Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Rosecrans Care Center during CMS and state inspections, most recent first.
Care plans were not kept current for several residents. A resident with dementia and skin integrity risk, a resident receiving Apixaban for CVA prophylaxis, and a resident with chronic pain all had care plans whose goals were not revised on a quarterly basis. Another resident with encephalopathy, DM, and tinea unguium refused podiatry care, but the non-compliance care plan was not revised to reflect the change in condition or the resident’s refusal. RN stated care plans should be reviewed every 3 months and updated when resident status changes.
Food items were left undated in the pantry and freezer, and raw fish was left uncovered and unattended on a cart in the kitchen. The DS stated the undated dry and frozen items lacked use by dates, and that labeling was needed to support safe storage and prevent contamination, spoilage, and foodborne illness. The DS also stated the raw fish had been left uncovered, could not say how long it had been exposed, and noted the risk of contamination and cross-contamination with nearby ready-to-eat foods.
Failure to notify physician of perma-catheter site changes. A resident with DM, ESRD, and impaired cognition had a right chest perma-catheter with redness and exudate at the insertion site and blood in the tubing. RN and IP staff stated these findings were a change in condition and reportable to the physician, but there was no documentation that the physician was notified.
PASRR screening was inaccurate for a resident admitted with paranoid schizophrenia, dementia, and DM. The H&P stated the resident lacked capacity for medical decisions, the MDS showed moderately impaired cognition and use of antipsychotic meds, and a physician order directed Abilify 15 mg daily for schizophrenia. However, the PASRR stated the resident had no serious mental illness and was not prescribed psychotropic meds, and the BA confirmed the PASRR was not accurate.
A resident with dysphagia, schizoaffective disorder, and CKD stage 5 had a care plan for language and communication needs, but the room did not have a communication board and staff did not know what resources to use to communicate with her. RN stated the care plan lacked measurable objectives, individualized interventions, and timeframes, and the resident said she had never seen the communication board and relied on her husband as her sole interpreter.
A resident with a stage 3 pressure ulcer, DM, ESRD, and severely impaired cognition had a physician order for a LALM for wound management, but staff observed the mattress set at 200 lbs. even though the resident weighed 169 lbs. RN and LVN staff confirmed the setting was incorrect, and RN stated the mattress should have been set closer to the resident's weight as part of skin management.
A resident with dementia, severely impaired cognition, and elopement risk was observed in a wheelchair without an ID band. A CNA confirmed the band was not on the resident’s wrist or ankle and said the resident kept removing it. An LVN and RN stated the ID band was needed to verify the correct resident for meds and treatments and for resident identification if the resident eloped; the facility policy required residents to wear an ID band.
Failure to arrange dialysis transportation for a resident with ESRD. The resident was ordered to receive dialysis on a regular schedule, but when the hospital-provided transport ended, the resident reported he had no ride to dialysis. An LVN said social services knew about the missing transportation, and the SSD stated the facility should have addressed the dialysis transport before the initial coverage period ended.
A resident with ESRD and dependence on renal dialysis missed one dialysis treatment after the facility failed to ensure transportation was arranged when the initial ride contract ended. The resident said he had no ride to dialysis, while the SSD acknowledged transportation planning should have been completed before the arranged coverage expired. The resident’s orders and care plan required dialysis transport on a regular schedule, and the facility was working on an insurance change for transportation coverage.
Missing Monthly Pharmacist Medication Regimen Review: A resident with Alzheimer's disease, major depressive disorder, and psychotic disorder with delusions had severely impaired cognition and lacked medical decision-making capacity, yet the consultant pharmacist did not complete monthly MMRs for several months. RN stated the review was needed for the resident's psychotropic meds, including Depakote and Risperidone, to assess GDR, therapeutic dosing, and monitoring of behavior and lab values, as required by facility policy.
Failure to Identify Resident Food Preferences: A resident with paranoid schizophrenia, dementia, and DM had a care plan and dietary assessment that did not reflect her cultural food preferences. The resident stated she had asked staff for foods from her culture and did not have a menu or alternative selections in her room, while the DS confirmed the resident was eligible for in-room menus and that staff had not reported the request or documented interactions about it.
QAPI meeting attendance sheets showed the IP did not attend two monthly meetings, and the ADM confirmed the IP was absent. The ADM stated the minimum QAPI attendance included the ADM, DON, IP, and three other members, and noted the IP would not be able to address infection control issues or clarify infection control information, concerns, and questions from the team when absent. The facility policy stated the ADM was responsible for ensuring the QAPI program complied with regulatory requirements.
Perma-catheter Site Not Maintained in a Clean and Sanitary Manner: A resident with DM, ESRD, severe cognitive impairment, and hemodialysis had a right chest perma-catheter with redness and exudate at the insertion site and blood in the tubing. Staff were ordered to monitor the access site for signs of infection, but the IP stated there was no documentation of the redness or exudate, despite the facility policy requiring assessment for redness, swelling, drainage, warmth, tenderness, or odor.
A resident with DM, COPD, severe cognitive impairment, and a sacral pressure ulcer experienced a significant change in condition when the ulcer progressed from Stage 2 to Stage 4 after readmission from a hospital. The TXN documented the Stage 4 ulcer on an admission skin reassessment and stated this progression was a significant change, and reported notifying the physician, nurse, and CNA but only attempting once to call the resident’s responsible party, without successful contact or voicemail. The DON stated that licensed nurses are responsible for notifying responsible parties of significant changes, and facility policy requires notifying a resident’s representative of significant physical, mental, or psychosocial changes, but the responsible party was not successfully notified in this instance.
Two residents were involved in an altercation in which one resident, with schizoaffective disorder and a history of aggression, entered another resident’s room and later reported being struck with a foldable chair. An RN responded after hearing screaming and, along with the ADON, confirmed that the aggressive resident continued to have episodes of yelling while awaiting transfer. Although the resident’s care plan called for early redirection and de-escalation techniques and facility policy required documentation of behavioral changes and interventions, the progress notes for that day did not record any behavioral interventions, redirection, de-escalation efforts, or non-pharmacological measures taken during the episode.
A resident with dementia, metabolic encephalopathy, epilepsy, and muscle weakness, and severely impaired cognition, developed a large dark bruise with swelling under the left eye that was unwitnessed and could not be explained, meeting the facility’s definition of an injury of unknown source. The DON and an LVN acknowledged that such injuries must be reported within 2 hours federally and within 24 hours to the state, and facility policy required reporting unusual occurrences and injuries affecting health and safety within 24 hours. Despite these requirements, the unwitnessed facial injury and resulting discoloration were not reported to the state agency within the mandated timeframe, resulting in a deficiency for failure to timely report suspected abuse, neglect, or injury of unknown source.
Surveyors found that the facility did not follow its policy requiring daily monitoring and documentation of refrigerator and freezer temperatures for multiple kitchen units. Temperature logs for three refrigerators (Produce and Breads, Milk and Dairy, Nourishment) and two freezers (Frozen Vegetables and Ice Cream, Frozen Meat) contained blank entries on several morning and evening shifts, indicating that required checks were not completed. The Dietary Supervisor reported that AM and PM cooks were responsible for these checks and acknowledged that failure to monitor and document temperatures could lead to food spoilage, contrary to the facility’s written standards for maintaining safe food storage temperatures.
Surveyors observed that one shower room had dry brown fecal matter on a shower stall wall and a small drop of feces on the floor, and a housekeeper acknowledged that not cleaning and disinfecting these surfaces could make residents sick. Review of the housekeeper job description showed that staff are required to follow infection prevention and control procedures, including cleaning and disinfecting walls and ceilings to remove contaminants with proper solutions. The facility’s infection control policy stated that its practices are intended to maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections, but these procedures were not implemented in this shower area.
Certified nursing assistants failed to fully close privacy curtains while providing ADLs, including incontinent care, to three residents with varying levels of cognitive and physical impairment. In each case, residents were left exposed or visible to others, despite staff acknowledging the importance of privacy and facility policies requiring it.
A resident with intact cognition, muscle weakness, gait impairment, and atrial fibrillation was not given timely discharge notice before a planned discharge. The BO, SSD, RD, and DON confirmed there was no IDT meeting before discharge, and the resident said he was first told about the discharge when asked to sign the NOMNC and that he had not been informed in advance about the discharge plan.
A resident with dementia and a history of wandering was not properly monitored during the night shift, resulting in her entering another resident's room and becoming trapped in her wheelchair. The incident was discovered after a roommate alerted staff, and documentation showed that required monitoring of the wandering behavior was not completed. Staff interviews confirmed awareness of the resident's wandering and the need for supervision, but facility policies for monitoring and supervision were not followed.
A resident with a history of stroke and high risk for bleeding was prescribed both aspirin and Eliquis for CVA prophylaxis. Despite care plan requirements to monitor for bleeding and bruising every shift, staff failed to document any such monitoring over several weeks. The DON confirmed that monitoring for adverse effects of anticoagulant therapy was not performed as required.
Surveyors found that several medications, including eye drops, an inhaler, insulin, lorazepam, and gabapentin, were either not labeled with open dates or not stored according to manufacturer requirements. An LVN confirmed that some medications requiring refrigeration were left at room temperature and that doses had been administered from improperly stored bottles.
A resident with multiple chronic conditions was observed receiving IV fluids through a catheter that lacked a date of insertion on the dressing, contrary to facility policy. Nursing staff confirmed responsibility for IV care and documentation but were unable to explain the missing date label, which is necessary for proper site management.
A resident dependent on supplemental oxygen did not have their oxygen saturation (O2 sat) levels checked every shift as ordered, despite physician instructions to monitor and titrate oxygen to maintain O2 sat at 92% or above. Documentation showed multiple missed O2 sat checks, and an LVN confirmed the monitoring was not consistently performed, contrary to facility policy.
Multiple rooms were found to be below the required minimum square footage per resident, with some rooms housing more beds than the available space allows. A review of facility records and a waiver request confirmed the deficiency, and the Adm acknowledged that while residents had not complained, the limited space could make care provision challenging for staff.
A resident with a history of polyneuropathy, repeated falls, and diabetes mellitus repeatedly reported severe pain after being struck, but no pain medication was administered despite an active physician order and documentation of pain at the required threshold. Both the LVN and DON confirmed that pain was documented but not treated, in violation of facility policy and physician orders.
Two residents with stage 4 pressure ulcers had their wound dressings unlabeled, contrary to the facility's policy requiring nurse initials, time, and date. An LVN admitted to not labeling the dressings, and the DON confirmed the policy was not followed, potentially risking wound infections and delayed healing.
The facility failed to implement its Enhanced Standard Precautions policy, which requires healthcare workers to wear PPE when providing care to residents at high risk for MDRO transmission. Two residents with pressure ulcers did not receive care in accordance with this policy, as observed when LVNs performed wound care without wearing isolation gowns, despite ESP signs being posted. This failure had the potential to result in the transmission of disease-causing organisms and delay wound healing.
The facility failed to ensure clean linens were not placed near washing machines with dirty and soiled clothing. During an observation, 11 linen carts filled with clean linen were found alongside three washing machines with dirty linen washing inside. Both the Housekeeping Supervisor and the Administrator confirmed that this practice could lead to cross-contamination and spread of infection, violating the facility's policy on laundry and linen.
The facility failed to ensure staff promoted dignity while assisting a resident during meals. A CNA was observed standing over the resident and not maintaining face-to-face eye contact, which could make the resident feel rushed and affect their dignity. Staff interviews and the resident's feedback confirmed the importance of assisting at eye level to promote comfort and dignity.
A resident with multiple diagnoses, including schizoaffective disorder and major depressive disorder, was administered Seroquel without documented informed consent. Facility staff confirmed that informed consent is required before administering psychoactive medications, but this policy was not followed.
The facility failed to ensure a safe, clean, and homelike environment for a resident with moderate cognitive impairment and multiple health conditions. The resident's room had chipping paint and visibly soiled walls, which were acknowledged by the Maintenance Supervisor, Housekeeping Supervisor, and Director of Nursing as unacceptable and potentially posing an infection control issue.
The facility failed to ensure an accurate MDS assessment for a resident regarding the pneumococcal vaccine. The resident, who was not eligible for the vaccine, was incorrectly documented as having declined it. The MDS Nurse confirmed the inaccuracy, and there was no supporting documentation in the resident's clinical records.
The facility failed to complete and resubmit the PASRR Level I screening and refer a resident with a new diagnosis of psychosis for a PASRR Level II evaluation. The resident's new diagnosis and use of psychotropic medication were not communicated to the business office, resulting in the case being closed without the required evaluation.
The facility failed to initiate a care plan for RNA services for a resident with ataxia, muscle weakness, repeated falls, and cardiomegaly. Despite physician orders for daily ambulation assistance, no care plan was created, potentially affecting the resident's care quality.
The facility failed to revise a resident's care plan to include a physician-ordered back brace for low back pain. Despite the order, the care plan was not updated, placing the resident at risk for inadequate back support.
The facility failed to provide adequate oral hygiene for a resident who was totally dependent on staff for daily living activities. The resident, with multiple diagnoses including cerebral infarction and diabetes, was observed with thick dried yellowish particles on her mouth and tongue. Despite the care plan specifying oral care every shift, this was not done, as confirmed by the DSD and DON.
The facility failed to provide a resident with her preferred activity of participating in group activities in the dining recreation area. Despite the resident's expressed desire and ability to participate, she remained in bed due to a lack of scheduling and limited supply of reclining wheelchairs. Staff confirmed there was no reason for her not to participate, and the Activity Director noted her absence from group activities.
A resident with limited range of motion was not provided with a left hand roll as ordered by the physician. Instead, the hand roll was incorrectly applied to the right hand, despite clear directives in the care plan and physician's orders. This error was confirmed by both the RNA and OT, highlighting a failure to follow the facility's policies on individualized, resident-centered care.
The facility failed to ensure a resident receiving hemodialysis had an emergency kit available at the bedside and did not communicate a fluid restriction recommendation from the dialysis center to the resident's physician. The absence of the emergency kit and lack of communication were confirmed by staff and violated the facility's policy.
The facility failed to label two medications with open dates and did not follow the manufacturer's guidelines for budesonide inhalation suspension for two residents. This was confirmed by an LVN and the DON, who emphasized the importance of documenting open dates to ensure medication potency and adherence to guidelines.
A resident with low back pain did not receive a physician-ordered back brace, despite the order being medically justified. Interviews and observations confirmed the back brace was not available, and there was a lack of communication between nursing staff and physical therapists. The facility's policy required therapeutic services to be provided upon a physician's written order.
A facility failed to offer the pneumococcal vaccine to a resident with multiple medical conditions, despite the resident being eligible according to the facility's policy. The Infection Preventionist Nurse did not document any offer, decline, or administration of the vaccine, increasing the resident's risk of developing pneumonia.
The facility failed to ensure that 17 resident rooms met the required square footage per resident, with multi-resident rooms measuring less than 80 square feet per resident and single-resident rooms measuring less than 100 square feet. The Administrator acknowledged the non-compliance but stated that resident care had not been affected. A waiver request had been submitted previously, indicating that there was adequate space for nursing care and that the health and safety of residents were not in jeopardy.
A resident with quadriplegia and significant mobility impairments sustained a right upper arm fracture due to inadequate supervision and assistance during ADLs. The care plan did not specify the need for two-person assistance, leading to a CNA providing care alone. This oversight resulted in the resident's injury and subsequent hospitalization.
A resident with quadriplegia and other severe impairments sustained a significant bruise and fracture, but the facility failed to report the incident to the State Survey Agency within the required two-hour window, delaying the investigation by over 24 hours.
Care plans not updated quarterly or revised after change in condition
Penalty
Summary
The facility failed to keep several residents’ care plans updated on a quarterly basis and failed to revise one resident’s care plan after a change in condition. Resident 4 had diagnoses including dysphagia and dementia. Two of Resident 4’s care plans, one for impaired skin integrity risk and one for communication problems related to dementia, showed goals last revised on dates that were not current. Resident 5 had diagnoses including occlusion and stenosis of the left middle cerebral artery and atrial fibrillation, and was receiving Apixaban for stroke prophylaxis. Resident 5’s anticoagulant therapy care plan showed goals last revised on a date that was not current. Resident 25 had diagnoses including neuralgia, neuritis, osteoarthritis, and chronic pain, and the chronic pain care plan also showed goals last revised on a date that was not current. During interview and record review, RN 1 stated care plans should be reviewed every three months. For Resident 5, RN 1 stated the anticoagulant care plan should have been revised three months after the prior review and that failure to revise it could affect whether staff knew if the medication was effective and whether lab results were abnormal. For Resident 4, RN 1 stated the care plans should have been reviewed every three months and that not doing so could leave staff unaware of changes in cognition or skin integrity status. For Resident 25, RN 1 stated the pain care plan should have been revised three months after the prior review so staff would know whether pain was resolving, ongoing, and whether the resident was tolerating the ordered pain medication. The facility also failed to revise Resident 87’s care plan after the resident refused podiatry care. Resident 87 had diagnoses including encephalopathy, diabetes mellitus, and tinea unguium. The MDS indicated moderately impaired cognition, need for supervision with toilet hygiene, showering, and dressing, and risk for pressure ulcers. A progress note documented that Resident 87 refused to be seen by the podiatrist. RN 1 stated the non-compliance care plan was not revised and that it should have included education on risks and benefits, monitoring of the feet, behavior reinforcement to encourage compliance, and updated approaches to assist with a successful outcome of care.
Food items left undated and raw fish left uncovered
Penalty
Summary
Food items were not dated in the pantry, refrigerator, and freezer, and prepared raw fish was left unsecured in the kitchen. During an observation on 6/2/2026 at 9:00 a.m. in pantry number one, a box of 100 tea bags and a box containing Nestle rich chocolate individualized bags did not have a use by date. During an observation on 6/2/2026 at 9:30 a.m. in freezer number one, one package of frozen chocolate chip cookies also did not have a use by date. In an interview, the Dietary Supervisor stated the two boxed items in the pantry and the frozen package of cookies did not have a use by date and stated that labeling dried and frozen packages with a use by date was essential to ensure food was stored safely and to prevent contamination, spoilage, and foodborne illness. During an observation on 6/4/2026 at 11:11 a.m. in the kitchen, four flat baking trays containing ten raw fish in yellow liquid were left uncovered and unattended on a three-tier cart. In an interview, the Dietary Supervisor stated the raw fish had been left uncovered and unattended and could not specify how long the fish remained uncovered. The Dietary Supervisor stated leaving raw fish uncovered on a baking tray exposed the fish to contamination from dust, debris, or airborne particles, and increased the risk of cross-contamination if juices drip or splash onto nearby ready-to-eat foods. The facility policy and procedure titled Food Receiving and Storage required dry foods to be labeled and dated with a use by date and rotated using a first in-first out system, and the Food Preparation and Service policy stated cross-contamination could occur when raw food touched or dripped onto cooked or ready-to-eat foods.
Failure to Notify Physician of Perma-Catheter Site Changes
Penalty
Summary
The facility failed to ensure the physician was notified when Resident 2 developed redness and exudate at the insertion site of a right chest perma-catheter, with blood noted in the catheter tubing. Resident 2 was admitted and readmitted to the facility with diagnoses including stage 3 pressure ulcer, diabetes mellitus, and end stage renal disease. The resident's H&P indicated the resident did not have the capacity to understand and make medical decisions, and the MDS indicated severely impaired cognition, dependence on staff for toilet hygiene, showering, and dressing, and risk for pressure ulcers. During an observation, Resident 2 was seen with a right chest perma-catheter double lumen with redness and exudate around the insertion site and blood in the lumen tubing. RN 1 reviewed the picture and stated the redness and exudate were a change in condition that should have been reported to the physician to ensure the catheter was properly in place and to prevent worsening of the insertion site. The Infection Preventionist also stated there was no documentation of redness, exudate, or blood in the catheter lumen and that these issues were reportable to the physician. The facility policy titled Change in a Resident's Condition or Status stated staff were to promptly notify the attending physician of changes in the resident's medical condition.
Inaccurate PASRR Screening for a Resident with Schizophrenia
Penalty
Summary
PASRR screening for mental disorders or intellectual disabilities was inaccurate for one sampled resident who was admitted with diagnoses including paranoid schizophrenia, dementia, and diabetes mellitus. The resident’s H&P stated the resident did not have the capacity to make medical decisions, and the MDS showed moderately impaired cognition, partial assistance needed for toilet hygiene, showering, and dressing, and use of antipsychotic medication. A physician order also directed Abilify 15 mg daily for schizophrenia. The resident’s PASRR, dated 7/24/2024, stated the resident was not diagnosed with any serious mental illness and was not prescribed psychotropic medications. During interview and record review, the Business Administrator reviewed the PASRR and stated the resident had schizophrenia and was administered psychotropic medication, and that the PASRR was not accurate. The facility policy stated staff would review the hospital-completed PASRR for newly admitted residents after a hospital stay.
Incomplete Communication Care Plan for an Armenian-Speaking Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered language and communication care plan for one of five sampled residents, identified in the report as Resident 45. Resident 45 was admitted with diagnoses including dysphagia, schizoaffective disorder, and chronic kidney disease stage 5. The H&P dated 6/2/2026 indicated the resident had the mental capacity to understand but lacked the capacity to make medical decisions. The MDS dated 2/27/2026 indicated the resident was able to understand and be understood by others, had intact cognition, and required substantial assistance from staff for ADLs and mobility. The care plan titled "Resident 45 was an Armenian speaking resident" dated 5/20/2026 included an intervention to provide staff and volunteers to interpret in the native language and a communication board as needed for effective communication. During observation and interview on 6/2/2026, the resident's room did not have a communication board, and the DSD stated she did not know if the resident spoke or understood English, did not know that a communication board was not placed in the room, and did not know what resources staff should use to communicate with the resident. During concurrent interview and record review on 6/3/2026, RN 1 stated the care plans did not include measurable objectives, individualized care and interventions, or timeframes based on the resident's assessed needs and preferences. During interview on 6/4/2026 using an interpreter, the resident stated she had never seen the communication board and that her husband was her sole interpreter.
Incorrect LALM Setting for Resident With Pressure Ulcer
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not ensured for one resident who had a physician order for a low air loss mattress (LALM) for wound management. The resident had diagnoses that included a stage three pressure ulcer, diabetes mellitus, and end stage renal disease. The resident's H&P indicated the resident did not have the capacity to understand and make decisions, and the MDS indicated severely impaired cognition, dependence on staff for toilet hygiene, showering, and dressing, and risk for pressure ulcers. During observation, the resident's LALM was set at 200 lbs. A review of the resident's weight showed 169 lbs., and RN and LVN staff confirmed the mattress was set above the resident's weight. RN stated the setting should have been 160 lbs., closer to the resident's weight, and stated the incorrect setting was part of skin management and could slow wound healing. The facility's policy required support surface settings to follow manufacturer recommendations, and the manufacturer manual stated the mattress should be adjusted according to the resident's weight or a health care professional's suggestion.
Missing Resident ID Band
Penalty
Summary
The facility failed to ensure that Resident 70 had an identification band on the wrist or ankle. Resident 70 was admitted with diagnoses including encephalopathy, dementia, and muscle weakness, and the history and physical stated the resident did not have the capacity to understand and make decisions. The MDS indicated the resident’s cognition was severely impaired and that the resident used a manual wheelchair. The care plan identified Resident 70 as an elopement risk/wanderer with a goal to maintain safety. During observation on 06/02/2026, Resident 70 was seen in the hallway in a wheelchair without an ID band. A CNA checked the resident’s wrists and ankles and confirmed there was no ID band, stating the resident kept taking it off and that the facility’s policy was for residents to wear an ID band. An LVN stated that without an ID band, nurses could not verify the correct resident before giving medications, and that the facility’s policy was for residents to wear an ID band. An RN stated all residents had to have an ID band for safety, that it was used to identify residents for medications and treatments, and that Resident 70 could be at risk of receiving the wrong medications if not properly identified. The RN also stated that if Resident 70 eloped without an ID band, there would be no way to identify the resident. The facility’s policy and procedure on resident identification stated that a resident identification system was used to help facility personnel provide medical and nursing care.
Failure to Arrange Dialysis Transportation
Penalty
Summary
The facility failed to provide transportation to dialysis for a resident with ESRD who was dependent on renal dialysis. The resident was admitted with diagnoses including ESRD and anxiety disorder, and the record showed fluctuating capacity to understand and make decisions, with intact cognition on the MDS. The physician ordered transport to dialysis weekly on Tuesday, Thursday, and Saturday, and the care plan identified dialysis on those same days. A hospital document indicated round-trip transportation had been arranged from the facility to dialysis from 5/5/2026 to 5/30/2026. During interview, the resident stated he should have been at dialysis but did not have a ride, and said the transportation driver told him the contract had ended. An LVN stated social services was aware the resident did not have transportation to dialysis and noted that missing dialysis could cause toxic buildup and fluid overload. The SSD stated she usually scheduled transportation after nurses entered appointments, that the hospital that transferred the resident covered the first 30 days of transportation, and that the facility should have worked on dialysis transportation before that first 30-day period ended so the resident would not miss dialysis.
Missed Dialysis Due to Lack of Transportation Planning
Penalty
Summary
The facility failed to ensure the Social Services Director planned transportation to dialysis for one resident with end stage renal disease, anxiety disorder, and dependence on renal dialysis. The resident’s record showed he was admitted with fluctuating capacity to understand and make decisions, was able to make decisions for daily activities, and required staff assistance with eating, oral and personal hygiene, and dressing. His physician ordered transport to dialysis weekly on Tuesday, Thursday, and Saturday, and the care plan identified dialysis on those same days. A hospital document indicated round trip transportation had been arranged from the facility to dialysis for a limited period. During interview, the resident stated he should have been at dialysis but did not have a ride, and said the transportation driver told him the contract had ended. The Social Services Director stated she usually scheduled transportation after nurses entered appointments and acknowledged the facility should have worked on the resident’s dialysis transportation before the initial transportation period ended so he would not miss dialysis. The Business Office Manager stated the resident needed an insurance change for transportation coverage, that the process had been started when he arrived, and that the facility expected it to be completed by the time the arranged transportation ended. The resident missed one dialysis treatment.
Missing Monthly Pharmacist Medication Regimen Review
Penalty
Summary
The facility failed to ensure a licensed pharmacist completed a monthly Medication Regimen Review (MMR) for one sampled resident, identified in the record as Resident 10. Resident 10 was admitted and later readmitted to the facility and had diagnoses of Alzheimer's disease, major depressive disorder, and psychotic disorder with delusions. The resident's H&P stated the resident lacked the capacity to make medical decisions, and the MDS dated 3/3/2026 indicated cognition was severely impaired and that the resident required supervision for oral hygiene and mobility. During a concurrent interview and record review on 5/21/26, RN 1 stated the consultant pharmacist did not complete a monthly MMR in January, February, March, April, or May 2026 for Resident 10's psychotropic medications, including Depakote 125 mg and Risperidone 0.5 mg. RN 1 stated the consultant pharmacist must review the resident's antipsychotic medications to ensure a gradual dosage reduction was considered, verify the dosage remained therapeutic, and monitor behavior and laboratory values for effectiveness. The facility's policy titled Medication Therapy stated the consultant pharmacist would review each resident's medication regimen monthly, upon staff or practitioner request, or when a clinically significant adverse consequence was confirmed or suspected.
Failure to Identify Resident Food Preferences
Penalty
Summary
The facility failed to ensure that the cultural and ethnic food choices of one resident were identified and reflected in the resident’s meal preferences. Resident 107 was admitted with diagnoses including paranoid schizophrenia, dementia, and diabetes mellitus, and the history and physical stated the resident did not have the capacity to make medical decisions. The MDS dated 4/17/2026 indicated the resident’s cognition was moderately impaired and that she was independent with eating. The care plan for nutrition and hydration deficit on therapeutic diet directed staff to adhere to food preferences within the diet order, and the physician orders indicated a no added salt, low sugar regular diet. The Dietary Quarterly Assessment dated 4/17/2026 indicated Resident 107 had no food preferences. During observation and interview on 6/3/2026, the menu and alternative food selection were not in the resident’s room, and the resident stated she wanted food choices from her culture, had told staff about her preferred foods, and was not aware the alternative food choices were posted near the kitchen. The Dietary Supervisor confirmed there were no menus in the room, stated residents with level 7 diets were eligible to have menus in their rooms to select diet alternatives, and acknowledged the resident had a level 7 diet. The supervisor also stated staff had not reported the resident’s request for cultural foods, could not produce documentation of random rounds, and agreed that the resident’s culture food preferences were essential so she could enjoy her meals. The facility policy stated food preferences should be assessed by interviewing the resident directly and documented in the care plan.
QAPI Meeting Lacked Required Infection Preventionist Attendance
Penalty
Summary
The facility failed to ensure the Infection Preventionist attended the February 2026 and May 2026 QAPI meetings. Record review of the monthly QAPI meeting attendance sheets dated 2/20/2026 and 5/22/2026 showed no signature for the Infection Preventionist. During a concurrent interview and record review on 6/5/2026 at 11:06 a.m. with the Administrator and the Director of Nursing, the attendance sheets were reviewed and the Administrator stated the Infection Preventionist did not attend those meetings. The Administrator stated the minimum staff in attendance for QAPI meetings were the Administrator, DON, Infection Preventionist, and three other members, and stated that if the Infection Preventionist was not in the meetings, the Infection Preventionist would not be able to address infection control issues or clarify infection control information, concerns, and questions from the team. Review of the facility policy titled Quality Assurance and Performance Improvement, dated 2/2020, indicated the Administrator was responsible for assuring the facility's QAPI program complied with federal, state, and local regulatory agency requirements.
Perma-Catheter Site Not Maintained in a Clean and Sanitary Manner
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when the facility failed to ensure a perma-catheter was maintained in a clean and sanitary manner for one of five sampled residents. Resident 2 was admitted and later readmitted to the facility with diagnoses including stage three pressure ulcer, DM, and ESRD. The resident’s H&P indicated the resident did not have the capacity to understand and make medical decisions, and the MDS indicated cognition was severely impaired, the resident was dependent on staff for toilet hygiene, showering, and dressing, was at risk for pressure ulcers, and was receiving hemodialysis. A physician order dated 3/17/2026 directed staff to monitor the right chest perma-catheter dialysis access site for redness, swelling, bleeding, drainage, and pain, and to apply pressure and notify the physician if bleeding was noted. During observation on 6/3/2026, Resident 2 had redness and exudate on the skin around the right chest perma-catheter double lumen, and blood was present in the tubing. During interview and picture review, the Infection Preventionist stated staff were to monitor the perma-catheter every shift, but there was no documentation of the redness or exudate around the perma-catheter. The facility policy required catheter care to be safe, sanitary, and appropriate and to assess the site for redness, swelling, drainage, warmth, tenderness, or odor.
Failure to Notify Responsible Party of Significant Change in Wound Status
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s responsible party of a significant change in condition. The resident was admitted and later readmitted with diagnoses including diabetes mellitus, a Stage 4 sacral pressure ulcer, and COPD. A History and Physical dated 1/14/2026 documented that the resident was non-verbal and lacked capacity to make medical decisions, and a subsequent MDS dated 2/28/2026 showed severe cognitive impairment with dependence on staff for toileting, bathing, and personal hygiene. Upon readmission from a general acute care hospital, the admission Skin Reassessment dated 2/25/2026 showed the resident now had a Stage 4 sacral pressure ulcer, whereas the Treatment Nurse stated the ulcer had been a Stage 2 prior to transfer. During interview, the Treatment Nurse stated that progression from a Stage 2 to a Stage 4 pressure ulcer was a significant change and that she notified the resident’s physician, nurse, and CNA, but was unable to notify the responsible party. She reported making one unsuccessful phone call to the responsible party and was unable to speak with them or leave a voicemail, and acknowledged she should have made another attempt. The DON stated that licensed nurses were responsible for notifying residents’ responsible parties when there was a significant change in condition and that such notification was important because it was the responsible party’s right to be informed and included in changes to the plan of care. The facility’s policy titled “Change in a Resident’s Condition or Status” indicated that, unless otherwise instructed by the resident, a nurse will notify the resident’s representative when there is a significant change in the resident’s physical, mental, or psychosocial status, which did not occur in this case.
Plan Of Correction
On March 5, 2026 the Treatment Nurse immediately notified the responsible party of the change in condition of the resident affected and documented this notification in the medical records. On March 5, 2026 the facility Social Services Department and Treatment Nurse interviewed residents' responsible party to address any concerns regarding the communication delay and Interdisciplinary Conference was scheduled for March 18, 2026. On March 5, 2026 the DON and Administrator issued a written warning and provided formal counseling to the treatment nurse for failing to document notifying the residents responsible party of the residents' change of condition. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken; The facility of Medical Records and DON conducted an audit of all residents who experienced a Change in Condition over the past 30 days and ensured that required notification to responsible parties were completed and properly documented. No other findings are noted. On March 6, 2026 and on March 20, 2026 the DON conducted a License Nurses in-service on the facility Change of Condition policy and procedure. The in-service focused on the critical requirement for timely notification of the responsible party and ensuring all communication is thoroughly documented. What measures will be put into place or what systemic changes will the facility make to ensure that deficient practice does not recur;On March 6, 2026 and on March 20, 2026, License Nurses received in-service and education on the facility Change of Condition policy and procedure, emphasizing the requirement to notify residents' responsible parties of any significant changes in a timely manner and the importance of documenting.The Medical Records will perform weekly audits of residents with a change of conditions to verify that the responsible party was notified and that such notification was documented. Findings will be reported to the DON and Administrator. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action is evaluated for its effectiveness. The POC is integrated into the quality assurance system; andThe Medical Records will perform weekly audits of resident with a change of condition to verify that the responsible party was notified and that such notification was documented. These audits will continue weekly for four weeks, followed by monthly reviews for three consecutive months. Audit results will be reported to the facility QAPI Committee for further oversight and trend analysis.Include dates when corrective actions will be completed. The corrective action completion dates must be acceptable to the State Agency.All corrective actions will be monitored daily, weekly compliance audits will be conducted by the Medical Record for four weeks then monthly for three months thereafter that with findings reported to the committee members during the facility's QAPI meeting.
Failure to Document Behavioral Interventions After Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to document behavioral interventions as indicated on the care plan for a resident following an altercation with another resident. Resident 1 was admitted with diagnoses including anemia and schizoaffective disorder and had a documented episode of increased aggression on 2/28/2026, during which he was unable to be redirected and was considered a danger to others. On that date, Resident 1 entered Resident 2’s room, and RN 1 responded after hearing Resident 1 screaming in the hallway. RN 1 found Resident 2 holding a foldable chair, and Resident 1 reported that Resident 2 had hit him on the head with the chair. Resident 2 had been admitted with chronic kidney disease and hypertensive urgency. Resident 1’s care plan, dated 2/28/2026, included interventions for staff to provide early redirection and de-escalation techniques to reduce episodes of verbal aggression. Record review of Resident 1’s progress notes for 2/28/2026 showed that the incident occurred at 11:20 a.m. and that Resident 1 was picked up for transfer at 4:45 p.m., but the notes did not document any early interventions, redirection, or de-escalation measures taken during the period when Resident 1 was intermittently yelling while awaiting transfer. RN 1 acknowledged that the progress notes did not indicate early interventions, redirection, or de-escalation that were done during Resident 1’s episodes of screaming. The ADON confirmed that Resident 1 was alert, oriented, ambulatory, and had episodes of screaming on 2/28/2026, and stated that the progress notes did not document interventions, including non-pharmacological ones. The DON stated that care plan interventions should have been documented if they were completed and that following care plan interventions was important to prevent further behavioral escalation and to keep residents and staff safe. The facility’s policy on Behavioral Assessment, Intervention, and Monitoring required that any improvements or worsening in behavior, mood, and function, as well as new or emergent symptoms, be documented and reported.
Plan Of Correction
How corrective action (s) will be accomplished for those residents found to have been affected by the deficient practice; On March 5, 2026 the Director of Nursing (DON) and Assistant Director of Nursing (ADON) immediately reviewed and updated their care plan to ensure all behavior interventions are current. On March 5, 2026 the DON and Administrator counsel the charge nurse on the specific required documentation following an altercation. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken; The facility of Medical Records and DON conducted an audit of care plans for residents with known behavioral episodes were documented, and any discrepancies found during this audit were corrected immediately. On March 6 and March 20, 2026, the Director of Nursing (DON) conducted in-service training for licensed nurses regarding behavioral de-escalation. The sessions specifically emphasized the requirement to document care plan interventions implemented when a resident exhibits behavioral symptoms. What measures will be put into place or what systemic changes will the facility make to ensure that deficient practice does not recur;The Medical Records Director (or designee) will conduct daily audits of the Electronic Medication Administration Record (EMAR) behavior monitoring. These audits will ensure that for every resident with a documented behavior, corresponding care plan interventions are implemented and charted. All findings will be reported directly to the Director of Nursing (DON) and Administrator for review.On March 6 and March 20, 2026, the Director of Nursing (DON) conducted in-service training for licensed nurses regarding behavioral de-escalation. The sessions specifically emphasized the requirement to document care plan interventions implemented when a resident exhibits behavioral symptoms. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action is evaluated for its effectiveness. The POC is integrated into the quality assurance system; andThe Medical Records will perform weekly audits of behavioral monitoring and progress notes for four weeks, then monthly for the three months. The results of these audits will be reported to the Quality Assurance and Performance Improvement (QAPI) committee for further review and to determine if additional training or systemic adjustments are necessary.Include dates when corrective actions will be completed. The corrective action completion dates must be acceptable to the State Agency.All corrective actions will be monitored daily, weekly compliance audits will be conducted by the Medical Record for four weeks then monthly for three months there after that with all findings reported to the committee members during the facility's QAPI meetings.
Failure to Timely Report Unwitnessed Injury of Unknown Source to State Authorities
Penalty
Summary
The deficiency involves the facility’s failure to report an unwitnessed injury of unknown source to the California Department of Public Health (CDPH) within the required 24-hour timeframe for one resident. The resident had diagnoses including metabolic encephalopathy, epilepsy, dementia, and muscle weakness, with documentation showing fluctuating decision-making capacity and severely impaired cognition. The Minimum Data Set indicated the resident required partial to moderate staff assistance for toileting hygiene, showers, and dressing. A Change of Condition note documented that the resident developed discoloration and swelling under the left eye, described as a dark purplish color. On observation, the resident was noted to have a large dark bruise partially around the left eye and was unable to explain how the injury occurred. Interviews and record reviews showed that the DON and LVN recognized the injury as an injury of unknown source, given that the incident was unwitnessed and the resident could not provide an explanation, consistent with the facility’s policy defining injuries of unknown source. Both the DON and LVN stated that such injuries should be reported within two hours federally and within 24 hours to the state. The facility’s “Unusual Occurrence Reporting” policy required notification to the Department of Health Services of all unusual occurrences, including facility-related injuries requiring medical treatment and other injuries affecting health and safety, within 24 hours. Despite this, the unwitnessed facial injury and resulting discoloration to the resident’s left eye were not reported to CDPH within the required timeframe, constituting the cited deficiency.
Plan Of Correction
How corrective action (s) will be accomplished for those residents found to have been affected by the deficient practice; On March 3, 2026 Registered Nurse (RN) supervisor and Charge nurse conducted a comprehensive physical assessment of Resident 1 to rule out further injury and ensure their safety. No other injury was noted and safety precautions in place. Staff receive re-education on the facility's policy and procedure on March 5, 2026, regarding reporting of unwitnessed injury with emphasis on reporting with the 24-hour time frame given by the Director of Nursing (DON). How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken; To identify if any residents could have been affected, on February 3, 2026 the DON and Medical Record staff conducted a facility-wide audit of all incident reports and clinical records from the past 30 days to ensure every unwitnessed injury or injury with unknown origin was reported to CDPH within the 24-hour regulatory window, none was noted. On March 5, 2026 and on March 10, 2026 the Director of Nursing provided in-service to the staff regarding the facility's Unusual Occurrence Policy and Procedure, emphasizing on the importance of reporting to CDPH within 24 hours for unwitnessed injury. What measures will be put into place or what systemic changes will the facility make to ensure that deficient practice does not recur;The Director of Nursing (DON) on March 3, 2026 updated the Incident Monitoring Log to track whether incidents were witnessed or unwitnessed. The log now also includes resident cognition levels to ensure more accurate reporting to the CDPH.Director of Nursing (DON) conduct weekly audits of incident reports for six weeks, followed by monthly audits ongoing, to verify that every unwitnessed injury is investigated and reported within CDPHN 24-hour regulatory window. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action is evaluated for its effectiveness. The POC is integrated into the quality assurance system;To ensure ongoing compliance, the Director of Nursing (DON) and Administrator will perform a weekly audit of the Incident Monitoring Log, verifying that every unwitnessed incident with injury has been reported to the California Department of Public Health (CDPH) within acceptable time frame.Monitoring results will be integrated into the facility's Quality Assurance and Performance Improvement (QAPI) system monthly for three months, where the committee will review the data to evaluate the effectiveness of the corrective actions and make necessary changes.
Failure to Consistently Monitor and Document Refrigerator and Freezer Temperatures
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to follow its policy and procedure titled "Refrigerators and Freezers" requiring daily monitoring and recording of refrigerator and freezer temperatures. During an interview and concurrent record review with the Dietary Supervisor in the kitchen, temperature logs for three refrigerators and two freezers for the year 2026 were reviewed. The logs showed blank entries, indicating that monitoring was not completed on specific dates and shifts. For the refrigerators labeled Produce and Breads, Milk and Dairy, and Nourishment, temperature logs were blank for the morning shift on 1/1/2026 and 1/2/2026, and for Produce and Breads and Milk and Dairy on the evening shift on 1/1/2026. For the freezers labeled Frozen Vegetables and Ice Cream and Frozen Meat, temperature logs were blank for the morning shift on 1/1/2026 and 1/2/2026, and for the evening shift on 1/1/2026. The Dietary Supervisor stated that the AM and PM cooks were responsible for ensuring timely monitoring and documentation of refrigerator and freezer temperatures and acknowledged that lack of monitoring and documenting refrigerator and freezer temperatures may cause food spoilage. Review of the facility’s policy dated 11/2022 indicated that the facility would ensure safe refrigerator and freezer temperatures and sanitation, observe food expiration guidelines, and maintain refrigerators and freezers in good working condition. The policy specified that refrigerators must keep food at or below 41°F and freezers must keep frozen foods frozen solid, and that food service supervisors or designated employees must check and record refrigerator and freezer temperatures daily with the first opening and at closing in the evening. The documented gaps in the temperature logs demonstrated that this policy was not followed on the identified dates and shifts.
Failure to Clean and Disinfect Fecal Contamination in Shower Room
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when, during an observation of the east shower room with a housekeeper, dry brown fecal matter was seen on the wall of the second shower stall and a small drop of brown feces was seen on the floor. The housekeeper acknowledged that failure to clean and disinfect the walls and floors may increase the risk of residents getting sick. Review of the housekeeper job description showed that housekeeping staff are required to perform cleaning procedures in accordance with established infection prevention and control procedures, including cleaning walls and ceilings by washing, wiping, spot cleaning, disinfecting, and deodorizing to remove dirt and other contaminants using proper cleaning and disinfecting solutions. Review of the facility’s infection control policy indicated that its infection policies and practices are intended to maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The deficiency arose because the shower room surfaces contaminated with fecal matter were not cleaned and disinfected in accordance with the facility’s housekeeping job description and infection control policies, as evidenced by the observed fecal matter remaining on the shower wall and floor during the survey.
Failure to Ensure Resident Privacy During Personal Care
Penalty
Summary
The facility failed to ensure privacy during care for three residents when certified nursing assistants (CNAs) did not fully close privacy curtains while providing activities of daily living (ADLs), including incontinent care. Observations revealed that in each instance, the privacy curtain was only halfway closed, and in one case, the bedside window curtains were also open, making the resident visible from outside. These lapses occurred while residents were exposed or naked during personal care. Resident 2, who had diagnoses including generalized muscle weakness, lymphedema, and morbid obesity, was observed receiving incontinent care with the privacy curtain only halfway closed and the window curtains open. Resident 2 was able to make decisions and expressed feeling embarrassed and unsafe when privacy was not maintained. Resident 3, with severe cognitive impairment and requiring assistance for ADLs, was observed naked during care with the privacy curtain only partially closed. Resident 4, also with severe cognitive impairment and requiring maximum assistance, was observed fully exposed while the privacy curtain was only halfway closed during cleaning. Interviews with the CNAs involved confirmed their awareness of the importance of closing curtains to maintain resident privacy and dignity. Additional interviews with nursing staff, including an LVN and an RN, reiterated the facility's expectations for privacy during care, such as closing doors and curtains and knocking before entering. Review of facility policies confirmed the requirement to promote and protect resident privacy, including bodily privacy during personal care and treatment procedures.
Failure to Provide Timely Discharge Notice and IDT Meeting
Penalty
Summary
The facility failed to notify one sampled resident of the discharge plan at least 30 days before the planned discharge date, as required by its Transfer and Discharge Notice policy. Resident 1 was admitted with diagnoses including muscle weakness, abnormalities of gait and mobility, and atrial fibrillation. The resident’s H&P stated he had the mental capacity to understand and make medical decisions, and the MDS indicated intact cognition and a need for supervision or touching assistance with several ADLs, including dressing, toilet use, personal hygiene, transfer, and mobility. Record review and interviews showed no documented IDT meeting before the planned discharge, and the resident stated he was not informed in advance about discharge plans. The resident reported that on 7/18/2025 he was told by the BO representative and SSD that he would be discharged and that his Medicare benefits would not be used, and he said he applied an appeal to Livanta that same day. The BO representative stated the NOMNC should be given 72 hours before discharge, that she attempted to obtain the resident’s signature after first finding him out of the room, and that the facility did not conduct an IDT meeting before the discharge date. The RD, SSD, and DON also confirmed that an IDT meeting was not conducted prior to the planned discharge and that the resident should have been informed about discharge planning before being asked to sign papers.
Failure to Monitor and Supervise Resident with Wandering Behavior
Penalty
Summary
A deficiency occurred when a resident with Alzheimer's disease and moderate cognitive impairment, who was known to wander and required substantial assistance with activities of daily living, was not adequately monitored during the night shift. This resident entered another resident's room at approximately 4:00 a.m. and became trapped between beds and curtains while in a wheelchair. The incident was discovered after the roommate heard noises and alerted staff, who then found the wandering resident in the room. Documentation and interviews confirmed that the resident's wandering behavior was not monitored or recorded during the relevant shift, despite care plan interventions and facility policy requiring such monitoring for residents at risk of unsafe wandering. The resident whose room was entered had intact cognition and required supervision or assistance with daily activities. He reported the incident as a grievance, expressing concerns about privacy and safety. Staff interviews acknowledged awareness of the wandering behavior and the importance of supervision, especially at night when confusion can increase. Facility policies reviewed indicated that staff should identify and monitor residents at risk for unsafe wandering and provide supervision based on assessed needs, but these procedures were not followed in this case.
Failure to Monitor for Bleeding in Resident on Anticoagulants
Penalty
Summary
Facility staff failed to monitor a resident for signs and symptoms of bleeding and bruising while the resident was receiving both aspirin and Eliquis for stroke prophylaxis. The resident, who had a history of hemiplegia and hemiparesis following a cerebral infarction and lacked capacity to make medical decisions, was identified as high risk for bleeding and bruising due to these medications. The care plan specifically required staff to monitor and document any signs of bleeding every shift. Despite these requirements, a review of the Medication Administration Record for the month showed that staff did not document monitoring for bleeding or bruising between the first and twenty-fourth of the month. The Director of Nursing confirmed that the facility did not actively monitor the resident for adverse effects related to anticoagulant therapy, which was contrary to both the resident's care plan and the facility's own anticoagulation protocol.
Failure to Properly Label and Store Medications
Penalty
Summary
Surveyors observed multiple deficiencies related to the labeling and storage of medications in the East Medication Cart. Specifically, an opened vial of latanoprost eye drops and an opened fluticasone/salmeterol inhaler were found without labeled open dates, affecting two residents. Additionally, an opened Lantus insulin pen was also found without an open date. These medications require labeling with the date of opening according to manufacturer instructions to ensure they are not used past their recommended period of effectiveness. Further, lorazepam oral solution and gabapentin oral solution, both prescribed to a resident, were found stored at room temperature instead of in the refrigerator as required by the manufacturer. The LVN interviewed confirmed that these medications should have been refrigerated and acknowledged that a dose of gabapentin had been administered that morning after it had not been properly stored. The facility's policy and procedure on medication labeling and storage, revised in February 2023, requires medications to be stored under proper temperature controls and labeled with expiration dates when applicable.
IV Catheter Insertion Date Not Labeled on Resident's Dressing
Penalty
Summary
A deficiency was identified when a resident with chronic kidney disease, hypokalemia, hyperlipidemia, and vitamin D deficiency was observed receiving intravenous (IV) fluids through a catheter inserted in the left wrist. The IV catheter's outer dressing did not display the date of insertion, as required by facility policy. The resident had severely impaired cognition and was unable to make medical decisions independently. Documentation in the resident's chart confirmed an order for a new IV catheter, but there was no indication that the date of insertion was labeled on the catheter dressing. During interviews and observations, a registered nurse confirmed that RNs are responsible for all aspects of IV care, including documentation and labeling. The nurse acknowledged the absence of the date on the IV catheter and stated uncertainty about why it was missing. Facility policy specifies that after taping the IV catheter in place, a label with the date of insertion should be applied to the catheter dressing. The lack of a date could impact the ability of staff to determine when the IV site should be changed.
Failure to Monitor Oxygen Saturation Every Shift for Resident on Supplemental Oxygen
Penalty
Summary
The facility failed to ensure that a resident who was dependent on supplemental oxygen had their oxygen saturation (O2 sat) levels checked every shift as ordered by the physician. Observation showed the resident was on 2 liters per minute of oxygen via nasal cannula. Record review revealed that the resident had diagnoses including dependence on supplemental oxygen, cardiomegaly, and a history of myocardial infarction, and was unable to make medical decisions. The resident's orders specified that O2 sat should be monitored every shift to maintain levels at 92% or above, with instructions to titrate oxygen and notify the physician if levels fell below 92%. Review of the resident's O2 sat documentation for the month showed that O2 sat levels were not being checked every shift, with several days in April lacking any recorded measurements. During an interview, an LVN confirmed that the required monitoring was not consistently performed and acknowledged that without regular monitoring, staff would not know if the resident's oxygen needs were being met or if further interventions were necessary. The facility's policy on oxygen administration also required assessment of vital signs and O2 sat while the resident was receiving oxygen therapy.
Resident Rooms Below Minimum Square Footage Requirements
Penalty
Summary
The facility failed to ensure that residents in multiple rooms, specifically Rooms 6, 7, 14, 15, 16, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, and 29, had the required minimum living space of 80 square feet per resident in multiple occupancy rooms and 100 square feet for single occupancy rooms. Observations revealed that some rooms, such as Room 26, contained four beds, and a review of the Client Accommodation Analysis confirmed that these rooms did not meet the minimum square footage requirements. The facility's own Room Variance Waiver request letter acknowledged that these rooms fell short of the required space. During an interview, the Administrator stated there had been no complaints from residents about the room sizes and that staff ensured residents could maneuver wheelchairs, but also acknowledged that the limited space could potentially make it difficult for staff to provide care.
Failure to Provide Ordered Pain Management for Resident
Penalty
Summary
A resident with a history of polyneuropathy, repeated falls, and diabetes mellitus was admitted to the facility and had an active order for acetaminophen 1000 mg by mouth every 6 hours as needed for severe pain, specifically for pain rated between 7/10 and 10/10. The resident was assessed as able to express needs and had no impairment in upper or lower extremities. On multiple occasions, the resident reported pain at a level of 7/10, particularly after being struck under the left eye by another resident. Despite the resident's repeated reports of severe pain, documentation on the Medication Administration Record (MAR) showed that no pain medication was administered during four nursing shifts when the resident reported pain at the threshold specified in the physician's order. Both the LVN and the DON confirmed during interviews and record reviews that the pain was documented but not treated according to the standing order. Facility policies and procedures required that medications be administered in accordance with prescriber orders and that staff identify and address residents' pain. However, the staff failed to provide the ordered pain management, resulting in the resident experiencing unrelieved pain that had the potential to interfere with activities of daily living.
Failure to Label Wound Dressings as per Policy
Penalty
Summary
The facility failed to ensure that wound dressings for two residents were labeled with the nurse's initials, time, and date, as required by the facility's policy. Resident 1, who had a stage 4 pressure ulcer, quadriplegia, and diabetes mellitus, was observed with unlabeled dressings on the left forearm and gastrostomy site. During an interview, an LVN admitted to not labeling the dressings and was unsure of the facility's policy regarding labeling. Similarly, Resident 2, who also had a stage 4 pressure ulcer and severe cognitive impairment, was found with unlabeled dressings on the sacro coccyx and gastrostomy site. Another LVN confirmed that they did not label the dressings with the required information. The Director of Nursing acknowledged that the facility's policy, which mandates labeling wound dressings with the nurse's initials, time, and date, was not followed. The policy, dated 2001, was intended to provide guidelines for care to promote wound healing. The failure to adhere to this policy had the potential to result in wound dressings not being changed, which could lead to wound infections and delayed healing.
Failure to Implement Enhanced Standard Precautions During Wound Care
Penalty
Summary
The facility failed to implement its Enhanced Standard Precautions (ESP) policy, which is designed to reduce the transmission of multi-drug resistant organisms (MDROs) by requiring healthcare workers to don personal protective equipment (PPE) such as gowns and gloves when providing care to residents at high risk for MDRO transmission. This deficiency was observed during wound care for two residents, both of whom had physician's orders for wound care due to pressure ulcers. The failure to use PPE as required by the facility's policy had the potential to result in the transmission of disease-causing organisms and delay the wound healing process for the affected residents. For Resident 6, who was admitted with diagnoses including muscle weakness, unspecified dementia, and quadriplegia, the facility's Licensed Vocational Nurse (LVN) 1 was observed performing wound care on the resident's left heel without wearing an isolation gown, despite an ESP sign being posted outside the resident's room. The resident had a physician's order for daily wound care on a Stage 3 pressure ulcer on the left heel, which required specific dressing and antiseptic procedures. LVN 1 acknowledged not using a gown, which was a precaution to minimize bacterial transmission to the wound. Similarly, for Resident 7, who had multiple unstageable pressure ulcers and chronic kidney disease, LVN 2 was observed performing wound care on the resident's sacrococcyx and left lateral malleolus wounds without wearing an isolation gown, despite the presence of an ESP sign. The resident's treatment administration record indicated daily wound care orders for these Stage 4 pressure injuries. LVN 2 admitted to not wearing the required gown before entering the room, which was necessary to prevent infection transmission. The Director of Nursing confirmed that ESP precautions should be used during wound dressing changes and for residents with a history of MDROs, emphasizing the importance of using PPE to prevent infection transmission during close contact activities.
Failure to Separate Clean and Soiled Linens in Laundry Room
Penalty
Summary
The facility failed to ensure clean linens were not placed near the facility's washing machines where dirty and soiled clothing was stored. During an observation in the facility's laundry room, 11 linen carts filled with clean linen were found placed alongside three washing machines with dirty linen washing inside. This practice was confirmed by the Housekeeping Supervisor, who acknowledged that having clean linen close to the washing machines with soiled linen could put residents at risk of infection and could spread throughout the facility. The Administrator also confirmed that the 11 carts had clean linen stored on them and should have been separated from the dirty clothing. The Administrator stated that the dirty linen was possibly soiled and could cause cross-contamination to the clean linen. The facility's policy and procedure on laundry and linen, dated January 2014, indicated that clean linen should remain hygienically clean and be kept separate from soiled linen to prevent environmental contamination. However, this policy was not followed, leading to the observed deficiency.
Failure to Promote Dignity During Meal Assistance
Penalty
Summary
The facility failed to ensure staff promoted dignity while assisting Resident 56 during meals. Specifically, a Certified Nursing Assistant (CNA) was observed standing over Resident 56 and not maintaining face-to-face eye contact while assisting with the meal. This action was confirmed by the CNA, who acknowledged that standing could potentially make the resident feel rushed and affect their dignity. Interviews with other staff members, including a Licensed Vocational Nurse (LVN), a Registered Nurse (RN), and the Director of Nursing (DON), corroborated that assisting residents with meals should be done at eye level to promote dignity and comfort. Resident 56 also expressed a preference for staff to sit down while assisting with meals, indicating discomfort when staff stood over them. Resident 56, who has diagnoses including epilepsy, chronic obstructive pulmonary disease (COPD), schizoaffective disorder, and major depressive disorder, was admitted to the facility on a specified date. The resident's Minimum Data Set (MDS) indicated moderate cognitive impairment and dependence on staff for activities of daily living (ADLs). The facility's policy and procedure on dignity, dated February 202, emphasized the importance of providing a dignified dining experience. The failure to adhere to this policy was identified as a deficiency that could potentially impact the resident's sense of well-being and self-worth.
Failure to Obtain Informed Consent for Psychoactive Medication
Penalty
Summary
The facility failed to ensure that a resident and/or their responsible party (RP) was informed in advance about the risks and benefits of psychoactive medication. Specifically, Resident 56, who had diagnoses including epilepsy, COPD, schizoaffective disorder, and major depressive disorder, was administered Seroquel without documented informed consent. The resident had a moderate cognitive impairment and was dependent on staff for activities of daily living. Despite these conditions, there was no informed consent found in the resident's medical chart for the psychoactive medication prescribed and administered starting from 11/13/2024. Interviews with the facility's staff, including an LVN, an RN, and the Director of Nursing, confirmed that informed consent is required before administering psychoactive medications. The staff acknowledged that the absence of informed consent could lead to residents taking medications without being aware of the side effects, risks, and benefits. The facility's policy and procedure on informed consent, dated 3/23/2015, also indicated that documentation of informed consent is necessary before initiating the administration of psychotherapeutic drugs. However, this policy was not followed in the case of Resident 56.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to ensure a safe, clean, and homelike environment for Resident 6, who was admitted with diagnoses including Type 2 diabetes mellitus, heart failure, and anxiety disorder. Resident 6, who had moderate cognitive impairment and was dependent on staff for activities of daily living, was found to have a room with chipping paint and visibly soiled walls. During an observation and interview, Resident 6 expressed dissatisfaction with the dirty walls. The Maintenance Supervisor and Housekeeping Supervisor both acknowledged the poor condition of the room, noting that it was not acceptable and could potentially pose an infection control issue. The Director of Nursing also confirmed that the room should be maintained in a homelike environment and that the current state could affect the resident's dignity and mood. The facility's policies and procedures were reviewed, revealing that walls, blinds, and window curtains in resident areas should be cleaned when visibly contaminated or soiled, and that maintenance service should ensure the building is in good repair and free from hazards. Despite these policies, the facility did not adhere to them, resulting in the deficient practice. The failure to maintain a clean and homelike environment for Resident 6 had the potential to expose the resident to dirt, harsh chemicals, infection, and accidents.
Inaccurate MDS Assessment for Pneumococcal Vaccine
Penalty
Summary
The facility failed to ensure an accurate Minimum Data Set (MDS) assessment regarding the pneumococcal vaccine for one of five sampled residents. Resident 75, who had diagnoses including end-stage renal disease, diabetes mellitus type 2, and heart failure, was not eligible to receive the pneumococcal vaccine according to their immunization history. However, the MDS assessment incorrectly indicated that the vaccine was not up to date and had been offered and declined. The MDS Nurse confirmed that the assessment was inaccurate and should have been coded as 'not eligible' instead of 'declined.' There was no documentation in Resident 75's clinical records to support that the vaccine was offered and declined. The facility's policy and procedure titled 'Certifying Accuracy of the Resident Assessment' requires that any person completing a portion of the MDS must sign and certify the accuracy of that portion. The MDS Nurse acknowledged the importance of having an accurate assessment, as it affects the care of residents. The failure to accurately assess and document Resident 75's immunization status had the potential to result in inappropriate care and services for the resident.
Failure to Complete and Resubmit PASRR Level I Screening for Resident with New Psychosis Diagnosis
Penalty
Summary
The facility failed to complete and re-submit the Preadmission Screening and Resident Review (PASRR) Level I screening and refer Resident 22 for a PASRR Level II evaluation after a new diagnosis of psychosis. Resident 22, who was originally admitted and later readmitted to the facility, had diagnoses including psychosis and major depressive disorder. A review of Resident 22's records indicated that the resident was receiving Risperdal for psychosis and did not have the capacity to understand and make decisions. However, the PASRR Level I screening submitted by the facility did not reflect the new diagnosis or the use of psychotropic medication, and the case was closed without a Level II evaluation being required. During an interview and record review, the Business Office Manager (BOM) acknowledged that she did not complete or resubmit the PASRR Level I screening because she was unaware of Resident 22's new diagnosis of psychosis and the initiation of Risperdal. The BOM also stated that there was no system in place for the nursing staff to communicate new mental illness diagnoses to the business office. The facility's policy indicated that all residents with newly evident or possible serious mental disorders should be referred to the state mental health authority for a PASRR Level II evaluation, but this was not done for Resident 22.
Failure to Initiate Care Plan for RNA Services
Penalty
Summary
The facility failed to initiate a care plan for Restorative Nursing Assistant (RNA) services for one resident, identified as Resident 74. Resident 74 was admitted with diagnoses including ataxia, muscle weakness, repeated falls, and cardiomegaly. The resident was assessed to be cognitively intact and required supervision with transferring, dressing, and toilet use. Physician orders indicated that Resident 74 should receive RNA services for ambulation with a front-wheel walker daily, five times a week as tolerated. However, a review of the medical record revealed that no RNA care plan was initiated for Resident 74. During interviews, both a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) confirmed that care plans are essential for providing guidance, interventions, and goals for residents. The LVN acknowledged that the absence of a care plan could result in not providing necessary and quality care. The DON emphasized that care plans should be initiated on admission, during changes in condition, and throughout the resident's stay. The facility's policy and procedures also indicated that care plans should include measurable objectives and timeframes to maintain the resident's highest practicable well-being.
Failure to Revise Care Plan for Back Brace
Penalty
Summary
The facility failed to ensure that Resident 43 had a revised care plan to implement an order for a back brace, which was prescribed for support due to low back pain. The resident was initially admitted with diagnoses including low back pain, muscle spasm, and myalgia. Despite a physician's order for a back brace on 3/25/2024, the care plan was not updated to reflect this new intervention. The care plan, last updated on 8/26/2021, did not include the necessary revisions to address the resident's current needs for back support. During interviews and record reviews, both the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) acknowledged that the care plan should have been revised to include the back brace. The facility's policy and procedure on comprehensive person-centered care plans emphasize the importance of updating care plans as residents' conditions change. The failure to revise the care plan placed Resident 43 at risk for inadequate back support, potentially leading to immobility, unsteady gait, and increased back pain.
Failure to Provide Adequate Oral Hygiene
Penalty
Summary
The facility failed to provide adequate oral hygiene for Resident 92, who was unable to perform activities of daily living independently. Resident 92, who had diagnoses including cerebral infarction with hemiplegia and hemiparesis, hypertension, and diabetes mellitus, was observed with thick dried yellowish particles on her mouth and tongue. The resident was totally dependent on staff for oral hygiene, as indicated in her Minimum Data Set and Treatment Worksheet. Despite the care plan specifying that oral care should be provided every shift and as needed, this was not done, as confirmed by the Director of Staff Development (DSD) and the Director of Nursing (DON). The DSD acknowledged that it was her responsibility to ensure CNAs provided oral hygiene, and admitted that Resident 92 had not received proper oral care since her readmission to the facility. During an observation and interview, Certified Nursing Assistant 5 (CNA 5) noted that Resident 92 was under hospice care and was on nothing by mouth (NPO). The DSD confirmed the presence of thick dried, crusty yellowish substance on Resident 92's mouth and tongue, indicating poor oral hygiene. The DON stated that failing to provide good oral hygiene put Resident 92 at risk for an oral infection and acknowledged that it would be embarrassing for the facility if family members saw the resident in such a condition. The facility's policy on Activities of Daily Living, dated March 2018, mandates that residents unable to carry out these activities independently should receive necessary services to maintain good personal and oral hygiene, which was not adhered to in this case.
Failure to Provide Preferred Activities for Resident
Penalty
Summary
The facility failed to provide Resident 3 with her preferred activity of staying in the dining recreation area to participate in group activities. Resident 3, who has diagnoses including cerebral infarction with hemiplegia and hemiparesis, diabetes mellitus, and epilepsy, expressed a desire to attend group activities and socialize with other residents. Despite being awake, alert, and able to make her needs known, Resident 3 was observed in bed on multiple occasions and stated she felt bored in her room. The facility's staff, including a Licensed Vocational Nurse (LVN) and a Certified Nursing Assistant (CNA), confirmed that there was no reason for Resident 3 not to be up in a reclining wheelchair and participate in group activities. However, the CNA mentioned that Resident 3 was not scheduled to get up in a reclining wheelchair due to a limited supply of such wheelchairs. The Activity Director acknowledged that Resident 3 enjoys group and mental activities and noted her absence from the dining recreation area. The Director of Nursing (DON) emphasized that it is the facility's responsibility to honor and follow each resident's activity preferences. The facility's Policy and Procedure on Activity Programs, dated June 2018, states that activities should be designed to meet the interests and support the physical, mental, and psychosocial well-being of each resident based on a comprehensive resident-centered assessment. The failure to provide Resident 3 with her preferred activities could potentially lead to a decline in memory, depression, and self-isolation, as noted by the Activity Director.
Failure to Apply Hand Roll as Ordered
Penalty
Summary
The facility failed to ensure that a resident with a limited range of motion was provided with a left hand roll as ordered by the physician. Resident 22, who had diagnoses including osteoarthritis, contractures, and dementia, was observed without the prescribed left hand roll on multiple occasions. Instead, the hand roll was incorrectly applied to the resident's right hand. This error was confirmed during interviews with the Restorative Nursing Assistant (RNA) and the Occupational Therapist (OT), who both acknowledged the mistake and the importance of applying the hand roll to the left hand to prevent further contractures. The resident's care plan and physician's orders clearly indicated the need for a left hand roll to maintain joint integrity and prevent further contractures. Despite these directives, the RNA was unaware of the correct application site and had been placing the hand roll on the right hand. The facility's policies on splinting and restorative nursing services emphasized individualized, resident-centered care, but these were not followed in this instance, leading to the potential for further decline in the resident's range of motion and worsening of contractures.
Failure to Ensure Hemodialysis Emergency Kit Availability and Communication of Fluid Restriction
Penalty
Summary
The facility failed to ensure a resident who received hemodialysis (HD) received treatment in accordance with standards of practice. Specifically, the facility did not ensure that the HD emergency kit (E-Kit) was always available at the bedside for safety measures in case of HD complications. During observations, it was noted that the E-Kit, which should contain tape, gauze, alcohol swab, dressing, and kerlix roll, was not present at the resident's bedside. This was confirmed by Licensed Vocational Nurse (LVN) 6, who acknowledged the absence of the E-Kit and stated it should be readily visible and accessible at all times in case of emergency bleeding. The Director of Nursing (DON) also confirmed that the E-Kit is used to control bleeding in emergencies and should be available at the bedside at all times. Additionally, the facility failed to communicate to the resident's physician regarding the recommendation from the dialysis treatment center staff to limit the resident's fluid restriction to 32 ounces per day. The resident's Dialysis Communication Record indicated this recommendation, but there was no documentation that the physician was notified. The Registered Nurse (RN) and the Registered Dietitian (RD) both confirmed that they were unaware of the recommendation, and the RD stated that the resident was currently on a 1200 cc fluid restriction per day. The facility's policy and procedure indicated that recommendations from the dialysis unit should be promptly communicated with the primary care physician to ensure necessary care and services, which was not followed in this case.
Failure to Label Medications with Open Dates and Follow Manufacturer's Guidelines
Penalty
Summary
The facility failed to ensure that two medications were labeled with open dates for two residents, Resident 13 and Resident 77, and did not follow the manufacturer's guidelines for budesonide inhalation suspension for Resident 77. Resident 13, who was admitted with chronic obstructive pulmonary disease (COPD) and dependence on supplemental oxygen, was prescribed Spiriva hand inhaler. During an observation, it was found that the Spiriva hand inhaler did not have a documented open date. Similarly, Resident 77, who was admitted with acute and chronic respiratory failure with hypoxia and a history of nicotine dependence, was prescribed budesonide inhalation suspension. The budesonide inhalation suspension also lacked a documented open date, and the manufacturer's guidelines for using the medication within two weeks of opening the foil were not followed. Licensed Vocational Nurse 1 (LVN 1) confirmed that the medications did not have open dates and stated that it is necessary to write an open date on the medication package to ensure the medication's potency and adherence to the manufacturer's guidelines. The Director of Nursing (DON) reiterated the importance of documenting open dates to prevent the use of expired or ineffective medications. The facility's policy and procedure for administering medications also required that the expiration or beyond-use date be checked prior to administration and that the date of opening be recorded on multi-dose containers.
Failure to Provide Physician-Ordered Back Brace
Penalty
Summary
The facility failed to ensure that a resident (Resident 43) received a back brace ordered by the physician to alleviate back pain. Resident 43 was initially admitted with diagnoses including low back pain, muscle spasm, and myalgia. Despite a physician's order dated 3/25/2024 for a back brace, the resident did not receive it. During an interview on 4/18/2024, Resident 43 confirmed not having received the back brace and expressed that the staff had not updated them about the order. Observations and interviews with staff, including a CNA and a PT, confirmed that the back brace was not available and had not been ordered by the facility, despite the physician's order being medically justified. The PT noted that the back brace should have been provided within 72 hours of the order to help improve the resident's quality of life and alleviate back pain. Further interviews with the DON revealed that there was a lack of communication between the nursing staff and physical therapists regarding the physician's order for the back brace. The facility's policy and procedure on specialized rehabilitative services, dated 7/2016, indicated that therapeutic services should be provided upon the written order of the resident's attending physician. The failure to provide the back brace as ordered had the potential to increase Resident 43's back pain, highlighting a significant lapse in the facility's adherence to its own policies and procedures.
Failure to Offer Pneumococcal Vaccine to Eligible Resident
Penalty
Summary
The facility failed to ensure that a resident was offered the pneumococcal vaccine, placing the resident at higher risk of acquiring pneumonia. The resident, who had end-stage renal disease, diabetes mellitus type 2, and heart failure, was admitted and readmitted to the facility. Despite having the capacity to understand and make decisions, the resident's Minimum Data Set indicated that the pneumococcal vaccine was not up to date. The Infection Preventionist Nurse reviewed the resident's immunization history and incorrectly stated that the resident was not eligible for the vaccine due to age, without documenting any offer, decline, or administration of the vaccine in the clinical records. The facility's Policy and Procedure for Pneumococcal Management, which recommended the vaccine for individuals with certain long-term health problems, was not followed. The Infection Preventionist Nurse acknowledged that the resident was eligible for the vaccine based on the facility's policy and that the resident would be more susceptible to developing pneumonia without it. The Centers for Disease Control and Prevention also recommend the pneumococcal vaccine for people with certain medical conditions, further highlighting the oversight in the resident's care.
Non-Compliant Room Sizes
Penalty
Summary
The facility failed to ensure that 17 out of 41 resident rooms met the required square footage per resident, with multi-resident rooms measuring less than 80 square feet per resident and single-resident rooms measuring less than 100 square feet. During a facility tour, rooms 6, 7, 14, 15, 16, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, and 29 were observed and measured to be out of compliance. The Administrator acknowledged the non-compliance but stated that resident care had not been affected. A waiver request had been submitted previously, indicating that there was adequate space for nursing care and that the health and safety of residents were not in jeopardy.
Failure to Provide Adequate Supervision and Assistance
Penalty
Summary
The facility failed to ensure adequate supervision and assistance for a resident with significant mobility impairments, resulting in a serious injury. The resident, who had quadriplegia, contractures, and aphasia, required assistance from two or more staff members for activities of daily living (ADLs) such as mobility, toileting hygiene, showering, and personal hygiene, as indicated in their Minimum Data Set (MDS). However, the care plan did not specify the need for two-person assistance, and staff were not consistently following this requirement. This oversight led to a Certified Nurse Assistant (CNA) providing care alone, during which the resident sustained a right upper arm fracture that required hospitalization for evaluation and treatment. The incident was discovered when a CNA noticed a bruise on the resident's right upper arm and reported it to a Licensed Vocational Nurse (LVN). Subsequent assessments and an X-ray confirmed the fracture. Interviews with staff revealed that the CNA had been performing ADLs alone, contrary to the MDS requirements. The Director of Nursing (DON) acknowledged that all total care residents should be assisted by two staff members to prevent injuries and was unaware that this protocol was not being followed. The facility's policies and procedures emphasized the importance of safety, supervision, and adequate assistance to prevent accidents. However, the care plans did not include specific interventions to ensure two-person assistance, and staff were not adequately trained or monitored to follow this protocol. This failure to adhere to established safety measures directly contributed to the resident's injury, highlighting a significant lapse in the facility's duty to provide a safe environment for its residents.
Failure to Timely Report Suspected Abuse and Injury
Penalty
Summary
The facility failed to follow its Administrative Manual titled, Elder/Dependent Abuse, which required reporting any allegations of abuse or incidents resulting in serious bodily injury to the State Survey agency immediately, but not later than two hours. This failure was observed in the case of a resident who sustained a baseball-sized bruise and a non-displaced fracture on her right upper arm. The resident, who had quadriplegia, contractures, and aphasia, was unable to move her body and extremities without assistance. The incident was reported to the Director of Nursing (DON) approximately 20 minutes after it was discovered, but the State Survey Agency was not notified until the following day, resulting in a delay of over 24 hours from the time of discovery. The resident's care plan did not include specific interventions for two or more persons to assist with mobility, despite the resident's need for such assistance as indicated in her Minimum Data Set (MDS). Additionally, the care plan lacked safety measures to prevent injuries, even though the resident was known to bruise easily due to the use of blood thinners. Interviews with staff revealed that the injury was suspicious given the resident's inability to move independently, and the delay in reporting the incident to the State Survey Agency hindered a timely investigation by the California Department of Public Health (CDPH).
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 6,934 citations issued within 25 miles in the last 12 months — including the 24 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Gardena
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Gardena Convalescent Center | 0.4 mi | ★★★★★ | 16 | 0 |
| Kei-ai South Bay Healthcare Center | 0.5 mi | ★★★★★ | 16 | 0 |
| Memorial Hospital Of Gardena D/p Snf | 0.9 mi | ★★★★★ | 13 | 0 |
| Clear View Convalescent Center | 1.1 mi | ★★★★★ | 4 | 0 |
| Clear View Sanitarium | 1.1 mi | ★★★★★ | 10 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Rosecrans Care Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.