:24 PM, and the pharmacy delivery receipt showed the medication was received at 6:38 PM that same day. The DON stated the first dose was given around 6 PM on 4/25/2026, and acknowledged there was no documentation explaining why the vancomycin order was not placed on admission. RN 1 stated the admitting nurse usually reconciles physician orders from the hospital, that first-dose antibiotics may be available through the ADC, but vancomycin oral suspension was not stocked there, and did not remember why the order was entered a day after admission.
Inadequate Pain Assessment and Management After Fall Injury
Penalty
Summary
Safe, appropriate pain management was not provided for a resident who was nonverbal, had dementia, and was unable to report pain after a fall with facial injury. The resident’s record showed diagnoses including hemiplegia, hemiparesis, cerebral infarction affecting the right dominant side, facial weakness, Alzheimer’s disease, dementia, left knee contracture, abnormal posture, and muscle weakness. The care plan identified altered comfort related to Alzheimer’s disease, hemiplegia, and muscle weakness, with interventions to medicate as ordered, monitor for non-verbal signs of pain, and watch for agitation, grimacing, and resistance to care. After the resident slid and fell from bed during repositioning, she struck her head on the nightstand and was later found with a scratch and active bleeding above the right eye, swelling and bruising around the orbital area, and agitation with arm movements and clutching at her gown. The resident was assessed using a numerical pain scale even though she was nonverbal and unable to make self-understood decisions, rather than using the PAINAD tool referenced by staff as appropriate for residents with dementia who cannot verbalize pain. The SBAR form left the question about non-verbal signs of pain blank, and the licensed nurse stated she thought the resident was itching rather than in pain and did not complete a full pain assessment. The resident did not receive pain medication despite the physician order for acetaminophen as needed for mild pain and despite documented signs that staff later identified as possible pain indicators. The MAR showed no pain medication was given. The resident remained with unrelieved pain from the time of the fall until transfer to the hospital for head trauma evaluation, and later records showed bilateral anterior jaw dislocation, mandibular condyle fracture-dislocation, and right orbit ecchymosis, with operative treatment required for the jaw injury.
Delayed and Missed Antibiotic Doses After Readmission
Penalty
Summary
The facility failed to order vancomycin from the pharmacy and administer it as ordered for one resident in a timely manner. Resident 1 was readmitted from a general acute care hospital with diagnoses including COPD, dysphasia following cerebral infarction, and need for assistance with personal care. The resident’s MDS indicated no speech, rarely or never able to express ideas and wants, rarely or never understood others, short- and long-term memory problems, severely impaired cognitive skills for daily decision making, and dependence on others for self-care and mobility. Resident 1 had an order dated 4/25/2026 for vancomycin oral suspension 50 mg/ml, 2.5 ml via G-tube every 6 hours. The DON reviewed the discharge medication list and confirmed the resident received the last dose at the hospital on 4/24/2026 at 1:37 PM, while the facility did not receive the first dose until 4/25/2026 at 6:38 PM and administered it at 6:45 PM. The DON acknowledged there was approximately 29 hours between doses, during which 1 dose was missed on 4/24/2026 and 3 doses were missed on 4/25/2026. There was no documentation of medication reconciliation on admission and no documented reason for the delay in entering the vancomycin order. The facility policy stated that upon admission, the nurse should reconcile the resident’s medications, the discharge orders from the previous institution, and obtain orders from the physician.
Failure to Assess Elopement Risk and Secure Entrance Door Leads to Resident Elopement
Penalty
Summary
The deficiency involves the facility’s failure to implement required elopement risk assessments and care planning, and to maintain environmental controls to prevent a resident from leaving the building unnoticed. The resident was admitted with diagnoses including congestive heart failure, type 2 DM, abnormalities of gait and mobility, and amputation of the right great toe and other right toes. An MDS dated 4/13/2026 documented moderately impaired cognition and a need for supervision or touching assistance for sit-to-stand and walking 50 feet with two turns, and staff reported the resident liked to walk around the facility and had a habit of being up at night in a wheelchair near the nurse’s station. Despite these factors, the admission record and subsequent chart review showed no completed elopement assessment or Leave of Absence without Notice (LAWN) assessment, and the care plan from 4/1/2026 to 4/23/2026 contained no elopement care plan, contrary to facility policy requiring LAWN evaluation upon admission and at set intervals. In the early morning hours of 4/23/2026, the resident was last seen by the night-shift RN at the nurse’s station at approximately 2:20–2:31 AM, after which the resident was no longer present. The resident later reported that, after sitting in the wheelchair in front of the nurse’s station and noticing no staff present, he stood up, walked to the front entrance, and followed an unidentified woman to the front door. The resident stated the front entrance door was propped open with no staff present, allowing him to walk out of the facility, cross several streets, and go to a bus stop where he slept for a few hours while waiting for a bus. The resident’s wheelchair was later found left at the front door, and facility documentation indicated the resident had eloped from the facility on foot at about 2:20 AM. Environmental observations and staff interviews showed that the front entrance door was programmed so that the alarm would only sound if the door was held open for at least one minute, and that all other doors were locked at night while the front entrance remained accessible. The maintenance supervisor demonstrated that the front door alarm did not activate until the door was held open for one minute, and the RN confirmed that if a resident exited and closed the door, no alarm would sound and staff would not immediately know a resident had left. The DON and ADON confirmed that the admitting RN was responsible for completing the LAWN assessment upon admission and that this had not been done for this resident, despite facility policies stating that residents at risk for wandering or elopement are to be evaluated by the IDT and monitored, with precautions taken to ensure their safety. The resident remained missing for approximately 3.5 hours before being located at a nearby bus stop and assessed as alert, oriented, and in no distress.
Failure to Document and Resolve Resident Grievance About Missing Belongings
Penalty
Summary
The deficiency involves the facility’s failure to promptly address and resolve a resident’s grievance regarding missing personal belongings from his van and to keep him informed of progress toward resolution, as required by the facility’s grievance policy. The resident was readmitted with diagnoses including quadriplegia, atherosclerosis of native arteries of other extremities with ulceration, and chronic pain syndrome. A History and Physical dated 1/3/2026 and an MDS dated 4/1/2026 documented that the resident had decision-making capacity and intact cognition. A complaint received on 4/17/2026 indicated the resident had previously reported missing belongings from his car, including a speaker, stereo, clothing, wires, and miscellaneous items. During an interview, the resident stated he had spoken with several unidentified facility staff about his van and personal belongings, but his concerns were not addressed. He indicated he no longer wished to discuss the incident and reported that he had spoken with the Ombudsman. Review of the facility’s grievance binder showed no documented grievances for this resident from 11/2025 through 04/2026. The Administrator acknowledged that the resident had a van parked at the facility, that he did not follow up with the resident regarding the missing items, and that there was no documentation of any resolution. The Administrator further stated that nothing had been done to resolve the resident’s grievance and that the van remained in the facility parking lot. Observations of the van showed it parked with windows closed, doors locked, no exterior damage, and a damaged steering wheel with some miscellaneous personal items inside. The Maintenance Supervisor reported the van was delivered by an auto-insurance company and left in the middle of the parking lot. The Social Services Assistant stated he spoke with the resident, who asked how the van got there, and he replied that he did not know. The Social Services Assistant recalled that there was a lot of the resident’s belongings in the van but could not specify what they were, did not notice if the steering wheel was broken, and could not recall documenting any communication with the resident about the van, belongings, or offering a grievance. He stated any staff could write a grievance on behalf of a resident, that grievances are given to social services and forwarded to the appropriate department, that the resident did not file a grievance about the van, and that grievances usually have a 48‑hour resolution. The facility’s grievance policy required staff to initiate a Grievance/Concern Form upon receipt of a concern, document it on the Grievance/Concern Log, and for leadership to investigate, document, and follow up on all formal concerns, with the Administrator serving as Grievance Officer and social services serving as resident advocates; these steps were not carried out for this resident’s concerns.
Incomplete informed consent for psychotropic medications
Penalty
Summary
The facility failed to obtain and maintain complete informed consent for psychotropic medications before administration for multiple residents. The report identified deficiencies involving Resident 1, Resident 2, Resident 13, Resident 16, and Resident 106, all of whom were receiving psychotropic medications such as antipsychotics, antidepressants, and anti-anxiety medications. Facility policies required staff and the physician to review the indication, rationale, alternatives, risks and benefits, and the resident’s or representative’s right to accept or decline treatment before documented consent was obtained, and to verify informed consent before administration. For Resident 1, the record showed diagnoses including dementia, depression, and anxiety disorder, and the resident was documented as having severe cognitive impairment and no capacity to understand and make decisions. The MAR showed administration of divalproex sodium, trazodone HCL, and Ativan from 2/1/2026 through 2/10/2026. The chart did not contain informed consent for divalproex or trazodone, and the Ativan consent form was incomplete because it did not include the resident’s diagnosis, duration of use, or specific observable behaviors indicating the purpose of the medication. Staff interviews confirmed that consent for trazodone and divalproex was missing and that the Ativan consent was incomplete. For Resident 2, the record showed dementia, aphasia, dependence on a respirator, inability to speak, and severe cognitive impairment, with Family Member 4 identified as the responsible party. The psychotropic consent form for quetiapine indicated verbal consent from the resident, but it did not include a date and did not show consent from the responsible party or representative. Staff stated the resident could not verbally consent and that the responsible party should have provided consent. For Resident 16, the record showed bipolar disorder, major depressive disorder, and schizophrenia, with fluctuating capacity to understand and make decisions. The psychotropic medication disclosures for Seroquel and escitalopram lacked the resident or representative signature and lacked physician counter-signatures, and disclosures for trazodone and buspirone also lacked physician signatures. For Resident 13, the record showed bipolar disorder, depression, and anxiety, and the disclosures for risperidone, trazodone, and buspirone were missing required physician information and signatures. For Resident 106, the record showed major depressive disorder and Alzheimer’s disease, with severe cognitive impairment and no capacity to make decisions. The consent form for imipramine was left unsigned by the resident’s representative and did not include the resident’s diagnosis or specific behaviors, and staff stated there was no valid consent for the medication.
Call Lights Not Kept Accessible for Two Dependent Residents
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of two residents by not keeping their call systems accessible when they were in bed. For one resident with respiratory failure, quadriplegia, a tracheostomy, and dependence on a respirator, the call light pad was observed clipped to the bed linen at the upper left corner of the bed and out of reach. The resident stated he could not call for help verbally and needed the call light pad to request assistance, including suctioning, but could not reach it because it was not next to his cheek. During the same observation, a CNA confirmed that the resident’s call light pad was clipped to the bed linen and not within reach of the resident’s cheek, and stated it should be placed next to the cheek because that is how the resident is able to call staff for help. An LVN later stated the resident could only move his head and neck and needed the call light pad next to his cheek to request help, including suctioning or in an emergency. The resident’s care plans did not include instructions directing staff to place the call light pad next to his cheek, and the DON stated that if a resident requires the call light next to the cheek, then it must be placed there. For another resident with hemiplegia, hemiparesis, left hand contracture, reduced mobility, and dependence for all functional/self-care areas, the call light system was observed stuck between the side rail and not within reach. The resident stated she was unable to move her arms or legs and could not reach or press the call light button. Her hands were contracted and her elbows were bent. A CNA stated the resident was fully dependent, could not move her arms because they were contracted, and if the call light was not within reach the resident could not call for help. The DON stated that if a resident was unable to press the call light system, the facility would replace it with an appropriate system such as a pad call light, and acknowledged the facility was not following its policy.
Advance directive forms were not placed in resident records
Penalty
Summary
The facility failed to ensure that Advance Directive Acknowledgement Forms were offered or obtained and readily accessible in the medical records for four sampled residents. The facility policy stated that a copy of the Advance Directive is to be maintained in the resident’s medical record, and if present, admission staff or designee were to place or scan it into the record and notify Social Services of its existence. Surveyors found that the forms for Residents 13, 14, 21, and 124 were not in the hard copy chart or electronic health record, and in some cases were still kept in a binder in the office instead of the resident’s medical record. Resident 13 was admitted with diagnoses including an upper right tibia fracture, end stage renal disease, and asthma. The resident’s H&P stated the resident had capacity to understand and make decisions, and the MDS later indicated intact cognition. A review of the resident’s Advance Health Care Directive Acknowledgment Form showed that an Advance Health Care Directive was in place, but the POLST stated the resident did not have an Advance Directive. During interview, SSA 1 stated the resident had an Advance Directive but did not provide it to the facility, and there was no documentation of it. The SSD confirmed the Advance Directive was not readily available in the facility and stated there had been verbal follow-up only, with no documentation of follow-up. Resident 14 was admitted with acute respiratory failure, hypertension, and dysphagia, and the MDS and care plan described severely impaired cognition, impaired cognitive function, and aphasia. Resident 21 was admitted with post-laminectomy syndrome, spinal stenosis, and hypertension; the H&P stated the resident had capacity to understand and make decisions, and the MDS later showed intact cognition. Resident 124 was admitted with a left femur fracture, anemia, and MI; the H&P stated the resident had capacity to understand and make decisions, while the MDS showed moderately impaired cognition. During record review, RN 3 stated there were no ADA forms in the hard copy records or EHR for Residents 14, 21, and 124, and the SSD stated the forms were still in a binder in the office rather than in the residents’ medical records. The DON stated the ADA form must be readily accessible in the hard copy record so licensed nurses would know how to respond and provide treatment in accordance with the residents’ medical treatment wishes.
Medications Left Unattended and Unlabeled on Medication Carts
Penalty
Summary
The facility failed to ensure that medications were securely stored and labeled in accordance with its Medication Labeling and Storage policy. During observation, an LVN left a medication cart in the hallway unattended with Resident 96’s medications on top of the cart, including nitroglycerine, midodrine, and Depakote. The LVN stated she had gone outside to speak with the DON and forgot to place the medications inside the drawer, leaving them accessible without staff present. The DON and Administrator both stated that medications should not be left unattended and should be stored inside the medication cart. The facility also failed to keep discarded medications secured inside the waste containers on medication carts. On Medication Cart 1, two white pills and one yellow-green capsule were observed on top of the pharmaceutical waste container lid, visible and able to be taken by hand while residents were nearby. On Medication Cart 2, one white pill was observed on top of the waste container lid in the same manner. Staff stated the medications should have been inside the waste container or secured inside the cart, and the DON stated that unsecured discarded medications could be taken and ingested by residents or visitors. The facility further failed to ensure that several medications and house supply items had opened-date labels. On Medication Cart 2 and Medication Cart 4, house supply medications including docusate sodium, multivitamin with minerals, and senna were observed without an opened-date label. On Medication Cart 4, opened medications for residents included diclofenac sodium topical gel for two residents and an open bottle of valproic acid oral solution for another resident, all without labels showing when they were opened. Staff stated the medications needed opened-date labels to track expiration and effectiveness, and the facility policy stated that medication containers with missing or improper labels should be handled according to pharmacy instructions.
Unsafe Food Storage, Labeling, and Cooling Practices
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional food service standards and its own policies. During a kitchen tour and interview with the Certified Dietary Manager, surveyors observed multiple refrigerated items stored past their labeled use-by dates, including one case of apples, one case of oranges, one case of iceberg lettuce, one case of onions, eleven cups of vanilla yogurt, one five-pound tub of sour cream, and four plates of chef salads. One case of tomatoes had no received date or use-by date, and two jars of opened applesauce were observed, one marked with handwritten dates and one with no use-by date. The CDM stated that refrigerated foods without labels or with incorrect dates were considered unsafe for resident consumption and that staff were responsible for properly labeling, dating, and disposing of foods past their shelf-life dates. Surveyors also observed a tray of cooked beans with a cooling label dated 2/1/2026, but the cooling log was blank. The CDM stated the cook did not record temperatures in the cooling log, and the cook stated he cooked the beans around 12 PM, checked them again around 2:30 PM, and should have checked them again according to the log instructions. On later review, the CDM stated the facility did not have a policy for cooling TCS foods and that the cooling log was not initialed from 2/2/2026 to 2/5/2026 by the cooks or the CDM to verify proper cooling each working day. The facility policy required all food to be appropriately stored, labeled, and dated, and the Food Life Reference Sheet listed shelf-life limits for sour cream, applesauce, fresh vegetables, and fresh whole fruit.
Inaccurate medication orders and falsified psychotropic consent documentation
Penalty
Summary
The facility failed to ensure accurate communication, verification, and documentation of medical records for Residents 176 and 168 when LVN 2 documented telephone orders to extend the morning medication pass by two hours without confirming the orders with the physician. For Resident 176, the chart showed an order entered by LVN 2 stating that MD 1 had authorized the extension, but interviews with MD 3 and NP 1 indicated neither had been notified of the delay or given such an order. LVN 2 stated she had spoken with MD 2 about a delay affecting residents under MD 2’s care, but she did not provide resident names or medication details, did not return the call to clarify the order, and later entered the order under MD 1’s name. The resident’s 9:00 AM medications were still not documented as given nearly three hours later, and the order lacked specific details about which medications were included and the exact timeframe for the extension. For Resident 168, LVN 2 documented a similar telephone order from MD 2 to extend the morning medication pass by two hours, but MD 2 stated she had only instructed LVN 2 to call back with the specific residents and medications involved before any adjustment could be made. MD 2 later stated she received another call that evening after the medications had already been given late and then provided specific instructions for adjusting administration times. The documented order again lacked specific details about which medications were affected and the exact start and end times for the extension. DON 2 stated that licensed staff were expected to communicate directly with the physician when medications were late and that any extension order should clearly identify which medications were to be administered or held. The facility also failed to ensure accurate and authorized documentation of informed consent for psychotropic medications for Resident 106. Resident 106 had diagnoses including major depressive disorder and Alzheimer’s disease, and the record indicated she lacked capacity to make decisions, with FM 3 listed as the responsible party. The record contained psychotropic medication consent forms for Imipramine and Trazodone, but RN 3 later stated she wrote and backdated DON 2’s name on the Imipramine consent and wrote LVN 3’s name on the Trazodone consent without authorization. RN 3 also added dates and other information to the forms after the fact. FM 3 stated she did not consent to antidepressant medications and had not received follow-up from PMHNP 1, while LVN 3 and DON 2 both stated they had not verified or obtained the consents and did not write the names appearing on the forms. PMHNP 1 stated he did not know Resident 106 lacked decision-making capacity, did not know FM 3 was the responsible party, and did not obtain informed consent before prescribing Trazodone or Imipramine.
Infection control program not followed during influenza outbreak and enhanced barrier precautions
Penalty
Summary
The facility failed to implement its infection prevention and control program by not keeping the infection control policy binder readily available to staff and by not ensuring staff knew where to find the current list of reportable communicable diseases. During interview, the Infection Preventionist Nurse stated the facility’s infection control policies were only available online, there was no printed copy in the facility, and she could not find the current reportable disease list. RN 1 and RN 2 also stated they did not know where to find the infection control policies or the current reportable communicable disease list. The facility also did not follow the county Department of Public Health’s influenza outbreak guidance for residents who were close contacts of confirmed influenza cases. Resident 96 developed cough and fever, was hospitalized, and tested positive for influenza A. Resident 99 was transferred to the hospital for respiratory distress and later reported positive for influenza at the hospital. The Infection Preventionist stated she did not test the roommates and close contacts of these residents, including residents who were asymptomatic, and the facility’s line list only included symptomatic residents. The report also states that Resident 137, a roommate of Resident 96, had cold-like symptoms that were not known to the Infection Preventionist until the surveyor informed her. Resident 34 developed cough and cold-like symptoms, later had fever and right lower lobe pneumonia, and was transferred to the hospital; the Infection Preventionist stated she did not follow up with the hospital or family to confirm the influenza diagnosis and did not include Resident 34 on the line list. The facility further failed to offer Tamiflu to two residents who were close contacts of Resident 96, and failed to monitor or test multiple close contacts for influenza as directed by public health guidance. The Infection Preventionist stated she did not document offering Tamiflu to residents 128 and 137, and both residents denied being offered the medication. She also stated she used the wrong influenza test kits, which made the tests invalid, because she assumed the kits used for COVID testing could also be used for influenza without verifying with the lab. In addition, the facility failed to follow Enhanced Barrier Precautions for residents with G-tubes: an LVN entered Resident 147’s room and administered medications via G-tube without wearing an isolation gown, and another LVN did the same for Resident 153. A third LVN failed to change isolation gowns when providing care between two residents, including one resident on EBP for a G-tube, despite the facility’s policy requiring PPE for high-contact care activities involving feeding tubes.
Failure to Provide Bed-Hold Notice and Documentation
Penalty
Summary
The facility failed to ensure that one of three sampled residents, Resident 170, was provided written information regarding the facility and state bed-hold policies when the resident was transferred to a general acute care hospital. The facility’s Bed-Holds and Returns policy stated that all residents or representatives are to be provided written information about bed-hold policies that address holding or reserving a resident’s bed during hospitalization or therapeutic leave. Resident 170 was admitted on 3/19/2025 with diagnoses including type II diabetes mellitus and hyperlipidemia, and an MDS dated 10/6/2025 indicated no cognitive impairment. Resident 170’s MDS dated 12/12/2025 indicated discharge to a short-term general acute care hospital after a fall. During interview and record review, the Assistant MDS Nurse stated there was no record of a transfer order in the medical record and no bed-hold order transcribed in the resident’s records. The Bed Hold Policy Notice & Authorization also lacked specific bed-hold dates, resident/representative and facility signatures, and a signing date, and there was no documented evidence that staff provided the bed-hold notice to Resident 170 at the time of transfer. The DON stated the nurse should have obtained a physician order for transfer and bed hold, kept the notice in the medical record, and provided the bed-hold notice to ensure the resident’s rights to return to the facility were respected and honored.
Baseline Care Plan Not Initiated Within Required Timeframe
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for one of three sampled residents, a resident admitted with Type 2 Diabetes Mellitus with a foot ulcer, essential hypertension, and hyperlipidemia. The facility policy stated that the baseline care plan is to be developed within 48 hours of admission and include the minimum healthcare information necessary to properly care for the resident, including initial goals based on admission orders and physician orders. The resident’s admission record showed admission to the facility on [DATE], and the history and physical signed by the NP indicated the resident had the capacity to understand and make decisions. The baseline care plan was not initiated until 2/02/2026, three days after admission, and it did not specify which of the resident’s needs would be met, such as specific treatments, diagnoses, or medications. A separate care plan for hyperglycemia/hypoglycemia related to diabetes was also initiated and created on 2/02/2026. During interview, the admitting LVN stated she forgot to initiate the baseline care plan on admission and assumed the incoming shift nurses would complete any missing baseline care plans and assessments. The DON stated that baseline care plans should be initiated within 48 hours of admission and that this resident’s plan should have been initiated when the resident was admitted.
Incomplete care plans for dementia, pressure injury risk, and language access
Penalty
Summary
Resident 1 did not have a resident-specific comprehensive care plan that addressed the resident’s dementia diagnosis or the use of Ativan, trazodone HCL, and divalproex sodium. The resident’s record showed diagnoses that included dementia, depression, and anxiety disorder, and the MDS indicated severe cognitive impairment and that the resident was receiving antipsychotic, antianxiety, and antidepressant medications. The H&P stated the resident did not have the capacity to understand and make decisions. The order summary showed divalproex sodium 500 mg three times daily for labile mood, trazodone HCL 50 mg at bedtime for depression manifested by inability to sleep, and Ativan 1 mg every 12 hours for anxiety manifested by aggressive behaviors. During interviews, the LVNs and DON stated the resident should have had a dementia care plan and separate care plans for each of these medications so staff would know the resident’s diagnoses, medications, goals, and interventions. Resident 14 was identified as being at risk for pressure injury, but the care plan did not include a comprehensive plan based on that risk. The resident’s record showed admission with diagnoses including acute respiratory failure, hypertension, and dysphagia. The MDS indicated severe cognitive impairment and dependence for rolling, sit-to-lying, and chair/bed transfers. The Braden Scale dated 11/11/2025 indicated the resident was at risk for developing pressure ulcer. CNA documentation from 1/1/2026 through 2/4/2026 indicated turning and repositioning per resident comfort and as needed, and the record review with the DSD showed the resident was repositioned when needed. However, the care plan did not contain a comprehensive intervention plan for pressure injury prevention. During observation, the resident’s sacrococcyx skin was red and non-blanchable, and an LVN stated the resident did not have a special mattress and should have been repositioned every two hours. Resident 44 had a documented language barrier, but the care plan was not implemented as written to provide interpreter support in the resident’s room. The resident’s assessment identified Cantonese as the primary language, and the impaired communication care plan included use of a language line and allowing sufficient time to process and respond. During observation, the resident did not have a bilingual communication board in the room and responded only by nodding until asked about language preference, when the resident stated Chinese. With a Chinese interpreter, the resident stated he did not communicate with facility staff because they did not understand him and rarely had a Chinese interpreter, and he said he felt very sad because nobody understood him. Staff interviews reflected that the resident did not have a communication board and that staff were not aware he could not understand them, while the DON stated the resident should have had a communication board or translator line in the room.
Failure to Provide Haircut and Grooming Assistance
Penalty
Summary
The facility failed to provide necessary care and services to assist three sampled residents with grooming, including haircuts, resulting in residents not maintaining good personal hygiene and a clean appearance. Resident 28 had diagnoses including COPD and hypertension, had no cognitive impairment, and required supervision with personal hygiene. Resident 24 had diagnoses including type II diabetes mellitus and hypertension, had no cognitive impairment, and was independent with ADLs including personal hygiene. Resident 73 had right-sided hemiplegia and type II diabetes mellitus, was moderately impaired with cognition and memory, and required substantial/moderate assistance with personal hygiene. During observation and interview, Resident 28 stated the facility had not provided or offered haircut assistance since November 2025 and that haircut events for male residents were no longer being arranged. Resident 24 stated the facility had not offered haircut services for male residents for two to five months, so he had to arrange and pay for a haircut outside the facility himself. Resident 73 stated he requested a haircut upon admission after a month-long hospitalization, but it had not been provided; he showed blunt children's scissors he used to trim the sides of his hair himself, leaving the top and back long because he could not reach those areas. The Social Services Director stated the person who previously provided haircut services for male residents resigned in December 2025 and a replacement had not yet been found. The SSD acknowledged she did not inform or assist the three residents or their responsible parties about options for transportation and financial assistance to obtain haircuts outside the facility. The DON stated haircuts were important to preserve residents' dignity, particularly for Resident 73, and to ensure safety and prevent injury when trimming his own hair. Facility policies on dignity, activities/social services, and ADLs stated residents should be cared for in a manner that promotes self-worth, that the facility should help arrange outside activities as much as possible, and that residents unable to perform ADLs independently should receive services necessary to maintain good grooming and personal hygiene.
Failure to Reconcile Hospital Diabetes Medications on Admission
Penalty
Summary
The facility failed to provide appropriate medication reconciliation on admission for a resident with Type 2 diabetes mellitus and a foot ulcer. The resident was admitted from a general acute care hospital with discharge instructions listing Alogliptin 12.5 mg daily, Glipizide 5 mg twice daily before meals, and Insulin Lispro sliding scale to be given before meals and at bedtime. The facility’s policy required review of the hospital discharge medication list to ensure medications continued without interruption, but the admitting nurse reviewed only the hospital active medication list and not the discharge orders or instructions. Because the discharge orders were not reviewed and transcribed, the resident’s admission orders did not include Glipizide, Alogliptin, or Insulin Lispro. The resident’s blood glucose readings during the admission period ranged from 136 to 267 and later from 112 to 280, yet no insulin coverage was administered during the four-day period described because the insulin order had not been entered. The resident told staff that the diabetic medications he had been taking before admission were not being given, and he was informed they were not included in the physician’s orders. The admitting nurse stated she did not locate the hospital discharge medication list, reviewed only the hospital active medication list, and forgot to endorse the task of obtaining the discharge orders before leaving her shift. She later entered the missed oral diabetes medications after the discharge orders were obtained on a later date. The RN, NP, and DON all confirmed that the discharge orders were not properly reviewed and that the admitting nurse did not communicate the missing discharge medications or diabetes management information to the admitting provider.
Failure to Assist Dependent Resident With Ordered Transfers and Mobility
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not met for one sampled resident who was dependent on staff for rolling, bed mobility, and chair/bed-to-chair transfers. The resident was admitted with diagnoses including post-laminectomy syndrome, spinal stenosis, and hypertension, and the MDS indicated intact cognition but dependence on staff for multiple mobility tasks. The care plan identified the resident as requiring a mechanical lift with a large sling and two staff for transfers, and it was later updated to include transfer to a chair for 2 hours as tolerated with a pressure relieving cushion. Physician orders also directed staff to assist with transferring to a chair for 2 hours as tolerated with a pressure relieving cushion. The resident's ADL flowchart from 1/1/2026 through 2/4/2026 showed chair/bed-to-chair transfer as not applicable or left blank on all shifts. During observation, the resident was found lying in bed and stated he had not been assisted out of bed since the prior month. A CNA stated she did not assist the resident out of bed because she did not know the level of assistance required, and an LVN stated she had not assisted or offered the resident to get out of bed and did not remember the last time she saw him sit in a chair. The DSD stated CNAs should know their assignment, receive report from the previous nurse, and chart refusal if care is refused rather than marking not applicable. The facility's ADL policy stated residents unable to carry out ADLs independently should receive appropriate support and assistance with mobility in accordance with the plan of care.
Suprapubic catheter drainage bag left above bladder level
Penalty
Summary
The facility failed to implement interventions to prevent CAUTIs for one sampled resident with a suprapubic catheter. Resident 151 was admitted and readmitted with diagnoses including neuromuscular dysfunction of the bladder, muscle weakness, and surgery of the genitourinary system. The resident’s H&P documented that he had a suprapubic catheter and had the capacity to understand and make decisions, while the MDS indicated moderately impaired cognition and dependence for activities including toileting and rolling in bed. Resident 151’s physician orders included a suprapubic catheter to drainage bag, replacement of the drainage system if disconnections or leakage occurred, and monitoring of the catheter for urine color, hematuria, odor, and sediment with notification of the MD if abnormal. The care plan for the suprapubic catheter included a goal for no signs and symptoms of UTI and interventions for staff to place the catheter in proper placement. The facility’s CAUTI prevention policy required maintaining unobstructed urine flow by keeping the drainage bag below the level of the bladder at all times. During observation, Resident 151’s catheter bag was found on top of the bed next to his left leg and appeared empty. The resident stated he did not know why the bag was there or who placed it there. The AMDSN confirmed the bag was not draining properly because it was not below bladder level and stated urine could stay in or back up into the bladder, which could cause a urinary infection. TN 1 stated she had recently changed the catheter bag and forgot to place it below bladder level because she rushed out of the room. When the AMDSN placed the bag on the bed rail, approximately 100 mL of urine drained into it. The DON stated catheter bags must be placed below the bladder and that placing the bag on the bed was not appropriate.
Incomplete Post-Dialysis Assessments and Documentation
Penalty
Summary
The facility failed to ensure that post-dialysis assessments were completed and documented in the treatment record for a resident receiving ongoing hemodialysis. The facility’s Dialysis Care policy stated that nursing staff would communicate the resident’s current vital signs and any changes in condition to dialysis staff and would send a dialysis communication form to the dialysis center each time a resident was scheduled for off-site dialysis. The policy also stated that documentation would be maintained in the resident’s medical record. Resident 70 was admitted with ESRD, dependence on renal dialysis, and CHF, and the resident’s orders showed dialysis scheduled Monday, Wednesday, and Friday with transportation arranged for 1 PM treatments. The resident’s MDS indicated intact cognition, oxygen therapy, and dialysis. Review of the Hemodialysis Communication Record for 1/14/2026, 1/23/2026, and 1/30/2026 showed the Post HD Treatment section was not completed or signed by a licensed nurse. During interview, an LVN stated that when a resident returns from dialysis, staff must take vital signs and complete the post-dialysis section of the record. The DON confirmed the post-dialysis section should have been completed because it contains information needed to assess the resident and provide interventions as necessary.
Failure to Complete Required Physician Visits
Penalty
Summary
The facility failed to ensure the attending physician completed face-to-face visits for Resident 21 once every 30 days during the first 90 days after admission. Resident 21 was admitted on [DATE] with diagnoses of paraplegia, acute kidney failure, and a compression fracture of the T5-T6 vertebra. Review of the resident’s H&P showed the DNP visited the resident on 10/15/2025 and again on 1/27/2026, and the DON stated there was no documented evidence that the attending physician had visited the resident since admission and no evidence that the resident was seen by the DNP in November or October 2025. The DON also stated the DNP completed the H&P on 10/16/2025 and returned on 1/27/2026. The ADM confirmed that the attending physician had not assessed or evaluated Resident 21 since admission.
Incorrect Medication Preparation and Missed G-tube Flushes
Penalty
Summary
The facility failed to ensure medications were prepared and administered according to physician orders and professional standards of practice for a resident with epilepsy, dementia, dysphagia, and severely impaired cognition who received medications via G-tube. The resident’s orders included Levetiracetam oral solution 100 mg/mL, 5 mL via G-tube every 12 hours, along with Amlodipine, Cholecalciferol, Lisinopril, Multivitamin liquid, and a probiotic capsule administered via G-tube. The resident also had an order to flush the G-tube with 30 mL of water before and after medication administration, and at least 15 mL of water after each individual medication. During a medication administration observation, an LVN prepared Levetiracetam by pouring it into a medicine cup while holding the cup in the air at eye level. The amount poured was observed to be greater than 8.5 mL, although the ordered dose was 5 mL. The LVN stated the dose was correct, and later stated that if the surveyor had not intervened, she would have administered more than the prescribed amount. The LVN later acknowledged that she made a mistake when preparing the Levetiracetam because she poured 8.5 mL instead of 5 mL and did not recheck the amount before administration. The same observation showed that the LVN did not follow the ordered G-tube flushing protocol while administering Amlodipine, Cholecalciferol, Probiotic, Lisinopril, and Multivitamin liquid. The LVN did not flush the G-tube with 30 mL of water before medication administration and did not flush with at least 15 mL after each medication. The LVN stated that flushing before medication administration is important to prevent clogging and ensure the resident receives the full dose, and that flushing between medications is necessary to prevent medications from mixing in the G-tube. The DON stated that nurses must administer the correct dosage and flush the G-tube with the ordered amount of water before, after, and between medications.
Failure to Act on Pharmacist MRR Recommendations and Maintain Psychotropic Consents
Penalty
Summary
The facility failed to ensure that licensed nursing staff and the attending physician acted on the consultant pharmacist’s monthly Medication Regimen Review recommendations for one sampled resident. The resident was admitted and later readmitted with diagnoses including dementia, depression, and an anxiety disorder. The resident’s MDS indicated severe cognitive impairment and that the resident was receiving antipsychotic, antianxiety, and antidepressant medications. The resident’s H&P stated the resident did not have the capacity to understand and make decisions. The consultant pharmacist’s MRRs dated 12/1/2025, 12/17/2025, 1/1/2026, and 1/13/2026 identified that the carvedilol order should be updated to include administration with food or meals. Review of the MAR and order summary showed carvedilol 6.25 mg twice daily with hold parameters for blood pressure and heart rate, but the order did not include instructions to give with food or meals. During interview, the PC stated the recommendation should have been followed and that giving the medication with food or meals was important for absorption. The MRR also identified that informed consents for trazodone and Ativan should be current. The resident’s psychotropic medication disclosure/informed consent form for Ativan documented verbal consent from the RP, but it did not include the resident’s diagnosis, the duration of use, or specific observable behaviors indicating the purpose of the medication. The comprehensive medical chart did not contain a psychotropic medication disclosure/informed consent form for trazodone. Interviews with the PC and DON confirmed that informed consent for these medications should have been present and complete, and the facility’s policy stated that resident-specific irregularities and clinically significant risks are to be documented and reported, with recommendations acted upon and documented by facility staff or the prescriber.
Failure to Assess, Care Plan, and Treat Leading to Development of Stage 3 Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate pressure ulcer prevention and treatment for a newly admitted resident who was admitted without pressure ulcers and had paraplegia, muscle weakness, and lack of coordination. The admission record and history and physical documented no pressure ulcers on admission, and therapy evaluations showed the resident required maximal assistance for bed mobility, activities, and personal hygiene. Despite this high-risk profile, the Braden Scale for Predicting Pressure Ulcer Risk completed on the admission date was left incomplete, with no scoring or staff signature, and the resident’s risk level for pressure ulcer development was not determined as required by the facility’s Skin Integrity Management policy. From admission through several days, weekly body checks documented no skin breakdown, and the interdisciplinary care conference did not identify or address any pressure ulcer risk or presence. From admission through more than a week, the facility did not develop a comprehensive care plan with specific interventions to prevent pressure ulcers for this resident. No care plan was in place to address pressure ulcer prevention or to incorporate interventions such as repositioning, use of a low air loss mattress, or incontinence management, despite the resident’s dependence on staff for turning and repositioning. During this period, the resident remained on a regular mattress rather than a low air loss mattress. On one day, the resident’s family member assisted a CNA with an incontinent brief change and observed new redness and open skin on the buttocks/sacrococcyx area that had not been present previously. The CNA reported that the resident had refused an earlier brief change, did not know how long the brief had been soiled, and did not directly observe the buttock area during the change because she was holding the resident while the family member performed the cleaning. Later that same day, an LVN was informed by the family member about the skin issue and initially had not yet assessed the resident’s skin or notified the physician. After assessing the resident, the LVN documented a change in condition note indicating a deep tissue injury on the left buttock and a Stage 3 pressure ulcer with surrounding deep tissue injury on the sacrococcyx and reported notifying the physician with a recommendation for wound consultation and treatment orders. However, there was no documentation of physician wound treatment orders on that date, and the wound was not measured for length, width, depth, or other characteristics at the time of initial identification. Physician orders for wound treatment were documented the following day, directing cleansing with normal saline, application of Medi-Honey and barrier cream to the sacrococcyx Stage 3 ulcer, and zinc oxide to the left buttock DTI. The MAR/TAR showed no evidence that any initial wound or skin treatments were provided on the day the Stage 3 ulcer was identified, and no evidence that the ordered treatments were performed the following day. The LVN later stated she had received a telephone order for treatment but did not enter it into the electronic MAR/TAR because she did not know how, and she did not perform the initial wound treatments, assuming treatment nurses would do so. Subsequent wound assessment by a physician assistant documented a Stage 3 pressure ulcer on the sacrococcyx with purple discoloration, measuring 5 cm by 7 cm by 0.2 cm, with light serosanguineous drainage, and noted that surgical debridement was performed. Later observations confirmed the resident continued to lie in bed without a low air loss mattress, even after the pressure ulcer was identified. A Braden Scale completed several days after ulcer identification showed the resident at moderate risk for pressure ulcer development. Nursing leadership and staff interviews confirmed that the Braden Scale had not been properly completed on admission, that no pressure ulcer prevention care plan had been developed from admission through the period when the ulcer developed, that the wound was not initially measured, and that ordered wound treatments were not provided on the first two days after identification. Staff also acknowledged that the resident required assistance of two people for turning and repositioning and that interventions such as repositioning, maintaining clean and dry skin, frequent incontinence care, and use of a low air loss mattress were standard preventive measures that were not implemented in a timely manner for this resident. The report states that as a result of these deficient practices, the resident developed a deep tissue injury and a Stage 3 pressure ulcer on the sacrococcyx that required surgical debridement. The report further states that these deficient practices placed the resident at risk for infection, discomfort, and pain at the pressure ulcer site.
Failure to Honor Resident Choice and Provide Scheduled Shower
Penalty
Summary
The deficiency involves the facility’s failure to honor a cognitively intact resident’s right to exercise choice and autonomy regarding bathing on a regularly scheduled shower day. The resident, admitted with diagnoses including sepsis and type 2 diabetes mellitus, required substantial/maximal assistance with several ADLs, including shower/bath, and had a care plan indicating she needed partial/moderate assistance for bathing as necessary. Her care plan also documented that it was important for her to have daily routines and preferences accommodated, including choosing between a tub bath, shower, bed bath, or sponge bath. On the date in question, facility documentation for the resident’s bathing task listed all bathing-related items as “not applicable,” indicating no bath type was provided or recorded. On that same day, the resident reported she did not receive a shower despite it being her regular shower day and stated that staff often did not help her shower even when she asked multiple times, which made her feel depressed and useless. She stated she had her own personal hygiene products and did not understand why staff would not assist her. The assigned CNA confirmed that the resident’s regular shower days were Tuesdays and Thursdays and acknowledged that the resident did not receive a shower because the CNA was busy. The CNA reported that when she first approached the resident in the morning, the resident declined a shower at that time due to pain, and the CNA did not return later to offer the shower, nor did she notify anyone else that the shower had not been provided, stating she was busy and forgot. The DON stated that residents should receive showers on scheduled days and that CNAs who cannot provide a scheduled shower are expected to notify the charge nurse so another staff member can assist.
Failure to Restrict and Monitor Visitor Access for Resident With Ongoing Substance Use Incidents
Penalty
Summary
The deficiency involves the facility’s failure to implement and monitor its visitation and substance use disorder policies for a resident with a known history of psychoactive substance abuse and prior fentanyl overdose. The resident, who was cognitively intact but dependent on staff for transfers and with impaired mobility, had an active care plan for substance use that called for monitoring for signs and symptoms of substance use and abuse, such as confusion, drowsiness, outbursts of anger, and mood changes. Despite this, there was no documented evidence over multiple months that staff monitored the resident for these signs as outlined in the care plan. The facility’s visitation policy allowed for limiting or supervising visitors who abused, coerced, or exploited residents or who had a history of bringing illegal substances into the facility, but the facility did not operationalize these restrictions for this resident. Multiple documented incidents showed that the resident possessed or used substances and smoking materials, often in the presence of a specific family member visitor. On one occasion, staff observed the family member staying almost every night in the resident’s room and notified the DON and police due to suspicious behavior, but there was no documented investigation to determine the source of contraband. On another date, staff found the resident with vape devices and Blue Chew pills; these items were removed and given to a family member, and a late entry note by the DON recommended ongoing monitoring due to the resident’s substance-related history. However, there was no subsequent documentation that the resident was supervised or monitored for suspicious behaviors or signs of substance use as recommended. Later, staff documented that the resident’s room smelled like marijuana while the resident was with a visitor, and both were educated on facility policy, but the care plan was not revised to add new interventions related to this event. Further incidents continued without changes to visitation practices or documented monitoring. A restorative nursing assistant reported seeing the resident outside the facility with the same family member, who appeared to place an unknown smoking material to the resident’s mouth; this was reported to nursing and the administrator, and an order was obtained to closely monitor the resident for changes in level of consciousness, but there was no documentation that such monitoring occurred. Subsequently, the resident was found in his room vomiting, with foaming at the mouth and a smell of alcohol present; the family member at the bedside admitted giving the resident alcohol, and the resident was sent to the hospital and diagnosed with alcohol intoxication and alcohol abuse. When the resident returned from the hospital, there was no documentation that supervision or monitoring of the resident or the family member’s visits was implemented. Visitor sign-in records showed that the same family member and other friends continued to visit without restrictions or supervision. Interviews with the administrator, DON, nursing staff, and receptionist confirmed that no visitation restrictions or supervision were put in place for this family member, that there was no investigation into earlier contraband incidents, that the physician was not informed of key events, and that staff were not instructed on specific behaviors to monitor, despite the resident’s history and repeated episodes involving visitor-introduced substances.
Failure to Document and Resolve Resident Grievance Regarding Staff Responsiveness and Professionalism
Penalty
Summary
The deficiency involves the facility’s failure to follow its grievance policy and to promptly address and resolve a resident’s grievance. The facility’s policy titled “Grievances/Concerns,” dated 8/25/2021, states that upon receipt of a grievance or concern, staff will initiate a grievance/concern form and document it on the Grievance/Concern Log, and that the department manager will notify the person filing the grievance of the resolution and/or status within 72 hours. Despite this policy, there was no grievance form or log entry for the concerns raised about staff responsiveness and professionalism, and no written resolution was provided within the required timeframe. The resident involved was originally admitted and later readmitted with diagnoses including sepsis and type 2 diabetes mellitus. A History and Physical dated 12/30/2025 documented that the resident had capacity to understand and make decisions, and a Minimum Data Set dated 1/02/2026 indicated the resident was cognitively intact. On 12/22/2025, during dialysis, the resident reported to the dialysis social worker that staff at the facility did not respond when assistance was requested and that staff behaved unprofessionally, including cursing while at work. The dialysis social worker documented contacting the facility’s Social Services Director (SSD) by phone that same day, with the resident present, and the SSD stated she would follow up with the resident upon her return to the facility. Subsequent documentation from the dialysis center dated 1/12/2026 showed that the dialysis social worker attempted to contact the SSD again, left a voicemail, and did not receive a response. The facility’s grievance/complaint log for December 2025 contained no entries for this resident, and the resident’s progress notes from 12/22/2025 to 1/13/2026 contained no documentation of the concerns or any follow-up. In interviews, the dialysis social worker reported that the resident stated no one from the facility had addressed her concerns, and the resident confirmed that no one had followed up as of 1/13/2026. The SSD stated she had no documented grievances for this resident, did not document verbal concerns because there were too many residents, did not initiate grievance forms unless specifically requested, and could not recall the issues brought to her attention, resulting in no grievance resolution being provided to the resident.
Failure to Identify, Investigate, Report, and Protect After Allegation of Rough Handling During Care
Penalty
Summary
The deficiency involves the facility’s failure to identify, investigate, report, and implement protective measures in response to an allegation of abuse, as required by its Abuse Prohibition Policy and Procedures. The policy stated that staff must identify events that may constitute abuse, immediately remove the alleged perpetrator from duty pending investigation, initiate an investigation within two hours, protect patients during the investigation, and report allegations of abuse to appropriate agencies within specified time frames. Despite these requirements, when a family member reported that a CNA had handled a resident roughly during incontinence care and requested that the CNA not be reassigned, the facility did not treat this as a potential abuse allegation and did not follow the policy’s mandated steps. The resident involved had hemiplegia and hemiparesis following a cerebral infarction affecting the left dominant side, as well as essential hypertension, and was documented as cognitively intact with capacity to understand and make decisions. Staffing records showed that the CNA in question was assigned to the resident on consecutive shifts. A change in condition evaluation documented that the resident claimed the CNA was rough while turning him, and that the supervisor was made aware and the CNA was reassigned for the remainder of that shift. However, there was no indication that the incident was reported to the Administrator or DON as the abuse coordinator, and no immediate investigation or protective measures consistent with the abuse policy were initiated at that time. Interviews further substantiated the allegation and the facility’s failure to act in accordance with its policy. The family member reported that the resident said the CNA hurt his left arm and that a roommate, who was alert, confirmed hearing the resident scream during care. The resident later stated that the CNA pulled him by his left arm, causing pain, and that he screamed but the CNA did not stop or respond. The roommate reported hearing the resident say “you hurt me” while the CNA continued care and appeared to be in a hurry. Despite the family member’s request that the CNA not be reassigned, staffing records and interviews confirmed that the CNA was again assigned to the resident on a subsequent night shift, and the Administrator stated she was not informed of the complaint and that the CNA should not have been reassigned pending investigation. The CNA reported that no one interviewed her or explained why she had been reassigned on the day of the complaint, further demonstrating that no timely investigation or protective process was initiated as required by the facility’s abuse policy.
Failure to Timely Report Alleged Abuse and Prevent Reassignment of Accused CNA
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of abuse and to protect a resident from further contact with the alleged perpetrator, as required by its Abuse Prohibition Policy and Procedures. The policy, dated 2/23/2021, required that upon receiving information about suspected or alleged abuse, the designee report the allegation to CDPH, local law enforcement, the Ombudsman, and other required agencies within two hours, initiate an investigation within two hours, document witness interviews, and protect patients from further harm during the investigation. On 1/11/2026 at 10:00 AM, a cognitively intact resident with hemiplegia and hemiparesis following a cerebral infarction, and the resident’s family member, reported to an LVN that a CNA had been rough while turning the resident and had hurt the resident. The LVN documented the complaint in a Change in Condition Evaluation and reassigned the CNA for the remainder of that shift but did not report the allegation to the DON or Administrator, assuming the RN on duty would do so. As a result, the Administrator, who is the facility’s abuse coordinator, was not informed and no required external reports were made within the mandated two-hour timeframe. The resident’s admission and assessment records showed that the resident had the capacity to understand and make decisions and was cognitively intact. The family member stated that the resident’s roommate, who was alert, confirmed hearing the resident scream while the CNA was changing the resident’s briefs. The family member reported the incident to the LVN and RN and specifically requested that the CNA not be assigned to the resident again. Despite this, staffing assignment sheets showed that the same CNA was again assigned to the resident on the night shift of 1/12/2026. The family member later reported that when she arrived the next morning, the resident stated no one had checked on or changed him during the night, and the family member found the resident’s diaper soaking wet; the resident identified the assigned CNA as the same CNA previously reported for rough handling. The Administrator confirmed she was unaware of the initial complaint and stated that, had she been informed, she would have initiated the abuse investigation and reporting process as outlined in the facility’s policy.
Failure to Control Visitor-Introduced Substances and Supervise High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free of accident hazards and to provide adequate supervision and assistance to a resident with a known history of substance abuse and prior fentanyl overdose. The resident was admitted with psychoactive substance abuse and paraplegia, required assistance with ADLs and transfers, and had care plans and policies in place related to substance use disorder, smoking, visitation, and comprehensive care planning. Despite these, the facility did not consistently assess, monitor, or document signs and symptoms of substance use or abuse as required by the resident’s care plans and the facility’s policies. Staff documented that a family member frequently stayed overnight in the resident’s room and engaged in unspecified suspicious behavior that led to police notification, but there was no documented investigation, IDT follow‑up, or reassessment of the resident for substance use or abuse after this event. The facility also failed to adequately address multiple specific incidents involving contraband substances and unsafe smoking. On one occasion, an LVN observed the resident vaping a substance that smelled like marijuana in his room, with his roommate coughing from the smoke. The resident was later found in possession of vape pens, a marijuana “live resin” vape, and non‑prescribed Blue Chew erectile enhancement pills, which were confiscated. Progress notes and interviews show that although these items were removed and a care plan was created to monitor for changes related to non‑prescribed medications, there was no documented ongoing monitoring for substance use, suspicious behaviors, or adverse effects, and the physician was not informed of these incidents. Staff also documented complaints of the resident’s room smelling like marijuana when the resident was with a visitor, but there is no evidence that the substance abuse care plans were revised with new interventions in response. The facility further failed to enforce its smoking and visitation policies and to implement increased supervision despite repeated incidents involving the same visitor. A smoking evaluation documented that the resident was not allowed to smoke due to being under the legal smoking age and unable to safely hold a cigarette, yet a restorative nursing attendant later observed the same family member placing an unknown smoking material in the resident’s mouth outside the front of the facility. Staff and the administrator approached and educated the resident, and an NP ordered close monitoring for changes in level of consciousness, but there is no documentation of reassessment for substance use or abuse or of specific supervision of visits. Subsequently, the same family member visited again; staff entered the resident’s room, noted smells of smoke, marijuana, and alcohol, and found the resident vomiting, foaming at the mouth, and unable to hold his head up. The visitor admitted providing alcohol, and hospital records confirmed acute alcohol intoxication. After the resident’s return, visitor logs show that the same family member continued to visit without documented restrictions or supervised access, and interviews confirm that staff were not instructed to monitor or supervise visits or to watch for specific substance‑related behaviors, despite the resident’s history and prior documented incidents.
Failure to Provide Ordered Electric Wheelchair and Medically Related Social Services
Penalty
Summary
The deficiency involves the facility’s failure to provide medically related social services, specifically an ordered electric wheelchair, to a paraplegic resident. The facility’s policy on Social Services, dated September 2021, stated that medically related social services are provided to maintain or improve each resident’s ability to meet everyday physical needs, including equipment for ambulation. Resident 1, originally admitted in November 2023 and later readmitted, had diagnoses including paraplegia and psychoactive substance abuse. A Minimum Data Set dated October 10, 2025, documented intact cognition and memory, with the resident requiring partial to total assistance for activities of daily living and being dependent for transfers and toileting. On July 14, 2025, the physician ordered an electric wheelchair for the resident and directed the facility’s case manager to request authorization. However, there was no documentation or endorsement of follow-up on this order. During an interdisciplinary care conference on September 26, 2025, attended by the resident’s family member, Social Services staff, the Director of Rehabilitation, and the Director of Staffing and Development, the team determined that providing an electric wheelchair was not appropriate at that time. Their rationale was the resident’s history of substance use disorder, prior fentanyl use, and recent contraband incidents involving marijuana vape products and non-prescribed supplements, and they believed access to an electric wheelchair could increase the potential for self-harm related to drug-seeking behavior. The record also noted that the resident was using a manual wheelchair with staff and family assistance and could navigate the facility and go on outings with support. Interviews and observations showed that the resident could not independently and safely propel the manual wheelchair. The resident’s family member reported that the resident had requested an electric wheelchair since July 2025 and had not received it, and that the resident was experiencing isolation and loneliness. During observation in the resident’s room, the resident stated he could not safely wheel himself alone and felt his mobility and right to move freely were restricted; when attempting to propel the manual wheelchair in a straight line, he veered to the right and struck the bedside table and wall. A physical therapist confirmed the resident could not propel a manual wheelchair due to poor coordination. The current case manager stated she was unaware of the electric wheelchair order and that there was no documentation regarding the request. The Social Services Director stated she believed Social Services only arranged DME for residents being discharged and did not know what happened to the July 2025 order, while the DON stated Social Services was responsible for arranging DME for custodial residents. The Administrator acknowledged that there was no documented follow-up on the July 14, 2025 electric wheelchair order until the September 26, 2025 meeting and that the decision not to provide the electric wheelchair was based on concerns about the resident’s safety related to illegal substance use behaviors.
Failure to Maintain Resident Dignity During Care Procedure
Penalty
Summary
Certified Nursing Assistants (CNAs) 2 and 3 failed to treat a resident with respect and dignity during a fecal disimpaction procedure. The resident, who was cognitively intact but fully dependent on staff due to quadriplegia and had a history of anxiety and depression, was present in the room when CNAs 2 and 3 engaged in a personal conversation that included derogatory and inappropriate comments. Specifically, while Registered Nurse (RN) 1 left the room to retrieve lubricant, CNA 2 made a comment, "What if you spit on it?" in response to CNA 3's remark, "You can either hit it or quit it," both of which were made in the presence of the resident. The resident reported feeling uncomfortable and upset by these comments and responded by yelling at the staff. Facility policy and procedures reviewed indicated that residents are to be treated with dignity and respect at all times, and demeaning practices are prohibited. The resident's care plan specifically noted the need for staff to maintain the resident's dignity and comfort during incontinence care. Interviews with the CNAs confirmed the inappropriate conversation took place in the resident's presence, and the Director of Nursing acknowledged that such comments could be perceived as hurtful and offensive, potentially resulting in psychosocial harm.
Failure to Implement Fall Prevention Interventions for High-Risk Resident
Penalty
Summary
The facility failed to implement the care plan for a resident with a history of falls, specifically neglecting to ensure the placement of bolster pillows on the mattress while the resident was in bed. The resident, who had diagnoses including Parkinson's Disease with significant tremors and contractures, was dependent on staff for all activities of daily living and functional mobility. Despite being identified as at risk for falls and having experienced unwitnessed falls resulting in pain and hospital transfer, the care plan interventions such as attaching bolster pillows to the mattress and positioning the resident in the center of the bed were not carried out. Observations and interviews revealed that, following the resident's falls, the care plan was revised to include specific interventions like keeping a floor mat on the left side of the bed, moving the right side of the bed against the wall, and ensuring the bed was in the lowest position. However, during multiple observations, the resident was found in bed without the required bolster pillows, and staff confirmed that the bolsters were not present. Staff interviews indicated awareness of the resident's frequent involuntary movements and the need for bolsters to prevent sliding or falling, yet the intervention was not implemented. Further review and interviews with facility staff, including the Assistant Director of Nursing, revealed that the care plan was not updated promptly after the initial fall and that the recommended interventions were not consistently applied, particularly after the resident was transferred to a different room. The lack of communication and follow-through resulted in the omission of the bolster pillows, despite clear documentation and interdisciplinary team recommendations to use them as a preventive measure for recurrent falls.
Failure to Inform and Involve Responsible Party in Pressure Ulcer Care Planning
Penalty
Summary
The facility failed to ensure that the responsible party (RP) for a resident with a stage 4 pressure ulcer was properly informed and included in care planning meetings, as required by facility policy. The resident, who had severe cognitive impairment and lacked decision-making capacity, was admitted with significant medical conditions including a stage 4 sacral pressure ulcer, Type 2 Diabetes Mellitus, and a tracheostomy. Facility policies mandated that the RP be notified of the care plan and participate in the development and revision of the comprehensive care plan, especially for significant conditions such as pressure ulcers. Record reviews and interviews revealed that although the RP was listed as an attendee in care conference documentation, she was not actually present during the meetings. Instead, she was informed separately by phone after the meetings concluded, and the information provided was limited. The RP reported that she was only told that the wound had re-opened, without being informed of the wound's stage, measurements, or specific details. Facility staff confirmed that updates to the RP were not provided regularly or in sufficient detail, and that the RP was not given the opportunity to ask questions or participate meaningfully in the care planning process. Staff interviews further indicated that the RP was not informed about the staging or measurements of the wound, with some staff expressing that such details were withheld because they believed the RP would not understand or would ask more questions. The responsible party was not included in the interdisciplinary care conferences, contrary to facility policy and regulatory requirements, and was not kept fully informed about the resident's wound status or treatment plan. This resulted in the RP being unaware of the severity and progression of the resident's pressure ulcer.
Failure to Administer and Document Physician-Ordered Medications and Treatments
Penalty
Summary
The facility failed to administer prescribed medications and treatments as ordered by the physician for a resident with multiple medical conditions, including epileptic seizures, a pressure ulcer, and chronic kidney disease. Specifically, the resident did not receive scheduled doses of nystatin cream for wound care, Zoryve foam for seborrheic dermatitis, and normal saline flushes for PICC line maintenance on several documented occasions. Review of the Treatment Administration Record (TAR) and IV Administration Record revealed multiple blank entries, indicating missed administrations of these medications and treatments. Interviews with nursing staff confirmed that the absence of documentation on the TAR and IV Administration Record meant the medications and treatments were not given. Both the Licensed Vocational Nurse and the Registered Nurse Supervisor acknowledged that the resident should have received these medications daily as ordered, and that the records should not have contained blank spaces. The staff also confirmed that the missed administrations were not documented as given or offered. The resident reported not receiving his prescribed creams and described feeling unwell as a result. The facility's policy required medications to be administered within one hour of the prescribed time unless otherwise specified, and for all administrations to be documented. The failure to follow physician orders and document medication and treatment administration resulted in the resident not receiving necessary care for his wounds and PICC line maintenance.
Failure to Maintain Consistent Documentation for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to maintain current, detailed, and consistent medical records for one resident who required turning and repositioning every two hours to prevent the worsening of a stage four pressure ulcer, as ordered by the physician. The facility's policy required documentation of the date and time care was given, the names and titles of staff involved, the position in which the resident was placed, reasons for changing position, resident participation, any problems or complaints, refusals and interventions, and the signature and title of the person recording the data. However, a review of the resident's records revealed multiple gaps in documentation by both CNAs and nurses over several days, with missing entries for required time slots and shifts. The resident involved had severe cognitive impairment, a history of a stage four pressure ulcer, Type 2 Diabetes Mellitus, and tracheostomy status, and was unable to make decisions or understand care instructions. Despite physician orders and facility policy, staff failed to consistently document turning and repositioning in both the bedside folder and the computer system. During an interview, the RNS confirmed that if documentation was missing, it indicated the resident was not turned or repositioned as required. These documentation lapses were observed over a period of several days, affecting the resident's prescribed wound care regimen.
Pest Infestation in Resident Room
Penalty
Summary
The facility failed to maintain an effective pest control program to keep Resident 3's room free of pests. Resident 3 was admitted with paraplegia and generalized muscle weakness, was cognitively intact, used a wheelchair, and was dependent on staff for transfers, toileting, and bathing. His care plan identified him as at risk for pest issues and environmental and infection concerns related to hoarding and excessive personal items, with interventions focused on explaining deep cleaning, offering alternative storage, and encouraging him to avoid hoarding food at bedside; however, the care plan did not include pest control treatments in or around his room. During observation, Resident 3 was sitting in his wheelchair with a tray of half-eaten food on his bedside table, and multiple small black pests were seen flying and crawling on the food tray and around the room. Multiple food containers and eating utensils with a foul odor, along with a basin containing a urinal with a strong urine odor, were observed on the bedside drawer next to his bed, and insects were seen crawling and flying around the bedside table and landing on the urinal and utensils. Resident 3 stated there had been flies in his room for a while and they do not go away. CNA 2 stated staff were aware of flies in the room and that she had informed the charge nurse and supervisor multiple times, while the DON stated he was not aware of the flies and that no interventions aside from educating Resident 3 on cleanliness had been completed.
Failure to Post Accurate and Current Nurse Staffing Data
Penalty
Summary
The facility failed to ensure that accurate and current nurse staffing data, including the total number and actual hours worked by licensed (RNs, LVNs) and unlicensed (CNAs) nursing staff, were posted daily at the beginning of each shift as required. Observations revealed that the posted staffing document in the facility's front lobby was outdated by five days and only displayed projected staffing hours rather than the actual hours worked for each shift. The document did not meet the facility's policy, which requires posting the actual time worked for each category and type of nursing staff within two hours of the beginning of each shift. Interviews with the Administrator confirmed that the Director of Staff Development, who was responsible for updating and posting the staffing data, had been on leave, and no other staff member was assigned to this responsibility. The Administrator acknowledged not noticing the outdated posting and had created a document showing only projected staffing hours, not actual hours worked. This resulted in the facility not maintaining compliance with its own policy and regulatory requirements for daily nurse staffing postings.
Failure to Ensure Timely Response and Respectful Communication for Residents
Penalty
Summary
The facility failed to honor residents' rights to dignity and respect in two separate instances involving two residents. In the first case, a cognitively intact resident who was physically dependent on staff for all activities of daily living (ADLs) was observed waiting at least 19 minutes for assistance after activating the call light. During this period, staff were seen at the Nurses' Station while the call light remained illuminated and audible. The resident reported frequent delays in staff response, sometimes waiting up to an hour, and often had to rely on his roommate to seek help. Interviews with staff revealed confusion and lack of accountability regarding who was responsible for responding to the call light, with some staff assuming others would respond. The facility's policy required timely response to call lights, but this was not followed, resulting in unmet needs and compromised the resident's dignity and safety. In the second instance, another resident reported that a CNA used derogatory language, calling him a "stupid old man" after he requested hot water. The resident stated that when he confronted the CNA, the CNA responded, "I don't care." The resident felt disrespected and neglected, and subsequently noticed that the CNA no longer acknowledged or assisted him during assigned shifts. The incident was reported to a nurse, and the resident provided a description of the CNA involved. Documentation and interviews confirmed that the resident felt a change in the CNA's behavior towards him after the incident, leading to further feelings of neglect. Both cases were substantiated through interviews, observations, and record reviews. The facility's policies on answering call lights and treating residents with dignity and respect were not adhered to, resulting in residents experiencing delays in care and disrespectful communication. The deficiencies were directly observed and corroborated by resident statements, staff interviews, and review of facility records.
Failure to Develop and Implement Comprehensive Care Plan for Resident with Inappropriate Behaviors
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident who exhibited inappropriate physical contact with other residents. The care plan did not specify the exact behaviors to be monitored during one-to-one supervision, nor did it provide clear, resident-centered interventions or define the duration and criteria for discontinuing the supervision. The lack of specificity in the care plan was confirmed during interviews with nursing staff and the Assistant Director of Nursing, who acknowledged that the care plan's directive to monitor for episodes of inappropriate touching was vague and not tailored to the resident's actual behaviors. Observations and interviews revealed that the one-to-one supervision outlined in the care plan was not consistently implemented. On multiple occasions, the resident was observed without a staff member providing the required one-to-one supervision. Staff interviews indicated that the assigned sitter was sometimes absent, and coverage was not always provided as required by the care plan. One staff member admitted to monitoring the resident from the hallway while performing other duties, rather than providing continuous, direct supervision as specified. The resident involved had a history of cognitive impairment and required moderate assistance with activities of daily living. The care plan was initiated after incidents of inappropriate touching were reported by another resident, who described multiple episodes of unwanted physical contact. Despite the care plan and orders for one-to-one monitoring, facility staff failed to ensure that supervision was maintained at all times, and the care plan lacked the necessary detail to guide staff in effectively monitoring and addressing the resident's behaviors.
Failure to Provide Adequate Pain Management and Assessment
Penalty
Summary
The facility failed to provide adequate pain management for a resident following a fall that resulted in a right ankle fracture. Despite the resident's ongoing complaints of pain, especially during physical therapy and ambulation, there was a lack of consistent and thorough pain assessment, documentation, and follow-up. The facility's policy required assessment of pain type, frequency, intensity, and duration, as well as re-evaluation of interventions, but these steps were not consistently performed. Documentation often showed zero pain levels and no administration of pain medication, even when physical therapy notes and staff interviews indicated the resident was experiencing pain and refusing to ambulate due to discomfort. There were multiple instances where the resident's pain was not communicated to the nurse practitioner or physician, despite persistent complaints and refusal to participate in therapy. Physical therapy and CNA staff noted the resident's pain and functional decline, but this information was not always relayed to licensed nursing staff or documented in the medical record. Additionally, when pain medication was administered, there was insufficient documentation of pain reassessment to determine the effectiveness of the intervention, as required by facility policy. The lack of communication and documentation led to poor pain control and a decline in the resident's mobility. Interviews with staff confirmed that pain complaints were sometimes forgotten or not reported due to workload, and that there was a lack of awareness regarding the resident's physical restrictions and pain status. The resident's medical history included a right ankle fracture and fluctuating cognitive capacity, which further complicated assessment and management. The failure to accurately assess, document, and communicate the resident's pain, as well as to notify the appropriate medical providers, resulted in inadequate pain management and contributed to the resident's refusal to ambulate and functional decline.
Menu Item Substituted Without RD Approval
Penalty
Summary
The facility failed to ensure the standardized lunch menu was followed when roasted cauliflower listed on the 8/19/2025 menu was not available for all residents and was replaced with alternative vegetables without Registered Dietician approval. During tray line service, Cook 1 served steamed cauliflower to six resident meal trays, and later [NAME] 1 served steamed sliced carrots to 15 resident meal trays instead of the roasted cauliflower listed on the menu for a total of 21 residents. [NAME] 1 stated he ran out of roasted cauliflower, and the Dietary Supervisor stated he did not know why the facility ran out of the item and had to serve alternative vegetables. The Dietary Supervisor stated the replacement was unexpected and the facility was unable to inform residents beforehand or contact the RD before changing the menu. The supervisor also stated residents could be dissatisfied if they expected roasted cauliflower but were served different vegetables without being informed. Resident 39 stated the facility had done this before and that he did not eat the carrots he was sent. Resident 124 stated he was not informed the facility had run out of roasted cauliflower before lunch and wished he had been given a chance to choose an alternative vegetable before the tray was delivered.
Catheter Monitoring and Drainage Bag Positioning Failures
Penalty
Summary
The facility failed to identify and monitor sediment in the urine of residents with indwelling catheters as required by their plans of care, physician orders, and facility policies. The report states that for four sampled residents—Resident 84, Resident 27, Resident 26, and Resident 103—the facility did not consistently document catheter monitoring for sediment in the drainage tubing and drainage bag. The report also states that for Resident 26 and Resident 103, both of whom had suprapubic catheter drainage bags, the bags were not kept below the level of the bladder as required by policy. Resident 27 was admitted with diagnoses including type 2 diabetes and BPH, had fluctuating decision-making capacity, and was dependent for toileting hygiene and showering. The resident had an indwelling catheter and an order for a suprapubic catheter to be flushed every shift. The care plan directed staff to monitor urine for sedimentation. On observation, sediment was seen in the catheter tubing, and the record review showed no documented evidence that a change of condition was completed for the sediment. Staff interviewed stated that sediment in urine could indicate a UTI and that the physician should be notified. Resident 84 had diagnoses including type 2 diabetes mellitus, Fournier gangrene, urethral fistula, and ESRD, and had an indwelling catheter ordered for straight drainage. The care plan and physician order required monitoring the catheter for color, hematuria, odor, and sediment every shift, but the TAR contained multiple dates with incomplete documentation for that monitoring. Sediment was observed in the drainage tubing and bag during the survey. The DON stated that incomplete documentation meant the catheter was not monitored for color, odor, and sediment. Resident 26 had a suprapubic catheter and a care plan intervention to keep the collection bag below bladder level. During observation, the drainage bag was hanging from the bed frame on the upper handrails next to the resident’s head. An LVN stated the bag should not be positioned there and should be below waist level to prevent urine from flowing back into the urinary tract. Resident 103 also had an indwelling catheter and a care plan for catheter care twice daily and as needed; during observation, the suprapubic catheter drainage bag was likewise hanging from the bed frame above waist level next to the resident’s head. The DON stated that both residents’ drainage bags needed to be maintained below waist level to prevent backflow into the bladder.
Failure to Implement Pharmacist MRR Recommendations
Penalty
Summary
Licensed nursing staff and the physician failed to act on multiple consultant pharmacist Medication Regimen Review (MRR) recommendations for four sampled residents. The facility’s Medication Utilization and Prescribing – Clinical Protocol stated that staff and the consultant pharmacist were expected to identify factors affecting medication effectiveness and risks, conduct regimen reviews, and address medication-related problems. The report identified failures involving Resident 100, Resident 4, Resident 8, and Resident 7, with the pharmacist’s recommendations documented in the MRRs but not reflected in the residents’ orders, MARs, or care plans as reviewed by surveyors. For Resident 100, who was admitted with end stage renal disease, depression, and anxiety disorder and had fluctuating capacity to understand and make decisions, the physician ordered escitalopram 10 mg daily for depression. The pharmacist recommended that the physician include the manifested behavior related to escitalopram use in the order and ensure it was recorded in the MAR. The MAR from June through August 2025 showed escitalopram was administered as ordered, but no behavior was documented as being monitored each shift. The DON confirmed the pharmacist had recommended specifying the behavior to monitor, and also confirmed the order and MAR did not include a specific behavior or manifestation to track. For Resident 4, who had schizophrenia, bipolar disorder, depression, and syncope and lacked capacity to understand and make decisions, the physician ordered Risperdal 1 mg twice daily for schizophrenia and schizoaffective disorder, bipolar type. The consultant pharmacist recommended weekly orthostatic hypotension monitoring with blood pressure taken in lying and sitting positions on the same day. The care plan addressed monitoring for mental status changes and side effects, but did not include orthostatic hypotension monitoring. BP summaries showed daily readings with inconsistent position documentation and no indication that orthostatic hypotension monitoring was performed, and the MARs also did not reflect such monitoring. The pharmacist and DON both stated the monitoring should have been conducted, and the manufacturer’s label identified orthostatic hypotension as a known risk. For Resident 8, who had hemiplegia, hemiparesis, and type 2 diabetes mellitus and lacked capacity to understand and make decisions, the physician ordered gabapentin 300 mg via G-tube three times daily, cholecalciferol 50,000 units daily, and Protonix 40 mg oral packet via G-tube each morning. The pharmacist recommended that gabapentin capsule contents be mixed with water before administration, Protonix granules be mixed with apple juice only and not with other liquids or foods including water, and cholecalciferol 50,000 units be changed from daily to weekly dosing. The MARs did not include the mixing instructions for gabapentin or Protonix, and cholecalciferol remained ordered and administered daily rather than weekly. The pharmacist stated the mixing instructions were needed for proper absorption and effectiveness, and the DON acknowledged the pharmacist’s recommendations were not implemented. For Resident 7, who had schizophrenia and severe cognitive impairment and lacked capacity to understand and make decisions, the physician ordered Risperdal 0.5 mg daily via G-tube for symptoms manifested by sudden mood shifts from pleasant to anger, including yelling. The consultant pharmacist recommended weekly orthostatic hypotension monitoring with blood pressure taken in lying and sitting positions on the same day, and later specified that the physician should be notified if systolic BP differed by 20 mmHg or more or diastolic BP differed by 10 mmHg or more between positions. The MARs did not reflect orthostatic hypotension monitoring, and BP summaries showed daily readings with inconsistent position documentation and no indication that orthostatic monitoring was performed. The care plan also did not include orthostatic hypotension monitoring. The pharmacist and DON stated the recommendations were not followed.
Improper Food Storage and Labeling in Kitchen
Penalty
Summary
Food storage was not maintained in accordance with the facility’s policy titled Food Storage- Cold Foods and Food Receiving and Storage. During observation and concurrent interview, a bin of onions stored under the food preparation desk in the kitchen was found with a group of fruit flies when the onions were removed for inspection. Two of the 12 onions in the bin had mold on them. The Dietary Supervisor stated the cook was responsible for checking all produce, even if it was not used, and that dietary staff should have inspected the stored produce when new ordered items were received. During another observation and concurrent interview, a ton of vanilla ice cream in the walk-in freezer was found without a label showing the date opened or a use-by date. The Dietary Supervisor stated he did not see a use-by date or date opened on the package and stated that any kitchen staff who opened the ice cream was responsible for labeling it when it was placed in the freezer.
Missing Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent before administering psychotropic medications to two residents. The report states that the facility did not ensure a written consent, signed by the physician or designee, was obtained showing that the resident or responsible party was informed of the risks and benefits of the proposed treatment before use of Mirtazapine for one resident and Ativan for another resident. The facility policy required the prescriber to inform the resident or resident representative of the initiation, reason for use, and risks associated with psychotropic medications, and required informed consent prior to initiation and verification before administration. One resident was admitted and later readmitted with diagnoses including hemiplegia and hemiparesis. The resident’s H&P stated the resident did not have the capacity to understand and make decisions, and the MDS indicated moderate cognitive impairment. A physician’s order dated 6/30/2025 ordered Mirtazapine 7.5 mg at bedtime via g-tube for depression and noted consent obtained from RP. However, the Psychotropic Medication Administration Disclosure Form was undated and unsigned by the physician, and the form was not complete. During interview, RN 2 stated the form was missing the physician’s signature and the date the consent was obtained, and the DON stated the form did not include whether the risks and benefits were discussed with the RP, the physician’s signature, or the date consent was obtained. The second resident was readmitted with diagnoses including depression and anxiety disorder. The resident’s H&P indicated fluctuating capacity to understand and make decisions, and the MDS showed severely impaired cognitive skills for daily decision making. An order dated 5/20/2025 directed Ativan 1 mg by mouth three times weekly before hemodialysis for anxiety. The Psychotropic Medication Administration Disclosure for Ativan dated 6/19/2025 did not contain the resident or resident representative signature and did not have a counter signature by a second licensed nurse. During interview, the DON confirmed the missing resident representative signature and nurse counter signature and stated the document was a legal document that should have been verified for validity and accuracy.
Call Light Not Within Resident’s Reach
Penalty
Summary
The facility failed to ensure Resident 108’s needs were accommodated by staff according to the resident’s needs and preferences when the resident’s call light was not kept within reach while in bed. The facility’s policy titled "Answering the Call Light" stated that call lights are to be accessible to the resident when in bed to ensure timely responses to requests and needs. During observation on 8/20/2025 at 6:12 AM, Resident 108’s call light was observed behind the bed. During a concurrent interview and observation, CNA 1 confirmed the call light was behind the bed and stated it needed to be within the resident’s reach so the resident could call for help when necessary. CNA 1 also stated the resident would not be able to get help when needed or if he had a medical problem if the call light was not within reach. Resident 108’s record showed diagnoses including type 2 diabetes and cerebral infarction affecting the left side, and the H&P stated the resident did not have the capacity to understand and make decisions. The MDS indicated severely impaired cognitive skills and dependence for multiple ADLs, including toileting hygiene, bathing, dressing, and transfers.
Failure to Notify Physician of Change in Condition
Penalty
Summary
The facility failed to follow its policy and procedure for notification of a change in condition by not immediately informing the resident, the resident’s physician, and the resident representative about a significant change in condition for one sampled resident. Resident 84 was admitted and later readmitted with diagnoses including Type 2 DM, Fournier Gangrene, urethral fistula, and ESRD, and had an indwelling catheter due to Fournier Gangrene. The resident’s care plan directed staff to monitor urine for sediment, cloudy appearance, odor, blood, and amount, and to promptly report sediment, blood, cloudy urine, odor, or fever to the physician. Another care plan identified bilateral lower extremity edema as a fluid volume excess risk and directed staff to notify the physician if edema continued or increased. On 8/18/2025, the resident was observed with edema in both lower extremities and small amounts of sediment in the urine draining in the catheter tubing. During interview, the treatment nurse stated she was unaware of the swelling. Later that day, an LVN stated the prior shift had not endorsed the swelling, she had not assessed the resident’s feet that morning, and she had not notified the physician. The MDS staff reviewed the change-in-condition evaluations and stated none had been completed for the bilateral lower extremity swelling and urine sediment before the survey observation. The DON stated the physician was not notified of the swelling and urine sediment until it was brought to the facility’s attention.
Failure to Update and Safeguard Resident Personal Property
Penalty
Summary
The facility failed to ensure proper documentation, tracking, and safeguarding of a resident's personal property. The facility policy titled Resident's Personal Property stated that all items brought into the facility must be listed on the Inventory of Personal Effects form, that additional items brought in after admission must be added to the list, and that the facility would make reasonable efforts to safeguard resident property and reimburse or replace stolen or lost property at current value. Resident 71 was admitted and later readmitted to the facility with diagnoses including acute kidney failure and hypertension. His history and physical indicated fluctuating capacity to understand and make decisions. The Inventory of Personal Effects form dated 1/23/2025 listed only a hospital nightgown, and under items acquired after original entry it stated no belongings. The form instructions stated that belongings should be identified on admission and updated as necessary throughout the resident's stay. During observation, Resident 71 was noted to be hard of hearing and stated he could not hear well. LVN 3 stated that Social Services was responsible for updating inventory lists and that she had previously seen the resident wearing hearing aids during family visits. The resident was observed retrieving hearing aids from his bedside drawer and asking for help putting them on, while LVN 3 was not aware the hearing aids were stored there. The resident's family representative stated the hearing aids were present at admission, were lost around March 2025, and after unsuccessful attempts to locate them, the family purchased a new set that was kept at the bedside. SSA 2 stated the inventory list had not been updated since admission to reflect the personal belongings currently at the bedside.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Montebello
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Montebello Care Center | 1.2 mi | ★★★★★ | 24 | 0 |
| Pico Rivera Healthcare Center | 1.2 mi | ★★★★★ | 21 | 0 |
| El Rancho Vista Health Care Center | 1.5 mi | ★★★★★ | 23 | 0 |
| Monterey Healthcare & Wellness Centre, Lp | 2 mi | ★★★★★ | 24 | 0 |
| Green Acres Healthcare Center | 2.1 mi | ★★★★★ | 12 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.