Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Royal Gardens Healthcare during CMS and state inspections, most recent first.
Surveyors found that two residents did not receive care according to MD orders and facility policy. One resident with severe cognitive impairment and a cervical spine wound had a documented daily wound care order with Dakin’s solution, Betadine, and calcium alginate, but the TAR showed no wound treatments documented over multiple days, and nursing staff acknowledged that new wound orders were not entered or carried out. Another resident with chronic pain conditions and moderate cognitive impairment had MD orders for PRN analgesics and a possible referral to a pain specialist; the resident and a CNA reported ongoing pain and delays in pain medication, and both the SSD and an LVN admitted they did not follow up on the MD order for a pain specialist referral, resulting in no appointment being arranged.
Two residents experienced lapses in infection control when an RN performed wound care on a resident with a sacral stage 4 pressure ulcer and local skin infection without changing gloves or performing hand hygiene after removing a soiled dressing and cleansing the wound, and then left the room after doffing PPE without hand hygiene, contrary to facility policies requiring aseptic technique and hand hygiene after glove and PPE removal. In a separate incident, an RN used the same reusable BP cuff on two residents without disinfecting it between uses, despite facility policy and the DON/IP’s expectation that reusable equipment be cleaned and disinfected between residents.
A resident with muscle weakness, COPD, depression, moderate cognitive impairment, and dependence on staff for most ADLs was observed lying in bed with the call light placed on the top corner of the bed, out of reach, while the resident stated being thirsty and unable to summon help. A CNA confirmed the call light was not within reach and acknowledged it should have been, and the DON stated call lights should always be accessible. Facility policy on answering call lights required that call lights be accessible to residents in bed, on the toilet, in the shower/bath, and from the floor, but this was not followed in this instance.
A resident with Parkinson’s disease, dementia, muscle weakness, difficulty walking, and severe cognitive impairment was identified as high risk for falls and required substantial assistance with most ADLs. Progress notes documented an unwitnessed fall after the resident got up without asking for help, and multiple staff (a CNA, an LVN, and an RN) reported the resident routinely attempted to get up alone, often to have an adult brief changed. Despite this ongoing behavior and a prior fall, the DON confirmed there was no individualized care plan addressing the resident’s unassisted attempts to get up and no revision of the care plan after the fall, contrary to facility policy requiring an IDT-developed, person-centered care plan with measurable objectives and updates for changes in condition.
Two residents experienced significant medication-related deficiencies involving both administration and reconciliation. For one resident with multiple chronic conditions and moderate cognitive impairment, an RN administered seven medications without verifying identity via wrist band or photo and without explaining the medications or their indications, and Eliquis for DVT prophylaxis was not available because it had not been refilled in time. For another resident with psychosis and schizoaffective disorder, the DSD inaccurately transcribed a risperidone order during admission, entering three tablets twice daily instead of one tablet twice daily despite a system alert, which led to the pharmacy not dispensing the drug and the resident not receiving risperidone for several days.
A resident with schizoaffective disorder, depression, anxiety, and severely impaired decision-making, who had documented episodes of physical and verbal aggression such as yelling profanities and throwing or shoving objects, was left briefly unattended in a hallway by the Admission Director while en route to a shower. During this time, a visitor observed the resident screaming at another resident seated in a wheelchair and pushing a laundry cart into that resident, who cried out in pain, while the aggressive resident continued cursing. Staff interviews confirmed the aggressive behavior pattern and that the laundry cart, normally kept at the side of the hallway, was behind the wheelchair at the time of the incident. The DON acknowledged that despite early manifestations of aggression, the resident’s behaviors were not placed on behavior monitoring and that the facility failed to prevent the physical abuse, in violation of its abuse and neglect policy.
A resident with paraplegia, urinary retention, and a right lower abdominal urostomy was allowed to perform self-catheterization without a physician order, competency assessment, or care plan, contrary to facility policy. Staff acknowledged they had never observed or assisted with the resident’s urostomy care and were unaware of the peristomal skin condition. From admission for several days, there was no urostomy care order, no documented assessment of the resident’s ability to self-catheterize, no records of catheterization frequency, and no monitoring or documentation of intake/output, urine characteristics, or stoma/skin condition as required by the facility’s urostomy and self-catheterization P&Ps.
Unsafe and Unmaintained Resident Room Environment: The facility failed to keep resident rooms safe and well maintained when an air vent above one resident's bed was coated with dust, a bedside table and bed control in another resident's room were chipped and rough, a third resident had a cracked bed control and cracked overhead light, and a fourth resident's TV was not working despite the resident enjoying TV. The DON, DSD, MS, and RNS all confirmed the conditions during observation and interview, and the residents involved had significant medical and functional needs including dementia, COPD, diabetes, heart failure, hemiplegia, and dependence with ADLs.
A facility failed to set low air loss mattresses according to resident weight for several residents with PU risk and existing skin breakdown. Staff observed mattresses set too firm or at incorrect settings for residents with orders for pressure-relieving support, and an RN supervisor, DON, MDS nurse, and LPN confirmed the settings were not correct. The facility also failed to fully assess and document a resident’s stage 3 sacrococcyx PU on readmission, including wound size and ongoing weekly measurements.
Incomplete nurse and CNA competency documentation was found for multiple staff members. CNA skills check evaluations lacked dates, signatures, and clear documentation of how tasks were validated, while LVN and RN records also showed missing evaluator information, incomplete med administration competency forms, blank orientation fields, and absent skills check checklists. The DSD acknowledged that some evaluations were done as a shortcut, that not all tasks were observed, and that some required documentation was missing from employee files.
Two residents did not receive scheduled 9 AM meds within the facility’s one-hour administration window. One resident with dementia, BPH, and CHF had multiple oral meds given late because the LVN was busy with another resident, and another resident with severe cognitive impairment and a G-tube had several meds administered late by an RNS. The DON confirmed both were medication errors because the meds were given outside the allowed time frame.
Failure to Monitor Insulin and Anticoagulant Therapy Two residents receiving insulin were not documented as being monitored for signs and symptoms of hypo- or hyperglycemia, despite diabetes care plans identifying those risks. One of those residents was also receiving enoxaparin for clot prevention, and there was no documented monitoring for bleeding, bruising, or hematoma. The MDS nurse stated the care plan interventions were not followed and that the chart lacked evidence of the required monitoring.
Medication administration errors exceeded the allowed rate when an LVN and an RN supervisor gave scheduled meds outside the required 1-hour window for two residents. One resident with dementia, BPH, and heart failure received several 9 AM meds late because the LVN was busy with another resident, and another resident with severe cognitive impairment and a G-tube received multiple scheduled meds late as well. Interviews with nursing staff and the DON confirmed the late administration was a medication error.
Food service equipment and storage practices were not maintained in a sanitary manner. In the kitchen, a can opener was chipped and soiled with food residue, a blender was chipped with discoloration around the blade, an onion powder container was partially closed and missing an open/discard date, a stand mixer had peeling paint with exposed metal, and a coffee maker spout was cracked. The DS and Cook stated that equipment should be clean, in good condition, and that opened foods should be labeled, dated, and sealed per facility P&P.
A resident with CKD, anxiety disorder, and COPD, who required substantial assistance with ADLs, reported that a CNA pulled a sheet from under them and threw it on the floor during evening care. The facility’s CGR form for this grievance was left incomplete, with no documented steps of the investigation, no summary of findings or conclusions, and no confirmed decision date. The SSD, DON, and DSD all acknowledged that required investigative elements—such as incident details, involved staff, witness accounts, and interview documentation—were not recorded, and that the CNA involved was initially misidentified, demonstrating a failure to follow the facility’s grievance investigation policy.
A resident with CKD, anxiety disorder, and COPD, who was cognitively intact and dependent for many ADLs, reported that a CNA on the evening shift was mean, pushy, and made the resident cry by roughly yanking a drawsheet, throwing it on the floor, pulling out the resident’s brief, and grabbing and holding the resident’s arm to prevent the resident from fastening the brief tabs. The facility initiated an investigation but failed to follow its abuse investigation policy: the Investigation Report and CNA statement were incomplete, missing the investigator’s name, resident and staff identifiers, dates, times, signatures, and other required details, and key leaders (ADM, DON, DHI, DSD) acknowledged that the investigation process and documentation did not meet the facility’s Abuse Investigation and Reporting requirements.
A resident with CKD, COPD, and anxiety, who needed substantial assistance with ADLs, alleged that a CNA was rough, rude, and verbally abusive during incontinence care, including yanking a drawsheet from under the resident, throwing it on the floor, and holding the resident’s arm up to prevent adjusting brief tabs. An RN supervisor heard loud voices, found both the resident and CNA upset, and was told the drawsheet had been thrown on the floor, but did not report this possible abuse due to being busy. Another CNA was told by the resident that staff had been rude but also failed to report it. The resident later informed Social Services, yet the allegation was still not immediately reported to external authorities as required by facility policy, which mandates reporting alleged abuse within 2 hours, resulting in a failure to timely notify the State Survey Agency, ombudsman, and law enforcement.
A resident with CKD, anxiety disorder, and COPD, who was cognitively intact and dependent for several ADLs, reported that a CNA on the 3 PM–11 PM shift was pushy, yanked a drawsheet from under her and threw it on the floor, pulled out her brief, and roughly held her arm straight up during care, causing her to cry. The facility initiated an investigation, but the DSD did not re-interview the resident after speaking with involved CNAs, and the Investigation Report contained incomplete and inaccurate information about which CNA was allegedly rough. Multiple CNA statements were missing key elements such as dates, interviewer names, and signatures, and the DSD and SSD acknowledged that the abuse investigation and documentation did not comply with the facility’s Abuse Investigation and Reporting and Abuse Prevention Program policies.
Call Light Left Out of Reach: A resident with dementia, aphasia, weakness, and severely impaired decision-making had a care plan that required the call light to remain within reach because the resident could not verbally communicate and was at risk for falls. Surveyors observed the call light coiled on the bed rails and hanging out of reach, and a CNA later saw the resident looking for it and unable to reach it. An LVN stated the call light should be within reach and is the resident’s way to communicate needs.
A resident with DM, a gastrostomy, lack of coordination, and severe cognitive impairment was dependent on staff for ADLs and bed mobility. The physician order and care plan directed that the LAL mattress be set to the resident's weight and checked each shift, but observations showed it was set at 300 lbs and later 350 lbs despite the resident weighing 112 lbs; the MDS nurse confirmed the setting was incorrect and not implemented as planned.
Failure to Provide Nail Care: A resident with dementia, DM, and muscle weakness required partial/moderate help with personal hygiene and had a care plan directing staff to check, trim, and clean nails. Surveyors observed the resident’s fingernails to be dirty and crusted with gunk, and both the DON and a CNA confirmed the nails were dirty and needed cleaning; the CNA also noted the nails were not smooth.
A resident with severely impaired cognition, bilateral extremity impairment, and dependence for most ADLs did not receive activities aligned with her care plan and stated preferences. Her record showed she enjoyed music, classical music, piano, and westerns, but she was observed without any activity in the activity room and later in bed with the TV off; the AD confirmed there was no documented evidence that music activities were provided and noted she did not have a radio at bedside.
A resident with severely impaired cognition, bilateral upper and lower extremity ROM limitations, muscle weakness, muscle wasting, and abnormal posture was observed sitting in a Geri chair. The MDS Nurse stated the resident had always used the chair without an order, and there was no documented rehab consult or recommendation for the device. The DON confirmed the resident’s mobility and positioning needs were not properly addressed, and the facility policy required assistive devices to be based on a comprehensive assessment and documented in the care plan.
Failure to monitor and empty a resident’s nephrostomy drainage bag as ordered led to a deficiency. The resident had CKD and a left flank nephrostomy, and observations showed a dirty dressing with greenish-brown drainage, minimal redness, and a slight foul odor. The TAR had multiple blank entries for the 3 PM to 11 PM shift, and both the TXN and DON stated the LPNs did not complete the ordered nephrostomy checks, empty the bag every shift, or follow the care plan and facility policy.
Failure to provide ordered adaptive eating utensils: A resident with Parkinson's disease, dementia, and bilateral lower extremity impairment had an order for built-up utensils to support self-feeding, but was repeatedly observed eating with regular spoons instead. OT notes said the resident preferred regular utensils, COTA verified the adaptive utensils were not on the tray, and the DON confirmed the order was not implemented during meals.
Kitchen Dumpster Left Open and Overflowing: One of two kitchen dumpsters was observed uncovered and overflowing with trash. The DS confirmed the dumpster was left open, and staff stated dumpsters are supposed to be kept closed and not overflowing to prevent odor and avoid attracting flies and rats. Review of the facility policy showed outside dumpsters are to be kept closed and free of surrounding litter.
Inaccurate MAR, care plan, and progress note documentation: The facility documented behavior monitoring for a resident’s anxiety using Xanax even though the physician order had been changed to clonazepam, and the MDS nurse confirmed the MAR and care plan still reflected the wrong medication name. The facility also documented another resident’s change of condition as weight gain instead of a 7-lb weight loss, and the RD and ADM both acknowledged the notes were incorrect.
The facility failed to provide the required 80 sq. ft. per resident in 12 of 17 multiple-occupancy rooms, including Rooms 101, 102, 104, 106, 109, 110, 111, 112, 114, 115, 116, and 117. Surveyors observed one resident waiting on the edge of his bed for morning meds while his roommate remained in bed; the resident and ADM stated the room space was adequate, staff had enough room to provide care, and the facility was seeking a room waiver because it believed resident health and safety were not affected.
A resident with cognitive impairment, hemiparesis after stroke, and oropharyngeal aphagia had an ST evaluation indicating the need for assisted feeding to enhance safe swallow, and care plans addressing aspiration risk and swallowing problems. However, staff did not relay the ST recommendation for feeding assistance to the physician or obtain corresponding orders for an extended period, and did not notify the physician or obtain an order for ST reevaluation after the resident was observed to be able to feed himself without 1:1 assistance. A physician order for 1:1 feeding to prevent aspiration was not in place during the timeframe when these assessments and observations occurred.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors.
A resident was not adequately prepared for a safe transfer or discharge, as the facility did not ensure the process met the individual's needs and preferences.
Two residents with significant cognitive and physical impairments did not have their wound care treatments accurately documented on the TAR, despite physician orders for daily dressing changes. The responsible nurse confirmed that treatments were performed but not signed for, and the DON acknowledged the documentation lapse, resulting in incomplete medical records.
A resident with diabetes and kidney failure did not receive a recommended Controlled Carbohydrate Diet (CCHO) due to a lack of communication between the Registered Dietitian (RD) and the primary physician. The resident continued on a No Added Salt (NAS) diet, which did not meet their dietary needs. The facility's policy requires physician-prescribed therapeutic diets, but the RD's recommendations were not implemented, placing the resident at risk for uncontrolled blood sugar levels.
A facility failed to maintain a safe and homelike environment for several residents. A resident's room was excessively warm, causing discomfort, while another resident experienced frustration due to a malfunctioning television. Two residents' rooms had a strong odor of urine due to incontinence issues, and a resident's room had a chipping wall trim, posing a potential hazard. Staff acknowledged these issues, which affected the residents' well-being.
The facility failed to implement proper pressure ulcer prevention and treatment measures for three residents. A resident with a history of stage 4 pressure ulcer had a low air loss mattress set incorrectly, risking skin breakdown. Another resident with a history of pressure injuries had an alternating air pressure pad mattress set too firm, potentially causing pressure injuries. A third resident with a stage 3 pressure ulcer reported discomfort from a hard mattress, risking further skin damage. The facility did not adjust mattress settings based on residents' weights, as required by policy.
The facility failed to maintain proper pharmaceutical services, with issues such as ice build-up in the medication freezer, dusty storage room counters, and improper temperature control in the medication storage room. Medications like Valproic Acid and Lidocaine were stored at 83°F, exceeding the recommended range, leading to their disposal to prevent adverse reactions.
The facility failed to label opened food items with use-by dates, risking foodborne illnesses. Observations revealed unlabeled items like butter, chocolate syrup, and hash browns in the kitchen, and No Bake Custard and Gravy Mix in storage. The DS admitted the absence of labels, and the DON and RD confirmed the policy requirement for labeling to ensure food quality and safety.
A long-term care facility failed to follow infection prevention and control practices for several residents. A urine-soaked diaper was found on a paper towel dispenser, and two LVNs did not use required protective equipment while administering medications via gastrostomy tubes. Additionally, a nebulizer mask was found on the floor, and a urinal bottle was placed next to a water pitcher, both posing contamination risks.
A resident with dysphagia and cognitive impairment waited 32 minutes for their meal tray while others at the table were eating. The delay occurred despite meal carts arriving on time, and the resident felt uncomfortable and disrespected. The facility's policy emphasizes providing a dignified dining experience.
The facility failed to ensure call lights were within reach for three residents, violating policy. A resident with cognitive impairment had a call light out of reach, confirmed by a CNA. Another resident with right side weakness had a call light on the wrong side, confirmed by an LVN. A third resident, unable to use fingers, had a call light on the floor, leading to yelling for help. The facility's policy requires accessible call lights.
A resident receiving antibiotic and anticoagulant therapies did not have a comprehensive care plan developed, as required by facility policy. The absence of care plans for Ceftriaxone and Eliquis meant the resident was not monitored for treatment effectiveness or side effects. The MDS Nurse and DON acknowledged the oversight, which was contrary to the facility's care plan policy.
A facility failed to monitor a resident's behavior for the use of psychotropic medications, Abilify and Depakote, as required by their policy. The resident, diagnosed with dementia and schizophrenia, had no documented behavior monitoring orders, and the MAR was blank for a month, indicating a lack of monitoring. This deficiency was identified during interviews and record reviews.
A facility failed to maintain a medication error rate below 5%, resulting in a 10.34% error rate. An LVN administered multivitamin, vitamin C, and vitamin D3 to a resident over an hour past the prescribed time. The resident had severe cognitive impairment and required assistance with daily activities. The facility's policy mandates medication administration within one hour of the prescribed time.
The facility did not post the required Daily Nurse Staffing Information for several days, as observed on 12/2/2024. The Assistant Administrator and Director of Nursing confirmed that the Direct Care Service Hours Per Patient Day (DHPPD) postings were missing, which are essential for informing residents, families, and staff about staffing levels. The facility's policy requires daily posting of nurse staffing data, but this was not followed, leading to a deficiency.
The facility did not meet the minimum 80 square feet per resident requirement in 12 of 17 rooms. Despite this, residents reported adequate space for care and movement, and a room waiver was requested, asserting no impact on health and safety. Observations confirmed adequate ventilation, lighting, and privacy, with sufficient space for wheelchairs and medical equipment.
The facility did not post daily staffing information as required, with outdated and incomplete Census and Direct Care Service Hours Per Patient Day (DHPPD) forms observed. The DON was unaware of the requirement to post completed forms daily, leading to missing postings for several days in September.
Three residents in an LTC facility did not receive consistent treatment for pressure ulcers, as documented in their Treatment Administration Records. A resident with a deep tissue injury and Stage 2 ulcer, another with a Stage 4 ulcer, and a third with an unstageable ulcer all missed prescribed treatments, including zinc oxide application, low air loss mattress therapy, and wound cleaning. Interviews confirmed that blank entries in records indicated treatments were not performed, violating facility policy.
A resident with dementia was physically abused by another resident with psychosis in the activity room of an LTC facility. The incident occurred when the aggressive resident, who had a history of physical altercations, struck the vulnerable resident in the face. Staff interviews confirmed the altercation, and it was noted that no staff were present in the room at the time to prevent the incident, despite the facility's policy to protect residents from abuse.
A facility failed to update a resident's care plan after a physical altercation with another resident. The resident, who has unspecified psychosis and moderately impaired cognitive skills, showed increased agitation and aggression. Despite the incident, the care plan was not revised to include new interventions for the resident's safety and behavior management, contrary to facility policy requiring updates for significant changes in condition.
Failure to Follow Wound Care and Pain Management Specialist Orders
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and professional standards for two residents. For one resident with osteomyelitis of the vertebra, intraspinal abscess, and granuloma, the resident’s MDS dated 3/5/2026 showed severe cognitive impairment and dependence or significant assistance needs for most activities of daily living, including transfers, bed mobility, dressing, and personal hygiene. Wound assessment documentation dated 2/10/2026 showed a physician-ordered daily treatment for a cervical spine wound using Dakin’s solution, Betadine, and a calcium alginate dressing. However, review of the Treatment Administration Record (TAR) for February 2026 showed no documented administration of this wound treatment for 10 days (2/8/2026 to 2/16/2026 and 2/18/2026). During interviews, the DON confirmed there was no documentation that the resident received wound care treatment for the cervical spine wound on those 10 days, and stated that treatment should have been done daily per the wound physician’s order. LVN 1, when reviewing the same records, stated that the last physician treatment orders stopped on 2/7/2026 and that no new orders were entered per the wound physician’s order documented in the wound assessment. LVN 1 acknowledged that the cervical spine wound treatment orders should have been followed up and entered into the system to avoid a delay in care or treatment. The DON further stated that no new orders were input for the cervical spine wound treatment from 2/8/2026 to 2/17/2026 and that the resident did not receive wound care treatment during the identified 10 days. Facility policies on pressure ulcers/skin breakdown, wound care treatment, and treatment administration required that wound treatments be performed and documented in accordance with physician orders and professional standards of practice. For a second resident with diagnoses including fibromyalgia, muscle weakness, and osteoarthritis, the MDS indicated moderate cognitive impairment, a need for supervision or touching assistance with toileting, bathing, dressing, and footwear, and that the resident experienced occasional pain that sometimes limited day-to-day activities, with moderate pain reported within the last five days of the assessment. Physician orders dated 1/16/2026 included PRN aspirin, oxycodone, and ibuprofen for varying levels of pain, and an order stating "May refer to Pain Specialist." The resident reported telling the Social Services Director (SSD) and LVN 1 about ongoing pain, stating that the facility would give aspirin for breakthrough pain but that pain persisted, and that LVN 1 told him he would have to wait until the next scheduled oxycodone dose. A CNA reported that when the resident was in pain and this was reported to licensed nurses, the nurses responded that it was not time yet for the resident’s pain medication. The SSD stated that she did not follow up on the physician’s order for a pain specialist and that no appointment was arranged, acknowledging that she should have followed up on the order. LVN 1 stated he did not follow up on the order for the resident to see a pain specialist, explaining that "May see a pain specialist" meant that if the resident’s pain was unmanaged by current medications, the resident could see a pain specialist, and that the facility needed to ensure the resident’s pain was managed. The DON stated that the physician’s order "May see a pain specialist" meant that if the resident was having unmanaged pain, the resident needed to see the pain specialist, and acknowledged that the resident should have been seen by a pain specialist but that this was not followed up or done. Facility policies on pain management and appointments indicated that acceptable pain control is defined by the resident, that pain should be accurately assessed and controlled, and that the facility will help residents contact specialty providers as needed based on health recommendations, with nursing staff informing the unit clerk or designee about appointment orders based on medical necessity.
Failure to Follow Hand Hygiene, Wound Care, and Equipment Disinfection Protocols
Penalty
Summary
The deficiency involves failures in infection prevention and control practices during wound care and vital sign assessment for multiple residents. For one resident with a sacral stage 4 pressure ulcer and local skin infection, an RN performed wound care without changing gloves or performing hand hygiene after removing the dirty dressing and cleaning the wound. The RN removed the resident’s soiled dressing, cleansed the wound, and then immediately applied santyl collagenase ointment, collagen powder, calcium alginate, and a dry dressing without changing gloves or cleaning her hands, despite facility policies requiring hand hygiene and glove change when moving from a soiled to a clean task. The RN later acknowledged she had applied the ointment and powder with a tongue depressor but then directly handled the calcium alginate and dry dressing with the same contaminated gloves. In the same episode of care, after completing the wound treatment in the resident’s room, the RN removed her PPE, discarded it in the trash, and exited the room with the treatment cart without performing hand hygiene. This occurred even though the facility’s hand hygiene and wound care policies required hand hygiene immediately after glove removal, after exposure to wound drainage, and after removing PPE, as well as strict adherence to aseptic technique and avoidance of cross-contamination of supplies. The DON/Infection Preventionist confirmed that staff are expected to change gloves and perform hand hygiene after removing old dressings and cleaning wounds, and to perform hand hygiene upon doffing PPE and leaving a resident’s room. A separate deficiency occurred when another RN failed to disinfect a reusable blood pressure cuff between residents. The RN was observed checking one resident’s blood pressure and administering medications, then shortly afterward using the same blood pressure cuff on another resident without disinfecting it in between uses. During interview, the RN stated she did not disinfect the cuff between residents and acknowledged that the cuff should be disinfected between residents for infection control reasons. The DON/Infection Preventionist stated that equipment should be disinfected before and after each resident, and the facility’s cleaning and disinfection policy specified that reusable items are to be cleaned and disinfected or sterilized between residents.
Failure to Keep Call Light Within Reach of Dependent Resident
Penalty
Summary
Surveyors identified a deficiency in which staff failed to ensure a resident’s call light was within reach while the resident was in bed. The resident had been admitted and later readmitted with diagnoses including muscle weakness, COPD, and depression. According to the MDS dated 3/6/2026, the resident was moderately impaired in cognitive skills for daily decision making and required substantial/maximal assistance with eating, oral hygiene, upper body dressing, and personal hygiene, and was dependent for toileting hygiene, showering/bathing, lower body dressing, and footwear. During an observation and interview in the resident’s room on 4/15/2026 at 2:53 PM, the resident was found lying in bed with the call light placed on the top right corner of the bed, out of the resident’s reach. The resident stated she was thirsty, needed water, and could not reach the call light to alert staff. In a concurrent observation and interview at 2:55 PM, CNA 2 confirmed that the call light was placed on the top right corner of the bed, acknowledged that it was not within the resident’s reach, and stated that the call light should be within reach so the resident could call staff for assistance. In a subsequent interview on 4/16/2026 at 1:30 PM, the DON stated that the call light should always be within the resident’s reach so the resident can use it when assistance is needed. Review of the facility’s policy and procedure titled “Answering the Call Light,” revised 9/2022, indicated that staff are to ensure the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility, and from the floor. The observed placement of the call light for this resident did not comply with the facility’s policy or the stated expectations of staff and leadership.
Failure to Care Plan for High-Risk Resident’s Unassisted Getting Out of Bed
Penalty
Summary
The facility failed to develop an individualized, resident-centered care plan with measurable objectives, timeframes, and interventions to address one resident’s behavior of getting out of bed and up without assistance. The resident had diagnoses including difficulty walking, Parkinson’s disease, muscle weakness, and dementia, and was assessed as being at high risk for falls. The MDS showed the resident was severely impaired in cognitive skills for daily decision-making and required substantial/maximal assistance with most ADLs, and partial/moderate assistance with eating and oral hygiene. Progress notes documented an unwitnessed fall, with notation that the resident did not ask for assistance prior to mobility. Staff interviews confirmed that since admission the resident had a known tendency to get up without assistance, often related to needing an adult brief/diaper change. A CNA, an LVN, and an RN each stated that the resident frequently attempted to get up alone without calling for help. During review of the resident’s care plans over a multi-year period, the DON acknowledged there was no care plan addressing the resident’s behavior of getting up unassisted and no care plan revision after a prior fall, despite the expectation that the care plan be revised with each change in condition. This was inconsistent with the facility’s policy on comprehensive person-centered care plans, which requires the IDT, with the resident and representative, to develop and implement a comprehensive care plan based on assessment findings to describe services needed to attain or maintain the resident’s highest practicable well-being.
Medication Administration and Reconciliation Failures Affecting Two Residents
Penalty
Summary
The deficiency involves failures in pharmaceutical services and medication administration for two residents. For the first resident, who had atrial fibrillation, hemiplegia, hemiparesis following cerebral infarction, and moderate cognitive impairment, the facility did not ensure proper medication administration practices. This resident had multiple physician orders, including Eliquis for DVT prophylaxis, antihypertensives, GI medication, iron supplement, lactulose, calcium with vitamin D, and prednisone. On review of the MAR for the month, several medications, including ferrous sulfate, lactulose, oyster shell calcium + D, and metoprolol tartrate, were documented as refused. The resident stated he refused his medications on one day because the RN did not explain the seven medications being given. During a medication pass observation, RN 2 prepared medications for this resident and stated that the facility was out of Eliquis and needed to request a refill from the pharmacy. RN 2 then administered seven medications without checking the resident’s wrist band or the photograph in the medical record to confirm identity and did not explain the types of medications or their indications. In a subsequent interview, RN 2 acknowledged not explaining the medications or checking the wrist band before administration and confirmed that Eliquis had not been administered because it was not available and had not been refilled on time. The DON stated that nurses are expected to explain medications and indications, verify resident identity using identifiers such as wrist bands, and ensure timely refills so medications are given as ordered. Facility policies on administering medications and resident rights required verification of identity and informing residents about their treatment. For the second resident, who had diagnoses of unspecified psychosis and schizoaffective disorder and was severely cognitively impaired, the deficiency involved inaccurate medication reconciliation on admission. The hospital discharge medication reconciliation listed risperidone 3 mg, one tablet orally twice a day. However, the facility’s order summary, entered by the DSD, showed an order for risperidone 3 mg, three tablets by mouth twice a day for schizophrenia. A physician order note documented that this order, entered on admission, was outside the recommended dose or frequency and exceeded the usual dosing regimen. In interviews, an LVN described the standard admission process of reviewing the admission packet, notifying the MD, obtaining approval to continue medications, and accurately inputting orders, emphasizing the importance of double-checking alerts and reconciling orders to avoid transcription errors. The DSD stated that when admitting this resident, she was tired and transcribed the risperidone order incorrectly as three tablets twice a day instead of one tablet twice a day and did not notice the system alert that the dose was above the recommended range. The DON/IP confirmed that the medication reconciliation for this resident’s risperidone was not accurate and that the incorrect order prevented the pharmacy from dispensing the medication, resulting in the resident not receiving risperidone for three days, which the DON/IP stated could have further aggravated the resident’s condition.
Failure to Prevent Resident-to-Resident Physical Abuse Involving Laundry Cart Incident
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident. One resident with schizoaffective disorder, depression, anxiety, severely impaired decision-making, and a known history of physical and verbal aggression, including yelling profanities and shoving or throwing objects at others, was not being monitored for aggressive behaviors. A Change in Condition (COC) evaluation documented that this resident had episodes of yelling profanities and shoving objects at other residents, but there were no corresponding physician orders or behavior monitoring in the medical record to address or track these behaviors. On the day of the incident, the Admission Director was escorting this aggressive resident to the shower when the resident became upset about the appearance of the shower. The Admission Director briefly left the resident unattended in the hallway to obtain more towels. During this time, a visitor reported hearing yelling and observed the aggressive resident screaming at another resident who was seated in a wheelchair in the hallway. The visitor stated that the aggressive resident pushed a laundry cart or basket into the wheelchair-bound resident, who then yelled "ouch," and that the aggressive resident continued cursing at the other resident while walking toward the shower. Staff interviews and documentation corroborated that the aggressive resident had a pattern of rude, verbally aggressive, and unsafe behavior toward staff and other residents, including throwing items on the floor and being described as really aggressive and unsafe to others. A nurse heard the wheelchair-bound resident say "ouch" and the aggressive resident shouting profanities in the hallway, and was informed by the visitor that the laundry cart had been pushed into the resident in the wheelchair. The Director of Nursing acknowledged that the aggressive behavior, which began as early as the resident’s second day in the facility, had not been included in behavior monitoring and that the facility failed to prevent the aggressive resident from pushing the laundry cart into the other resident, contrary to the facility’s abuse and neglect policy requiring measures to minimize the possibility of abuse.
Failure to Assess, Order, and Monitor Urostomy and Self-Catheterization Care
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary urostomy and self-catheterization care and treatment for one resident in accordance with its own policies and procedures. The resident was admitted with diagnoses including urinary retention, paraplegia, and lack of coordination, and had an opening on the right lower abdomen for bladder drainage, using a straight catheter for voiding. The resident’s MDS documented an ostomy appliance, total dependence for toileting and dressing, and urinary incontinence, while cognitive skills for daily decision-making were independent. Despite these conditions, there was no physician order for urostomy care from admission until several days later, and the only order identified was to cleanse the urostomy site with normal saline, pat dry, and leave open to air, starting on a later date. The resident reported performing self-catheterization and primarily using personal supplies, requesting some items such as gauze from staff, but refused to show the stoma or provide details of the procedure. Nursing staff, including an LVN, stated that the resident performed self-catheterization but they had never assisted with or observed the urostomy care and were unaware of the condition of the skin around the stoma. The RN confirmed that urostomy care was not performed from admission until the date the urostomy care order was written, and that there were no physician orders, assessments, or documentation establishing that the resident could safely perform self-catheterization or indicating how often the resident catheterized. Further record review and interviews showed that the facility did not maintain required monitoring and documentation related to the resident’s urostomy and self-catheterization. There were no records of the resident’s intake and output, no documentation of urine output or its characteristics, and no evidence that the skin around the stoma was inspected for irritation or breakdown. The infection prevention nurse confirmed that the resident had not been evaluated for ability to perform self-catheterization, that there was no physician order for self-catheterization, and that no care plan addressing urostomy care and self-catheterization had been developed upon admission, contrary to the facility’s urostomy/ureterostomy care and self-catheterization policies, which require physician orders, competency verification, ongoing monitoring, and documentation of intake/output and peristomal skin condition.
Unsafe and Unmaintained Resident Room Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, sanitary, and home-like environment for four sampled residents by allowing environmental and equipment issues in resident rooms. Resident 4, who had dementia, diabetes mellitus, and COPD and was severely impaired in daily decision making, was observed in bed with an air vent above the head of the bed visibly coated with dust, including the surrounding frame. The DON stated the dust buildup was not acceptable and created a fire risk and was not good for the resident's health, and the MS stated the vent had not been cleaned. Resident 6, who had muscle weakness, acute kidney failure, and scoliosis, was dependent for several activities of daily living. In the resident's room, the bedside table was observed to be chipped with rough wood exposed, and the bed control was visibly damaged with chipped and cracked edges around the casing. The DSD stated the chipped bedside table and broken bed control could cause skin tears to the resident and staff. Resident 19, who had muscle weakness, diabetes mellitus, and heart failure, was observed with a bed control that had a crack and rough edges and an overhead light with cracks. The DSD stated the bed control was cracked, dirty, and had rough edges, and that the cracked overhead light was not acceptable and could cause accident, skin injury, and infection. Resident 35, who had diabetes mellitus, hemiplegia, and hemiparesis and needed substantial to maximal assistance with eating and oral hygiene, stated the TV in the room was not working. The resident's care plan indicated the resident enjoyed watching television, and the RNS attempted to turn it on but it did not work; the DSD stated the maintenance policy was not followed.
Pressure Relief Devices Not Set Correctly and Stage 3 Wound Not Fully Documented
Penalty
Summary
The facility failed to ensure that low air loss mattresses were set according to residents’ weights for five sampled residents, and it failed to completely assess and document a stage 3 sacrococcyx pressure ulcer for one resident upon readmission. The report states that Resident 2 had a physician order for a low air mattress set at resident weight for firmness and alternating float, but the mattress was observed set at 350 lbs. even though the resident weighed 141 lbs. The Registered Nurse Supervisor stated the setting should have been 150 lbs., and the Director of Nursing stated the 350 lbs. setting was too firm and could contribute to worsening of the pressure ulcer. Resident 6 also had a physician order and care plan directing the low air mattress to be set at resident weight for firmness and alternating float, but the mattress was observed in between 265 lbs. and 400 lbs. while the resident weighed 207 lbs. The RN Supervisor stated the setting should have been between 180 lbs. and 265 lbs. Resident 10 had an order for a low air loss mattress set at resident weight for firmness, yet the mattress was observed at 300 lbs. and later at 350 lbs. while the resident weighed 112 lbs. The MDS nurse confirmed the setting was not correct for the resident. Resident 31 had a physician order and care plan for a low air mattress set at resident weight for firmness, but the mattress was observed at 320 mmHg and later at 190 mmHg while the resident weighed 172 lbs. Staff stated the setting was too high and too firm. Resident 35 was readmitted with a diagnosis that included a stage 3 pressure ulcer of the sacral region, but the admission assessment did not include the wound size, and the record lacked documented weekly wound assessments or measurements after readmission. The DON stated the wound assessment should have included a complete description, including size, drainage, and odor, and that the licensed nurses needed more education regarding weekly wound assessment and documentation.
Incomplete Nurse and CNA Competency Documentation
Penalty
Summary
The facility failed to ensure that nurses and nurse aides had appropriate competencies and skill sets documented for resident care. During record review and interviews, the Director of Staff Development stated that CNA 2’s skills check evaluation competency was completed on 12/23/2025, but the form had a blank box for the initial skills check date, no dates documenting when tasks were evaluated, and no documentation in the comments section identifying the type of evaluation used for specific tasks. The DSD also stated that the evaluation was incomplete because the signature and date line was blank on the last page, and she refused to explain how the choking and Heimlich maneuver tasks were evaluated. A similar issue was identified for CNA 3. The skills check evaluation competency dated 1/7/2026 had a blank box where the initial skills check date should have been, only a few check marks, and no dates showing when tasks were evaluated. The DSD stated that CNA 3 was hired on 1/6/2026 and that she conducted the skills check evaluation on 1/7/2026, but also stated she was trying to do a shortcut with the forms by writing S in the first box and drawing a line down the checklist. She further stated that not all tasks were observed, some were discussed verbally, and that the evaluation lacked documentation showing how each skill was validated. For licensed nurses, LVN 2’s records included a performance evaluation, an undated skills checklist for medication administration, an undated and untimed med pass form, and a participant certification of skills competency evaluation dated 5/6/2025. The skills checklist and med pass form contained check marks but no description of how the skills were evaluated and no evaluator or observer name. The certification form did not have med administration or dietary checked or marked. The DSD stated that the missing check marks meant the evaluation was not done or the employee failed the training. Additional record review showed incomplete orientation and competency documentation for RN staff. RNS 3’s new hire orientation checklist had a blank employee signature/date box, and the DSD stated that the licensed nurse skills evaluation/orientation checklist for that employee was not in the employee folder. The facility consultant confirmed the checklist was missing and stated it should be kept in the employee file. For RNS 4, the orientation checklist was undated and incomplete, the licensed nurse skills evaluation/orientation checklist showed a hire date of 9/8/2025 but lacked required dates of observations and signatures, and the medication pass evaluation identified several items that were not marked correct and reviewed with the nurse. The Administrator stated she did not know why the employee files were incomplete and that if specific training was not in the file, it meant it was not done.
Late Administration of Scheduled Medications
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of two sampled residents when their 9:00 AM medications were not administered within the facility’s one-hour medication window on 1/22/2026. The report states that medications are to be administered within one hour before or after the scheduled time unless otherwise specified, and that late administration outside that window is considered a medication error. The deficiency was identified through observation, interview, and record review. Resident 17 was admitted with diagnoses including benign prostatic hyperplasia, dementia, and hypertensive heart disease with heart failure. The resident’s order summary included multiple scheduled medications, including ascorbic acid, bethanechol chloride, carbidopa-levodopa, docusate sodium, escitalopram oxalate, lactobacillus, and furosemide. During medication administration observation at 11:03 AM, LVN 2 prepared and administered six of Resident 17’s medications that were scheduled for 9:00 AM. During interview, LVN 2 stated the medications were given late because he was busy with another resident. The DON confirmed that Resident 17’s 9:00 AM medications were administered outside the allowed one-hour window. Resident 10 was admitted with diagnoses including diabetes mellitus, encounter for attention to gastrostomy, and lack of coordination. The resident’s assessment indicated severely impaired cognitive skills and dependence on staff for multiple activities of daily living. The resident’s order summary included scheduled medications such as Ativan, baclofen, benztropine mesylate, escitalopram oxalate, esomeprazole magnesium, senna, and Zyprexa. During medication administration observation at 12:44 PM, RNS 4 prepared and administered these medications, which were scheduled for 9:00 AM. The DON confirmed that Resident 10’s 9:00 AM medications were also administered late on the same day. The DON and LVN 2 both stated that if nurses were having difficulty administering medications within the allotted time, they should have asked another licensed nurse for assistance.
Failure to Monitor Residents on Insulin and Anticoagulant Therapy
Penalty
Summary
The facility failed to monitor two residents for signs and symptoms associated with insulin therapy, and failed to monitor one of those residents for signs and symptoms of bleeding while receiving anticoagulant therapy. Resident 1 had diagnoses including type 2 diabetes, right leg cellulitis, lumbar spine spondylosis, and lymphedema, and was documented as cognitively intact for daily decision making. Resident 1 was receiving Humalog insulin by sliding scale, but the MDS nurse stated there was no order to monitor for signs and symptoms of hypoglycemia or hyperglycemia and no documented evidence that such monitoring occurred. The resident’s diabetes care plan identified risk for hypoglycemia and hyperglycemia, and the MDS nurse stated the care plan interventions should have included monitoring for those signs and symptoms. Resident 32 also had DM II and was documented as cognitively intact. The resident was receiving Insulin Lispro before meals and at bedtime by sliding scale. The MDS nurse stated Resident 32 did not have an order to monitor for signs and symptoms of hypoglycemia or hyperglycemia, and there was no documented evidence in the nurses’ progress notes that the resident was monitored for those symptoms. Resident 32’s diabetes care plan identified risk for hypoglycemia and hyperglycemia and included interventions to monitor, document, and report signs and symptoms such as sweating, tremor, tachycardia, pallor, nervousness, confusion, slurred speech, lack of coordination, and staggering gait, but the MDS nurse stated those interventions were not followed and implemented because there was no documentation that staff monitored the resident. Resident 32 was also receiving Enoxaparin Sodium injection for blood clotting prevention. The MDS nurse stated the resident should have had monitoring for bleeding, bruises, and hematoma because of Lovenox use. The anticoagulant therapy care plan directed staff to administer anticoagulants as ordered and monitor for side effects and effectiveness every shift, including reporting adverse reactions such as blood in urine or stool, bruising, sudden headaches, nausea, vomiting, lethargy, shortness of breath, and changes in mental status or vital signs. The MDS nurse stated there was no documented evidence in the nurses’ progress notes that Resident 32 was monitored for signs and symptoms of bleeding while on anticoagulant therapy.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to keep its medication error rate below 5 percent. Surveyors identified 13 medication errors out of 35 observed medication administration opportunities, resulting in an overall error rate of 37.14 percent for two sampled residents. The deficiency was based on observation, interview, and record review during medication administration observations on 1/22/2026. One resident had diagnoses including benign prostatic hyperplasia, dementia, and hypertensive heart disease with heart failure. The resident’s order summary included multiple scheduled medications for 9 AM, including ascorbic acid, bethanechol chloride, carbidopa-levodopa, docusate sodium, escitalopram oxalate, lactobacillus, and furosemide. During observation at 11:03 AM, an LVN prepared and administered six of the resident’s medications after the 1-hour window for the scheduled 9 AM dose time. During interview, the LVN stated the medications were late because he was busy with another resident. A second resident had diagnoses including diabetes mellitus, attention to gastrostomy, and lack of coordination, and was dependent on staff for multiple activities of daily living with severely impaired cognitive skills for daily decision making. The resident’s order summary included scheduled G-tube medications such as Ativan, baclofen, benztropine mesylate, escitalopram oxalate solution, esomeprazole magnesium, senna, and Zyprexa. During observation at 12:44 PM, an RN supervisor administered the resident’s medications outside the 1-hour window for the 9 AM scheduled time. Interviews with nursing staff and the DON confirmed that medications were not administered within the required time frame and that doing so constituted a medication error. The DON also stated that when staff had difficulty administering medications on time, they should have asked for assistance from another licensed nurse.
Food Service Equipment and Storage Not Maintained in Sanitary Condition
Penalty
Summary
The facility failed to ensure proper food handling and maintain the kitchen and food service equipment in a clean and sanitary condition in accordance with its policies and procedures. During observations in the kitchen, the can opener was chipped and soiled with food residue, the blender was chipped with white to yellowish discoloration around the blade inside the jar, the onion powder container lid was partially closed and lacked an open and discard date label, and the stand mixer had peeling and chipped paint with exposed metal on the adjustment handle. The spout of the coffee maker was also observed to be cracked. During interviews, the Dietary Supervisor stated that the coffee maker pot was cracked, the stand mixer paint was chipped and peeling, the onion powder lid was not properly closed and was not dated, and the can opener had marinara sauce residue. The Dietary Supervisor stated that lids are supposed to be properly closed and dated with open and discard dates, the can opener should be washed daily after use, and equipment should be maintained in good condition to prevent food contamination. A Cook stated that the can opener should be cleaned after every use and that all opened food should be labeled, dated, and sealed properly. Facility policies titled Food Storage and Safety and Sanitation stated that opened and partially used foods shall be dated, labeled, and sealed before being returned to storage and that food and nutrition services employees shall perform job responsibilities in a safe and sanitary manner.
Failure to Properly Investigate and Document Resident Grievance
Penalty
Summary
The deficiency involves the facility’s failure to follow its grievance investigation and documentation procedures for a cognitively intact resident who filed a grievance about staff conduct during care. The resident, who had chronic kidney disease, anxiety disorder, and COPD, required substantial to maximal assistance with toileting, bathing, dressing, and transfers. A Complaint and Grievance Report (CGR) form documented that during an evening shift, an unidentified CNA pulled a sheet from under the resident and threw it on the floor during care. The Social Services Director (SSD) received the grievance report later and noted that the resident could not recall the CNA’s name, and the SSD endorsed the report to the Director of Staff Development (DSD) and nursing for follow-up. When surveyors reviewed the CGR form with the SSD, they found that key sections were left blank, including the steps taken to investigate the grievance, the summary of pertinent findings or conclusions, and the date the grievance decision was confirmed. The SSD acknowledged that the nursing department was responsible for follow-up interviews and documentation of the investigation, and that the CGR should have included details such as the in-service topic discussed with the CNA and a summary of the investigation. The SSD further acknowledged that she did not review or follow up on the investigation, did not complete the missing sections, and did not explain to the resident the steps taken to investigate the grievance. Additional interviews with the DON and DSD confirmed that the investigation was incomplete and not documented in accordance with facility policy. The DON stated that the CGR form lacked documentation of the steps taken to investigate and any attached investigation report, and that required elements from the grievance policy—such as date and time of the alleged incident, circumstances, location, names of witnesses and their accounts, and recommendations for corrective action—were not recorded. The DSD similarly stated that the nursing department was responsible for follow-up interviews and documentation, but the CGR form remained incomplete, missing information such as names of staff interviewed, the resident’s name, interview times and dates, and names of involved persons. The SSD later stated that the initial investigation had incorrectly identified the CNA involved, further demonstrating that the grievance investigation process and documentation were not properly carried out for this resident.
Failure to Properly Investigate Resident’s Allegation of Rough and Verbal Abuse
Penalty
Summary
The deficiency involves the facility’s failure to follow its abuse investigation policies and procedures after an allegation of verbal and rough physical treatment toward a resident. The resident, who had chronic kidney disease, anxiety disorder, and COPD, was cognitively intact and required substantial to maximal assistance with toileting, bathing, dressing, and transfers. The resident reported that a CNA on the 3 PM–11 PM shift had a bad attitude, was pushy, and was mean, and that this interaction made the resident cry. In interviews, the resident described an incident in which the CNA roughly yanked the drawsheet from under the resident and threw it on the floor near the door, pulled out the resident’s brief, and grabbed and held the resident’s right arm straight up while the resident was attempting to fasten the brief tabs, which the resident typically adjusted independently. The resident stated that this occurred on a Sunday night, that the CNA’s behavior was rough and scary, and that the resident did not like what the CNA did. The resident reported the CNA’s bad attitude to the Social Services Director the following day. Record review showed that the facility’s investigation documentation was incomplete and did not comply with the written Abuse Investigation and Reporting policy. The Investigation Report lacked the name of the investigator, the names of all staff interviewed, the name of the resident involved, and the times of the interviews. The Administrator, DON, DHI, and DSD each acknowledged that the investigation report and CNA statement were missing required elements such as dates, times, resident and staff identifiers, interviewer name, staff phone number, and signatures. The DON and DSD stated that the investigation process outlined in the abuse policy was not followed and that the documentation was inaccurate, incomplete, and not considered a valid investigation report, despite the policy requiring thorough review of documentation, resident interviews, staff interviews on all shifts, and review of events leading up to the alleged incident.
Failure to Timely Report Allegation of Abuse to Required Authorities
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of abuse within the required 2‑hour timeframe to the State Survey Agency, state ombudsman, and local law enforcement. A cognitively intact resident with chronic kidney disease, anxiety disorder, and COPD, who required substantial to maximal assistance with several ADLs, alleged that a CNA on the 3 PM to 11 PM shift was rough, pushy, and verbally abusive during incontinence care. The resident reported that the CNA yanked a drawsheet from under her, threw it on the floor near the door, pulled out her brief, grabbed her arm, and held it straight up while changing her, preventing her from adjusting the brief tabs as she preferred. The resident stated the CNA was mean, rough, and scary, and that the interaction made her cry. On the evening of the incident, an RN supervisor heard loud voices from the resident’s room, entered, and observed both the resident and the CNA were upset. The resident told the RN supervisor that the CNA had thrown the drawsheet on the floor and was not listening to her request to have two drawsheets. The resident refused further care from the CNA, and her voice was described as shaky. The RN supervisor acknowledged that she recognized this as a possible allegation of abuse but became overwhelmed and busy with her shift and did not report the incident to the Administrator, DON, or another licensed nurse as required. Another CNA later reported that the resident had told her the CNA who took over her care after 7 PM that Sunday was rude to her, but this CNA also did not report the allegation to supervisory staff. The resident reported the incident to the Social Services Director the following day, describing the CNA’s actions with the drawsheet and her perception that the CNA was rough and rude. The Social Services Director did not immediately conduct a thorough investigation or report the allegation to the appropriate agencies at that time. The facility’s policies on Abuse Investigation and Reporting and Abuse Prevention Program required that alleged violations of abuse, neglect, exploitation, or mistreatment be reported immediately, and not later than two hours if the alleged violation involved abuse or resulted in serious bodily injury. The DON confirmed that CNAs are mandated reporters and that staff should have reported the allegation within two hours, including when the resident told a CNA that staff was mean, which the DON identified as possible verbal abuse. Despite these requirements, the allegation was not reported within the mandated timeframe, resulting in the cited deficiency.
Failure to Thoroughly Investigate Resident’s Allegation of Rough Care by CNA
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an allegation of abuse involving one resident, as required by its abuse policies and procedures. The resident, who had chronic kidney disease, anxiety disorder, and COPD, was cognitively intact and required substantial/maximal assistance with several ADLs, including toileting, bathing, dressing, and transfers. During an interview, the resident reported that a CNA on the 3 PM–11 PM shift had a bad attitude, was pushy, yanked out the drawsheet from under her and threw it on the floor near the door, pulled out her brief, and grabbed and held her arm straight up while changing her, which the resident described as mean and causing her to cry. The resident stated she had reported the CNA’s bad attitude to the Social Services Director the day before the survey interview. The facility initiated an investigation documented on an Investigation Report dated 1/20/2026. That report reflected that another CNA stated the resident had told her that the CNA who took over the 3 PM–11 PM shift was rude, and that CNA 2 acknowledged taking over the resident’s care at 7 PM. CNA 2 reported that when she returned to change the resident, she rolled up and pulled out a dirty drawsheet, the resident grabbed and unrolled it, and food crumbs fell back on the bed; CNA 2 then took the drawsheet and left the room to look for the nurse in charge. The report also indicated CNA 2 informed an RN Supervisor that the resident had stated CNA 2 was being rough. However, the Director of Staff Development did not interview the resident after interviewing CNA 2 and CNA 3, explaining that the report was viewed as only involving pulling out the drawsheet and putting it on the floor. Record review and staff interviews showed that the investigation documentation was incomplete and inaccurate. The Social Services Director later acknowledged that the investigation conclusion was not accurate regarding which CNA the resident alleged was rough and that more in-depth follow-up interviews with the resident and involved staff should have been conducted. The DSD identified that CNA statements were incomplete or undated, missing the interviewer’s name, interview date, staff phone number, and staff signature, and stated that one CNA’s statement was not valid due to these omissions. The DSD also confirmed that the facility’s Abuse Prevention Program policy, which requires the investigator to record complete investigation results on approved forms and provide them to the Administrator, was not followed, as the investigation lacked essential information such as date and time, resident and staff involved, and the name of the interviewer/investigator.
Call Light Left Out of Reach
Penalty
Summary
The facility failed to ensure that Resident 4’s call light was within reach. Resident 4 was admitted with dementia, muscle weakness, and aphasia, and the MDS indicated severely impaired cognitive skills for daily decision making, partial/moderate assistance with personal hygiene, and dependence for toileting hygiene. The care plan identified the resident as at risk for falls related to confusion, history of falls, incontinence, unaware of safety needs, and poor vision, and also stated to ensure the resident’s call light was within reach and encourage use of it for assistance as needed. The care plan initiated on 5/28/2025 stated that Resident 4 could not verbally communicate, making the call light at the resident’s side very important, and that activities would trigger the call light for medications and pain management. During observation on 1/20/2026, the resident’s call light was seen coiled on the right side of the bed rails and hanging out of reach. During a concurrent observation and interview on 1/22/2026, CNA 1 observed the resident looking for the call light and stated it was coiled at the bed rails, hanging down, and unable to be reached. LVN 1 later stated the call light should be placed within the resident’s reach and was the resident’s way of communicating needs to staff. The facility policy on answering the call light stated that the call light should be accessible to the resident when in bed, from the toilet, from the shower or bathing facility, and from the floor.
Failure to Set Low Air Loss Mattress According to Resident Weight
Penalty
Summary
Resident 10 had diagnoses including diabetes mellitus, encounter for attention to gastrostomy, and lack of coordination, and the Minimum Data Set dated 1/2/2026 indicated severely impaired cognitive skills for daily decision making. The resident was dependent on staff for eating, oral hygiene, toileting hygiene, showering, upper and lower body dressing, putting on and taking off footwear, personal hygiene, and bed mobility including rolling, sit to lying, and lying to sitting on the side of the bed. The physician order summary dated 1/21/2026 included an order for a low air loss mattress to be set at the resident's weight for firmness and checked every shift for skin management, ordered on 10/27/2025. The care plan revised on 12/5/2025 also included interventions for the low air loss mattress to be set at the resident's weight and checked for proper setting and function. However, observations on 1/20/2026 and 1/21/2026 showed the mattress was set at 300 lbs and then 350 lbs, while the resident's weight was documented as 112 lbs. During interview, the MDS nurse stated the mattress should be set by the resident's weight and confirmed it was not implemented as planned.
Failure to Provide Nail Care
Penalty
Summary
The facility failed to provide grooming services for one sampled resident who was unable to perform activities of daily living independently. Resident 4 was admitted with diagnoses including dementia, diabetes mellitus, and muscle weakness. The resident’s MDS indicated severely impaired cognitive skills for daily decision making and partial/moderate assistance was needed with personal hygiene. The care plan identified the resident as at risk for ADL self-care deficit and directed staff to check nail length and trim and clean nails on bath day and as necessary. During observation, Resident 4’s fingernails were found to be dirty and crusted with gunk. The DON later observed the same condition and stated the resident’s nails needed to be cleaned. A CNA also observed dirty nails with dark-colored small particles under the fingernails and stated the nails were not smooth. The facility’s policy for fingernails and toenails stated nail care includes daily cleaning and regular trimming, with the purpose of cleaning the nail bed, keeping nails trimmed, and preventing infections.
Failure to Provide Activities Based on Resident Preference
Penalty
Summary
The facility failed to provide activities that supported Resident 10’s stated preferences and care plan goals. Resident 10 was admitted and later readmitted with diagnoses including diabetes mellitus, encounter for attention to gastrostomy, and lack of coordination. The MDS dated 1/2/2026 indicated severely impaired cognitive skills for daily decision making, impairment of both upper and lower extremities, and dependence on staff for eating, oral hygiene, toileting hygiene, showering, dressing, footwear, personal hygiene, and bed mobility. The care plan initiated on 11/14/2025 stated that Resident 10 enjoyed listening to the radio or watching TV, wanted juice daily, and should be taken to the activity room at least once a week. The activity interview for daily and activity preferences documented that Resident 10 had worked as a musical artist and performer, enjoyed music, found playing the piano comforting and relaxing, preferred classical music, and liked westerns on TV and movies. During observation on 1/20/2026, Resident 10 was sitting in a Geri chair in the activity room without any activity while other residents played board games. During observation on 1/21/2026, Resident 10 was lying in bed awake with the TV turned off. The Activity Director reviewed the record and stated there was no documented evidence that activities such as listening to music were provided, that Resident 10 did not have a radio at bedside but should have one, and that it was important to provide activities according to the resident’s assessment. The DON also stated that providing appropriate activities helps bring back memories and support mental health and quality of life.
Failure to Address ROM and Positioning Needs
Penalty
Summary
The facility failed to provide appropriate treatments and services to increase, prevent, or maintain range of motion for one resident, Resident 10, who was assessed with bilateral upper and lower extremity functional limitations in ROM. The resident’s record showed an admission and readmission history with diagnoses including diabetes mellitus, encounter for attention to gastrostomy, and lack of coordination. The Minimum Data Set dated 1/2/2026 indicated severely impaired cognitive skills for daily decision making, dependence on staff for eating, oral hygiene, toileting hygiene, showering, dressing, footwear, and personal hygiene, and dependence for bed mobility tasks including rolling, sit-to-lying, and lying-to-sit. The History and Physical dated 10/4/2025 documented muscle weakness, muscle wasting and atrophy, and abnormal posture. During observation on 1/20/2026, Resident 10 was seen sitting in a Geri chair in the activity room. During record review and interview on 1/21/2026, the MDS Nurse stated the resident had always used a Geri chair and not a wheelchair, that the chair was being used because of abnormal posture, and that there was no order for the Geri chair. The MDS Nurse stated rehabilitation should have assessed the resident and communicated a recommendation to nursing, and that there was no documented evidence rehabilitation was consulted regarding the resident’s abnormal posture. The DON stated rehabilitation should have communicated whether a Geri chair was recommended and that the resident’s mobility was not properly addressed since no recommendation was provided. The facility policy stated assistive devices and equipment are based on a comprehensive assessment and documented in the care plan.
Failure to Monitor and Empty Nephrostomy Drainage Bag
Penalty
Summary
The facility failed to provide care and treatment for one resident with a left flank nephrostomy tube by not monitoring and emptying the drainage bag in accordance with the physician’s orders, the resident’s care plan, and the facility’s Care of Nephrostomy Tube policy. The resident was admitted and re-admitted to the facility with diagnoses including chronic kidney disease, anxiety disorder, and COPD. The resident had intact cognitive skills for daily decision making and required substantial to maximal assistance with several activities of daily living, including toileting hygiene and transfers. During observation, the resident’s nephrostomy dressing had greenish-brown drainage, minimal redness, and a slight foul odor. The resident stated that the outgoing shift nurses were often reminded to tell the incoming shift to empty the bag at 1 AM, but this was often not done. The resident also stated the bag fills quickly, takes only a minute to drain, and when it fills up it can cause lower back pain because urine backs up to the kidneys, which can lead to infection and possible hospital transfer. The treatment nurse also observed that the dressing was dirty and had hair on it, and stated the nephrostomy site consistently had greenish-brown drainage. Record review showed physician orders to cleanse and dress the nephrostomy site, check for obstructive and reflux uropathy every shift, empty the drainage bag every shift or before completely full, and monitor urine output for changes every shift. The treatment administration record had blank signatures for the 3 PM to 11 PM shift on multiple dates, and the treatment nurse stated that blank spaces meant the licensed nurses did not check the nephrostomy, empty the drainage bag, or monitor the urine. The care plan required checking tube placement and patency, emptying the bag every shift or before full, monitoring urine output changes, and monitoring for urinary infection, but the treatment nurse and DON stated these interventions were not implemented. The DON also stated the dirty dressing, drainage, and redness were not normal and could cause infection.
Failure to Provide Ordered Adaptive Eating Utensils
Penalty
Summary
The facility failed to ensure that Resident 17, who had Parkinson's disease, dementia, hypertensive heart disease with heart failure, and bilateral lower extremity impairment, was provided built-up utensils during meals as ordered to increase independence for self-feeding. The resident's order summary dated 1/21/2026 included an order from 12/12/2025 to provide built-up utensils for meals, and occupational therapy notes documented that the resident preferred regular utensils despite education on using built-up utensils. During observations on 1/20/2026 and 1/21/2026, Resident 17 was seen eating lunch with a regular spoon from the meal tray. On 1/22/2026, COTA 1 verified that the lunch tray did not have built-up utensils and stated the resident refused them. On 1/23/2026, LVN 2 observed two regular spoons on the tray and stated the resident always had regular spoons and had never been seen using a special spoon, while also verifying the order for built-up utensils had been in place since 12/12/2025. The RD stated the refusal had not been communicated to her, and the DON stated the order was not implemented during meals and that the rehabilitation department should have communicated the refusal and re-evaluated the device's appropriateness. The facility policy stated adaptive devices will be provided for residents who need or request them and assistance will be provided to ensure residents can use and benefit from special eating equipment and utensils.
Kitchen Dumpster Left Open and Overflowing
Penalty
Summary
The facility failed to ensure that one of two kitchen dumpsters was kept closed and not overflowing, as required by its policy titled Food Related Garbage and Refuse Disposal. During a concurrent observation and interview with the Dietary Supervisor, one dumpster at the back of the facility was found uncovered and sealed improperly, with trash overflowing. The Dietary Supervisor confirmed that one of the two kitchen dumpsters was left open and overflowing with trash. During later interviews, staff stated that the kitchen dumpsters are supposed to be closed and not overflowing to prevent odor and to avoid attracting flies and rats. Review of the facility policy showed that outside dumpsters provided by garbage pickup services are to be kept closed and free of surrounding litter, and the Dietary Supervisor stated that this policy was not followed.
Inaccurate MAR, care plan, and progress note documentation
Penalty
Summary
The facility failed to maintain an accurate and complete record for a resident with chronic kidney disease, anxiety disorder, and COPD when the behavior monitoring documentation in the MAR and care plan continued to reference Xanax even though the physician’s order had been changed to clonazepam. The resident’s care plan for anxiety manifested by constant thoughts of over concern of health issues directed staff to monitor behavior episodes and document them in the MAR every shift for Xanax use, and the MAR contained the same wording. However, the physician’s order dated 8/5/2025 indicated clonazepam 0.5 mg by mouth in the morning for anxiety manifested by constant thoughts of over concern of health issues, while Xanax had been discontinued on 7/30/2025. During interview and record review, the MDS nurse stated staff were monitoring the resident for behavior episodes for clonazepam and not Xanax, and acknowledged the medication name in the MAR for the behavior monitoring was incorrect. The MDS nurse stated the licensed nurse should have clarified the order with the doctor so the care plan and MAR would reflect the correct medication name. The facility policy and procedure for charting and documentation stated documentation in the medical record must be objective, complete, and accurate, and the MDS nurse stated staff documentation should be consistent and accurate. The facility also failed to maintain accurate progress notes for another resident with Parkinson’s disease, dementia, and hypertensive heart disease with heart failure. The resident’s progress note documented a 7-pound weight loss in one month, but progress notes from the same period stated the resident was being monitored for a 7-pound weight gain in 30 days. The registered dietician stated the resident had a weight loss of 7 pounds and that licensed nurses should have documented weight loss rather than weight gain so other staff would be aware of the resident’s current condition. The administrator stated the resident’s change of condition on 1/19/2026 involved a 7-pound weight loss, that the nurses documented weight gain for several days, and that wrong documentation can lead to wrong treatment.
Insufficient Square Footage in Multiple-Resident Rooms
Penalty
Summary
The facility failed to provide a minimum of 80 square feet per resident in multiple-resident bedrooms for 12 of 17 resident rooms, including Rooms 101, 102, 104, 106, 109, 110, 111, 112, 114, 115, 116, and 117. During a facility tour, surveyors found these rooms did not meet the required square footage per resident. The room waiver letter dated 1/20/2026 listed the square footage and beds for each room, showing several rooms below the 80 square feet per bed requirement, including Rooms 101, 102, 104, 106, 109, 110, 111, 112, 114, 115, 116, and 117. During observation and interview in one room, Resident 3 was sitting on the edge of his bed waiting for morning medications while his roommate remained in bed. Resident 3 stated the room space was adequate and that his wheelchair allowed him to move around without difficulty, and he also stated staff had enough space to move around while providing care. The Administrator stated the facility had 17 resident rooms and that 12 did not meet the square footage requirement, and the facility continued to request a room waiver because it believed the reduced space did not affect resident health and safety. Survey observations noted adequate ventilation and lighting, bathroom and toilet facilities, privacy curtains, sufficient space for wheelchair movement, and enough room for staff to provide care and for residents' belongings.
Failure to Communicate ST Feeding Recommendations and Obtain Timely Physician Orders
Penalty
Summary
The facility failed to provide necessary care and services in accordance with standards of practice for one resident by not relaying a speech therapist’s recommendation for feeding assistance to the physician and not obtaining corresponding physician orders. The resident had a history of hyperlipidemia, hemiplegia and hemiparesis following a stroke affecting the right dominant side, and oropharyngeal aphagia. An MDS dated 12/10/2025 documented cognitive impairment and a need for staff supervision with eating, as well as partial/moderate assistance for oral and personal hygiene. A speech-language pathology evaluation and plan of treatment dated 11/16/2025 indicated the resident was on three meals with assistance of feeding to enhance safe swallow. However, there was no documented evidence that this recommendation was communicated to the physician or that an order for this assistance was obtained between 11/16/2025 and 12/21/2025. During this same period, from 11/17/2025 to 12/19/2025, the resident was observed and assessed to be able to feed himself without 1:1 assistance, yet the facility did not relay this change in status to the physician or obtain an order for a new ST evaluation to reassess the resident’s feeding needs. Physician orders only reflected a 1:1 feeding requirement to prevent aspiration beginning on 12/22/2025 at 10:56 PM, with no such orders in place from 11/16/2025 to 12/21/2025. The resident’s care plan for risk of aspiration, initiated 11/18/2024 and revised 12/18/2025, directed staff to monitor for signs and symptoms of aspiration, provide prompt intervention, and inform the physician, and a separate care plan for swallowing problems was initiated on 12/4/2025. Despite these care plan directives and the ST evaluation, the facility did not ensure physician notification and appropriate orders regarding feeding assistance and ST reevaluation during the identified timeframe.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation or review, indicating that the required protocols for protecting confidential resident information or proper record-keeping were not followed as expected. No additional details about specific residents, their medical history, or the exact circumstances of the deficiency are provided in the report.
Failure to Ensure Safe and Resident-Centered Transfer/Discharge
Penalty
Summary
The facility failed to ensure that the transfer or discharge process met the resident's needs and preferences, and did not adequately prepare the resident for a safe transfer or discharge. The report notes that the necessary steps to assess and address the resident's individual requirements and preferences during the transfer or discharge process were not followed. As a result, the resident was not properly prepared for a safe transition to the next care setting.
Failure to Accurately Document Wound Care Treatments
Penalty
Summary
The facility failed to maintain accurate documentation of wound care treatments for two residents, as required by its own policy and accepted professional standards. For one resident with a sacral pressure ulcer and significant physical and cognitive impairments, the Treatment Administration Record (TAR) was left blank and not signed for a scheduled wound care treatment. The physician's order specified daily dressing changes, but the lack of documentation on the TAR for a specific date resulted in an incomplete medical record for the care provided. For a second resident with multiple pressure ulcers at various stages and severe cognitive impairment, the TAR was not signed for several wound care treatments on two separate days. The physician's orders detailed specific wound care procedures for multiple sites, but the TAR lacked the initials of the nurse responsible for administering these treatments. During interviews, the nurse who provided the care confirmed that the treatments were performed but not documented at the time, and the Director of Nursing acknowledged that the TAR should have been signed immediately after care was provided. The facility's policy on charting and documentation requires that all services provided to residents be documented in an objective, complete, and accurate manner, including the date, time, and name of the individual providing care. The failure to document wound care treatments as required resulted in medical records that did not accurately reflect the care provided to the two residents.
Failure to Implement Recommended CCHO Diet for Diabetic Resident
Penalty
Summary
The facility failed to provide a Controlled Carbohydrate Diet (CCHO diet) for a resident with type 2 diabetes mellitus, dementia, and acute kidney failure. The resident was admitted with a diagnosis that required careful management of blood sugar levels. Despite the Registered Dietitian's (RD) recommendation to change the resident's diet to a CCHO diet, this was not communicated to or ordered by the resident's primary physician. The resident continued to receive a No Added Salt (NAS) mechanical soft diet, which did not meet the specific dietary needs for managing diabetes. The deficiency was identified during a review of the resident's care plan and medical records, which showed that the RD's recommendations were not reviewed by licensed nurses or communicated to the primary physician. The resident's Minimum Data Set (MDS) indicated a need for a therapeutic diet, but the current diet order did not reflect the necessary changes. Interviews with the Licensed Vocational Nurse (LVN), Kitchen Supervisor (KS), Registered Nurse (RN), and Director of Nursing (DON) confirmed that the RD's recommendations were not implemented, and the resident's diet card did not indicate the required CCHO diet. The facility's policy and procedure for therapeutic diets require that such diets be prescribed by the attending physician and regularly reviewed by the dietitian, nursing staff, and physician. However, the failure to communicate and implement the RD's dietary recommendations placed the resident at risk for uncontrolled blood sugar levels, which could lead to serious health consequences. The DON acknowledged the importance of providing a CCHO diet for residents with diabetes to prevent potential complications.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for several residents, leading to various deficiencies. Resident 8's room was observed to be excessively warm at 83 degrees Fahrenheit, which was outside the acceptable range of 71 to 81 degrees Fahrenheit. This was confirmed by the Maintenance Supervisor, who acknowledged the discomfort caused by the high temperature and adjusted the thermostat accordingly. Resident 194 experienced frustration due to a malfunctioning television, which was described as hazy and pixelated. This issue was observed during an interview with the resident, who expressed dissatisfaction with the situation. The Licensed Vocational Nurse present agreed that the television should be repaired to alleviate the resident's frustration. Additionally, the facility failed to maintain a clean and sanitary environment for Residents 18 and 28, as both rooms had a strong odor of urine. This was attributed to Resident 18's frequent urinary incontinence, which resulted in urine on the floor. The presence of an air purifier did not sufficiently address the odor, and staff acknowledged the impact on the residents' well-being. Furthermore, Resident 19's room had a chipping wall trim, which was identified as a potential hazard by both the Registered Nurse Supervisor and the Maintenance Supervisor, who recognized the risk of injury to the resident.
Improper Pressure Ulcer Prevention and Treatment Measures
Penalty
Summary
The facility failed to implement appropriate pressure ulcer prevention and treatment measures for three residents, as observed during a survey. Resident 30, who was at risk for skin breakdown due to a history of a stage 4 pressure ulcer, was found to have a low air loss (LAL) mattress set at an incorrect pressure setting of more than 350 mmHg, which was not aligned with the resident's weight of 220 pounds. This setting was too firm and not in accordance with the manufacturer's guidelines, potentially compromising the effectiveness of the mattress in preventing pressure ulcers. Resident 6, who had a history of pressure injuries and was moderately at risk for skin breakdown, was observed with an alternating air pressure pad (APP) mattress set at the maximum firmness level of 5. This setting was not ideal for the resident's weight of 163 pounds and could lead to the development of pressure injuries. The facility's failure to adjust the mattress settings based on the resident's weight was noted as a deficiency. Resident 1, who had a stage 3 pressure ulcer and was moderately at risk for skin breakdown, was found with an LAL mattress set at 250 mmHg, which was not appropriate for the resident's weight of 203 pounds. The resident reported discomfort due to the mattress being too hard, which could exacerbate existing pressure ulcers or cause new ones. The facility's policy required that mattress settings be adjusted according to the resident's weight, but this was not adhered to, leading to the identified deficiencies.
Medication Storage Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure the safe provision of pharmaceutical services as per its policy, resulting in several deficiencies related to medication storage. During an observation and interview with the Director of Nursing (DON), it was noted that the medication storage freezer had an ice build-up, which could affect the accurate temperature maintenance for medications stored inside. Additionally, the medication storage room counters and shelves were found to be dusty, indicating a lack of cleanliness and adherence to the facility's policy of maintaining a clean, safe, and sanitary environment. Furthermore, the temperature in the medication storage room was recorded at 83°F, which exceeded the recommended storage temperature range of 68°F-77°F for certain medications. This included one bottle of Valproic Acid, two bottles of 0.9% Sodium Chloride Irrigation, and one bottle of Lidocaine 2% viscous solution. The DON acknowledged that these medications were not stored under proper temperature control and stated that they would be discarded to prevent potential adverse reactions if administered to residents.
Failure to Label Food Items with Use-By Dates
Penalty
Summary
The facility failed to ensure that food items were properly labeled with use-by dates, which is crucial for preventing foodborne illnesses. During an observation in the kitchen, several opened food items, including a container of butter, a gallon of chocolate syrup, a bag of potatoes hash brown, and 20 tomatoes, were found without labels indicating their use-by dates. The Dietary Supervisor (DS) acknowledged the absence of labels and emphasized the importance of labeling to prevent the use of expired food, which could lead to stomach illnesses among residents. Further inspection in the dry storage room revealed additional items, such as packets of No Bake Custard and bags of biscuit Gravy Mix, also lacking use-by and expiration dates. The DS admitted that the original packaging, which contained the expiration dates, had been discarded, making it impossible to determine the freshness of these items. Interviews with the Director of Nursing (DON) and a Registered Dietary (RD) confirmed that the facility's policy required all opened food items to be labeled with open and use-by dates to maintain food quality and prevent foodborne illnesses.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to standard infection prevention and control practices for four out of fifteen sampled residents. In one instance, a urine-soaked diaper was observed on top of a paper towel dispenser in a communal bathroom, which was acknowledged by the Infection Prevention Nurse as a potential health risk. The Director of Nursing confirmed that such practices could lead to infections and hospitalizations for residents. Additionally, two Licensed Vocational Nurses (LVNs) did not follow Enhanced Barrier Precautions (EBP) while administering medications via gastrostomy tubes to residents who required such precautions. LVN 1 was observed not wearing gloves or an isolation gown while administering medication to a resident with severe cognitive impairment and multiple health issues, including hemiplegia and dysphagia. Similarly, LVN 2 did not wear an isolation gown while administering medication to another resident with severe cognitive impairment and dehydration. The absence of EBP signage and PPE outside the resident's room was also noted. Further deficiencies included a nebulizer mask found on the floor in a resident's room, which was identified as an infection control issue by LVN 5. Another resident's bedside urinal bottle filled with urine was repeatedly observed placed next to the resident's water pitcher, posing a contamination risk. The Registered Nurse Supervisor confirmed that such practices violated the facility's policy to maintain a clean and sanitary environment to prevent infections.
Resident Waits 32 Minutes for Meal Tray
Penalty
Summary
The facility staff failed to ensure a resident received their meal tray in a timely manner, resulting in the resident waiting for 32 minutes while other residents at the same table were already eating. This incident involved a resident who was admitted with diagnoses including dysphagia following a stroke and type II diabetes mellitus. The resident was cognitively impaired and dependent on assistance for eating, as indicated in their Minimum Data Set. During a dining observation, it was noted that the resident was left waiting for their meal tray, which was only provided 24 minutes after other residents had started eating. Interviews with staff and the resident revealed that the meal carts arrived on time, but the resident was not served promptly. The Activity Specialist confirmed the delay and was unsure why the resident was not assisted sooner. The resident expressed feelings of discomfort and disrespect due to the delay. The facility's administrator acknowledged that it was unacceptable for residents to wait longer than five minutes for their meals and emphasized the importance of treating residents with respect. The facility's policy on dignity, revised in February 2021, mandates that residents should be provided with a dignified dining experience, promoting their well-being and self-esteem.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light was within reach for three residents, which is a violation of the facility's policy and procedure. Resident 1, who has moderately impaired cognitive skills and is dependent on assistance for various activities, was observed with a call light placed out of reach on the left upper side of the bed. This was confirmed during an interview with a Certified Nurse Assistant, who acknowledged that the call light should be within the resident's reach to enable them to call for help when needed. Resident 6, who has severely impaired cognitive skills and is dependent on assistance for daily activities, was observed with a call light placed on the right side, despite having right side weakness and a contracted right hand. A Licensed Vocational Nurse confirmed that the call light should have been placed on the left side, as the resident could not reach it with their left hand. This oversight prevented the resident from being able to call for assistance. Resident 5, who has intact cognitive skills but is dependent on assistance for daily activities, was observed with a call light on the floor, out of reach. The resident, who cannot move their fingers, stated they would call for help by yelling, which was confirmed by their roommate. A Licensed Vocational Nurse later noted that the call button was changed to a call pad that the resident could use effectively, as the previous setup was inappropriate. The facility's policy and procedure require that call lights be accessible to residents, which was not adhered to in these cases.
Failure to Develop Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident, identified as Resident 22, who was receiving antibiotic and anticoagulant therapies. Upon review, it was found that the care plan did not include specific interventions for the use of Ceftriaxone, an antibiotic, and Eliquis, an anticoagulant. The MDS Nurse acknowledged that the care plan should have been established during the resident's admission, as the resident was already on antibiotic therapy. The absence of these care plans meant that the resident was not being monitored for the effectiveness of the treatments or for potential side effects, such as bleeding from the anticoagulant therapy. Resident 22 was admitted with diagnoses including osteomyelitis, congestive heart failure, and hypertension. The resident required partial to moderate assistance with various activities of daily living. The Director of Nursing confirmed that care plans should be initiated by the admitting nurse and completed by the Registered Nurse or Quality Assurance Nurse. The facility's policy indicated that comprehensive care plans should be developed within seven days of the MDS assessment and no more than 21 days after admission. However, this was not adhered to, resulting in a lack of monitoring for the resident's therapeutic treatments.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic drug use, as required by their policy and procedure. The resident, who had diagnoses including dementia, schizophrenia, and hypertension, was prescribed Abilify and Depakote for schizophrenia and bipolar disorder, respectively. However, there was no documented evidence that the resident's behavior was monitored for the use of these medications. The Minimum Data Set (MDS) indicated that the resident had severely impaired cognitive skills and required substantial assistance with daily activities, but did not show any mood or behavior indicators. During interviews and record reviews, it was revealed that there were no physician's orders for behavior monitoring specifically for the use of Abilify and Depakote. The Medication Administration Record (MAR) was blank for the entire month of November, indicating that the resident's behavior was not monitored for the use of these medications. The facility's policy required documentation of targeted behaviors and potential interventions, but this was not done, leading to a deficiency in the care provided to the resident.
Medication Administration Timing Deficiency
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a rate of 10.34% during a medication administration observation. This deficiency was identified when a Licensed Vocational Nurse (LVN) did not administer multivitamin, vitamin C, and vitamin D3 to a resident within the prescribed one-hour timeframe. The medications were supposed to be given at 9 AM, but were administered at 10:34 AM, exceeding the allowed time window. This practice was not in accordance with the facility's policy, which mandates that medications be administered within one hour of the prescribed time unless otherwise specified. The resident involved, identified as Resident 29, had a medical history that included mild protein calorie malnutrition, metabolic encephalopathy, and type 2 diabetes mellitus. The resident also had severe cognitive impairment and required varying levels of assistance with daily activities. During the medication pass observation, the resident was waiting for their medications, which were administered late by LVN 2. The Director of Nurses confirmed that medications should be given within the specified timeframe to prevent potential adverse effects.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the Daily Posted Nurse Staffing information for the dates 11/29/2024, 11/30/2024, and 12/1/2024, as required by their policy. During an observation on 12/2/2024, it was noted that the staffing posting area only contained forms dated 11/28/2024 and 11/29/2024, with the latter only showing projected hours rather than actual hours worked by nursing staff. Interviews with the Assistant Administrator (AADM) and Director of Nursing (DON) confirmed that the required Direct Care Service Hours Per Patient Day (DHPPD) postings were missing for the specified dates, and the purpose of these postings is to ensure transparency about staffing levels to residents, families, and staff. The facility's policy, revised in 8/2022, mandates that nurse staffing data be posted daily for each shift, including the number of nursing personnel responsible for direct care. This information should be computed and posted within two hours of each shift's start by the charge nurse or designee. The policy also requires that staffing information be maintained for 24 hours in a designated location and then filed as a permanent record for at least eighteen months. The failure to adhere to this policy resulted in a deficiency, as it potentially left residents and visitors uninformed about the facility's staffing levels.
Facility Fails to Meet Minimum Space Requirements in Resident Rooms
Penalty
Summary
The facility failed to provide the minimum required 80 square feet per resident in multiple resident bedrooms for 12 out of 17 rooms. This deficiency was identified during a facility tour and confirmed through interviews and record reviews. The rooms in question were Rooms 101, 102, 104, 106, 109, 110, 111, 112, 114, 115, 116, and 117. Despite the deficiency, residents reported having enough space for care and storage, and those using wheelchairs stated they could maneuver without difficulty. The Assistant Administrator acknowledged the deficiency and indicated that a room waiver was requested, asserting that the deficiency did not impact residents' health and safety. The facility's room waiver letter detailed the square footage per bed for each room, confirming that the space provided was below the required standard. Observations from 12/02/2024 to 12/05/2024 noted adequate ventilation, lighting, and privacy in the rooms, with sufficient space for residents' movement and care provision. The waiver request emphasized that the rooms accommodated wheelchairs and medical equipment, and did not adversely affect residents' health or safety. The Department recommended the room waiver for the affected rooms, acknowledging the facility's efforts to maintain a safe and functional environment despite the space deficiency.
Failure to Post Daily Staffing Information
Penalty
Summary
The facility failed to ensure that staffing information was posted daily in a visible and prominent place, as required. During an observation on September 30, 2024, the Census and Direct Care Service Hours Per Patient Day (DHPPD) form near the nursing station was found to be outdated, displaying the date September 27, 2024, with the section for Actual Direct Care Service Hours and DHPPD left blank. Further investigation revealed that no DHPPD forms were posted for several dates in September, including the 26th, 28th, and 29th. The Director of Nursing (DON) admitted to being unaware that the completed form with actual hours needed to be posted daily, as per the facility's policy and procedure titled 'Posting Direct Care Daily Staffing Numbers' dated July 2016.
Inconsistent Pressure Ulcer Care in LTC Facility
Penalty
Summary
The facility failed to provide consistent treatment for pressure ulcers for three residents, leading to a deficiency in care. Resident 1, who was readmitted with a deep tissue injury and a Stage 2 pressure ulcer, did not receive the prescribed treatments consistently. The Treatment Administration Record (TAR) lacked documentation of zinc oxide application, low air loss mattress usage, heel offloading, and cleansing with normal saline on several occasions, indicating that these treatments were not administered as ordered. Resident 2, admitted with a Stage 4 pressure ulcer, also did not receive consistent care. The TAR showed missing documentation for cleaning with normal saline, barrier cream application, and dry dressing on specific dates. Additionally, the low air loss mattress therapy and monitoring for leaks and settings were not documented, suggesting these treatments were not performed as required. Resident 3, with an unstageable pressure ulcer, experienced similar issues. The TAR lacked entries for cleaning with normal saline, applying barrier cream, and using a dry dressing. Monitoring of the low air loss mattress for leaks and settings was also not documented on several shifts. Interviews with the treatment nurse confirmed that blank entries in the TAR indicated treatments were not provided, which is against the facility's policy for documenting care.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect Resident 1 from physical abuse when Resident 2 struck them in the face. Resident 1, who was readmitted to the facility with diagnoses including difficulty in walking, type 2 diabetes mellitus, dementia, and chronic kidney disease, was in the activity room when the incident occurred. Resident 1's Minimum Data Set indicated severely impaired cognitive skills and required assistance with daily activities. On the day of the incident, Resident 1 was subjected to physical aggression from Resident 2, resulting in a care plan to prevent further injuries and emotional distress. Resident 2, who was also readmitted to the facility with diagnoses including unspecified psychosis, GERD, and essential hypertension, was involved in the altercation. Resident 2's records indicated moderately impaired cognitive skills and a history of physical altercations. On the day of the incident, Resident 2 exhibited increased agitation and aggression, leading to the physical altercation with Resident 1. The facility's records showed that Resident 2 had a care plan to prevent physical altercations and was under staff supervision for signs of danger to self or others. Interviews with facility staff, including the Director of Nursing, Infection Preventionist Nurse, Assistant Activities Director, and Registered Nurse Supervisor, confirmed the altercation between the two residents. Staff members witnessed Resident 2's aggressive behavior and the subsequent physical contact with Resident 1. The facility's policy on abuse prevention emphasized the residents' right to be free from abuse and the facility's responsibility to protect them from such incidents. However, at the time of the incident, there was no staff present in the activity room to prevent the altercation.
Failure to Revise Care Plan After Resident Altercation
Penalty
Summary
The facility failed to revise the care plan for a resident following a physical altercation with another resident. The care plan, which is intended to provide personalized care with measurable objectives and timeframes, was not updated to include specific interventions for the resident's care and safety after the incident. This oversight was identified during a review of the resident's records and an interview with the Registered Nurse Supervisor, who acknowledged that the care plan should have included new interventions and goals to address the resident's behavior and prevent future incidents. The resident involved in the incident was readmitted to the facility with diagnoses including unspecified psychosis, GERD, and essential hypertension. The resident had moderately impaired cognitive skills and required assistance with daily activities. Following the altercation, the facility's protocol was to notify authorities, but no new interventions were added to the care plan to manage the resident's increased agitation and aggression. The facility's policies require care plans to be revised when there is a significant change in a resident's condition, but this was not done in this case.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Alhambra
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sunny Village Care Center | 0.6 mi | ★★★★★ | 24 | 0 |
| Alhambra Hospital Med Ctr Dp/snf | 1.1 mi | ★★★★★ | 0 | 0 |
| Atherton Baptist Home | 1.4 mi | ★★★★★ | 10 | 0 |
| Heritage Manor | 1.8 mi | ★★★★★ | 33 | 0 |
| Monterey Park Conv Hosp | 1.9 mi | ★★★★★ | 0 | 0 |
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