Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Royal Oaks Manor-bradbury Oaks during CMS and state inspections, most recent first.
Failure to provide advance directive information to two residents. One resident had intact decision-making capacity and stated no AD information was ever provided, while the other resident had dementia, lacked capacity, and had records showing no AD copy in the chart and an unsigned acknowledgement form stating the AD fact sheet was not given at first contact. The SSD stated AD screening and written information were expected on admission, but the POLST and chart did not show that the AD discussion occurred.
Failure to provide needed ADL assistance: Three residents with documented needs for toileting, oral care, grooming, and hygiene were observed or reported to have unmet care needs. One resident said a CNA refused requested toilet assistance, while two other residents were observed with dry, peeling lips, food debris, drool, dirty fingernails, and eye discharge despite care plans calling for staff assistance with personal care and oral hygiene.
Controlled medications were deposited into the MedSafe whole and in original packaging, with the DON and an LPN reconciling the Controlled Drug Record, but the CP did not physically verify the contents of the MedSafe and could not confirm the medications matched the record. The CP and DON later removed the liner, sealed it in a cardboard box, and the box was stored in the DON’s office next to the desk without double-lock protection until pickup, contrary to facility policy requiring secure handling and storage of discontinued controlled drugs.
Masks were not readily available at the facility entrance despite posted masking signage, and gloves were not available outside two resident rooms for residents on EBP. One resident had a history of UTI, ESBL, sepsis, a GT, and severe cognitive impairment with dependence for ADLs, while another resident had ESRD on dialysis with moderate cognitive impairment and dependence for ADLs. Both rooms had EBP signage and PPE carts outside, but no gloves were present, and an IP stated masks and PPE availability was important for masking compliance and EBP.
A resident with glaucoma, IBS, and spinal stenosis, who was wheelchair bound and needed one-person assistance for toileting, reported that a CNA repeatedly refused toileting requests and told the resident the restroom was not needed. The resident said this made the resident feel bad and treated like a child. The AD confirmed the complaint, and other staff stated the resident preferred commode assistance for dignity and that toileting requests should be taken seriously.
A resident with orthostatic hypotension and unspecified dementia had a PASARR Level I screening that indicated SMI, but the facility did not respond to the DHCS notice of attempted evaluation, so a PASARR Level II mental health evaluation was not scheduled. The DON stated the facility did not reply to the notice, and the facility’s admission criteria policy required referral for the Level II screening process when Level I indicated MD, ID, or RD.
OTC Eye Wash Stored in Resident Room Without Order: A resident with impaired vision, moderately impaired decision-making, and hospice status had a bottle of eye irrigating solution found in the room even though the OSR did not show an order for it to be stored there. An LVN stated the eye wash was an OTC medication for eye treatment, should not be left in the resident’s room, and only licensed staff could administer it.
A resident with major depressive disorder and unspecified dementia did not have documented monthly MRRs completed for two months. The care plan called for monthly pharmacy review for the resident's Lexapro, but the DON confirmed the MRRs were not done and the facility's DRR policy required monthly review of medication orders and the documented medication administration process.
A resident with cognitive impairment and significant care needs did not receive hospice-ordered Boost nutritional supplement or diclofenac sodium topical gel for pain management, as these orders were not included in the facility's active medication and nutrition orders. The omissions were confirmed by nursing staff and led to missed administration of prescribed therapies, despite the resident experiencing weight loss and requiring pain management.
Two residents with significant mobility needs experienced delays of up to an hour in staff response to call lights, with one family member intervening to assist with bathroom needs due to staff inaction. Staff interviews confirmed the expectation for immediate response, and Resident Council Meeting minutes documented ongoing concerns about untimely call light responses and unmet needs, contrary to facility policy.
The facility failed to develop comprehensive care plans for two residents, leading to potential gaps in care. One resident, with multiple diagnoses including anxiety disorder, lacked an activities care plan, while another resident with a hip fracture and edema had no care plan addressing their swelling. Observations confirmed the absence of necessary care plans, which were required by facility policy to guide staff in providing appropriate care.
The facility failed to attempt appropriate alternatives before using bedrails for two residents, potentially leading to accidents. One resident with dementia and another with multiple diagnoses were observed with siderails up, without documented attempts of alternatives like low beds. The facility's policy required such attempts and evaluations, which were not followed.
A facility failed to ensure accurate medical records for a resident by not documenting the administration of Hydrocodone-Acetaminophen in the MAR and not recording a change in condition for a skin rash. The Controlled Drug Record showed medication removal, but the MAR lacked corresponding entries. Additionally, a rash observed on the resident was not documented in the medical record, and the required change of condition evaluation was not completed.
The facility failed to maintain its infection prevention and control program, with deficiencies including staff not following enhanced barrier precautions, unclean shared restrooms, and improper handling of clean linen. Maintenance technicians entered a resident's room without PPE or hand hygiene, a restroom had a fecal smear on the toilet seat, and an unlabeled cleansing cream was found. Additionally, clean linen was observed touching the floor in the laundry room, all of which were acknowledged as breaches of infection control practices.
The facility failed to ensure call lights were within reach for two residents, violating their policy. One resident's call light was looped around a G-tube pump, and another's was tucked between the bed and wall, making them inaccessible. Both residents had cognitive impairments and required assistance, highlighting the importance of accessible call lights for safety and communication.
A resident with severe cognitive impairment and dependency on staff for ADLs was found with a dark brown substance under three fingernails, indicating a failure in grooming care. Despite the facility's policy requiring assistance with personal hygiene, the resident's nail care was neglected, as confirmed by staff interviews and observations.
A resident with multiple diagnoses, including anxiety disorder and psychosis, was not provided with activities that met their preferences, such as listening to music and going outside. Observations showed the resident mostly lying in bed, and records indicated no activities were provided for a period. The Activities Staff acknowledged the need for regular activities, but the facility failed to adhere to its policy of reflecting resident interests.
A resident with a history of a fractured femur and hypertension did not receive care in accordance with physician's orders for edema management. Despite orders for elastic stockings to reduce swelling, the resident was observed wearing regular socks, with both legs swollen. Staff interviews confirmed the oversight, and the facility's policy on applying anti-emboli stockings was not followed.
A facility failed to provide floor mats for a high-risk resident, as required by the care plan and physician's order. The resident, with diagnoses including cancer and mobility issues, was observed without floor mats, despite being at high risk for falls. A CNA and the DON confirmed the oversight, which deviated from the facility's fall prevention policy.
A facility failed to follow a pharmacist's recommendation for a gradual dose reduction of Seroquel for a resident with dementia, leading to potential unnecessary medication use. The resident, who was frequently observed asleep, had a care plan indicating a previous dose reduction, but no follow-up on the latest recommendation was documented. The facility's policy required gradual dose reductions unless contraindicated, which was not followed.
A resident with a history of anemia, hypertension, and GERD was administered Potassium Chloride ER without food, contrary to the facility's policy and pharmacist's recommendation. The medication was given at 9 a.m. while the resident had not eaten, potentially causing gastric irritation. The LVN acknowledged the error, and the DON emphasized the importance of following physician orders for medication administration.
A facility failed to properly store and label medications in Med Cart 2, affecting a resident with multiple diagnoses, including diabetes and dementia. Observations revealed medications without opened dates and insulin requiring refrigeration stored improperly. This deficiency could compromise medication effectiveness and resident safety.
A resident, who was eligible and consented to receive the influenza vaccine, did not receive it despite a physician's order and facility protocols allowing for its administration. The resident's medical records indicated the capacity to consent, and the facility's vaccination log confirmed the vaccine was not administered. This oversight was identified during a review by the Infection Prevention Nurse.
A resident with a fractured femur and dementia experienced severe pain, which was not promptly addressed due to a lack of communication between staff. The CNA did not report the resident's pain to the LVN, who was unaware of the situation until later. The LVN administered morphine but failed to assess the pain's location. The DON highlighted the need for immediate pain assessment and management, as outlined in the facility's policy.
A resident with a history of seizures and chronic atrial fibrillation fell and sustained a fracture when a CNA attempted to transfer them alone using a mechanical lift, contrary to the facility's policy requiring two-person assistance. The incident highlighted a significant deficiency in adherence to safety protocols and staff training.
A resident with dementia and high risk for falls and elopement fell and sustained fractures due to the facility's failure to implement care plan interventions and provide consistent supervision. The resident's care plan was not updated despite staff recognizing the need for one-to-one supervision.
Failure to Provide Advance Directive Information
Penalty
Summary
The facility failed to inform and provide written information regarding advance directives for two residents. Resident 21 was admitted with diagnoses including a displaced trimalleolar fracture of the left lower leg, subsequent encounter for an open fracture type IIIA, IIIB, or IIIC with routine healing, and trigeminal neuralgia. The resident's H&P indicated decision-making capacity, and the MDS indicated cognitive skills for daily decision making were intact. The care plan stated that advance directive preferences were to be discussed with the resident or responsible party on a quarterly basis and as needed, and that advance directive education would be provided upon admission and as needed. During interview and record review, the Social Service Director stated the facility's policy was to give residents information regarding advance directives by the second or third day of admission. The POLST for Resident 21 did not indicate that advance directives were discussed. Resident 21 stated the resident did not have an advance directive and had never received information regarding advance directives from the facility. Resident 22 was admitted with diagnoses including unspecified dementia with psychotic disturbance, mood disturbance, and anxiety. The H&P stated the resident did not have the capacity to understand and/or sign any form due to dementia, and the MDS indicated moderately impaired cognitive skills for daily decision making and that the resident did not have an AD. The record included an undated and unsigned Advance Health Care Directive Acknowledgement Form stating the resident was not given a copy of the Advance Health Care Directive Fact Sheet at the first face-to-face contact or clinic visit. The SSD stated the facility was responsible for obtaining or screening residents upon admission for AD information and could not find a copy of Resident 22's AD in the chart, while the resident's EC stated the facility asked about an AD only during a meeting two weeks after admission.
Failure to Provide Needed ADL Assistance
Penalty
Summary
The facility failed to ensure that residents who were unable to perform activities of daily living received appropriate assistance with toileting, hygiene, and grooming. Surveyors identified deficient practices for three sampled residents who had documented ADL care needs in their records and care plans, including assistance with toileting, oral care, bathing, and personal hygiene. Resident 29 was admitted with diagnoses including glaucoma, irritable bowel syndrome, and spinal stenosis, and was described as alert and wheelchair bound. The resident’s bowel and bladder screening indicated the resident was always mentally aware of the need to toilet and needed one-person assistance to get to the bathroom or toilet, with assistance needed for adjusting clothing and wiping. The care plan stated the resident was totally dependent on one staff member for toilet use and should be encouraged to participate to the fullest extent possible. During interview, Resident 29 stated that when asking CNA 2 for help to the restroom, CNA 2 told the resident, “No you don’t have to go,” and did not take the resident or give a reason. The AD later stated the resident had reported that CNA 2 did not take the resident to the toilet when asked. Staff interviews confirmed that if a resident requested restroom assistance, staff were to take the resident or seek help from another staff member. Resident 5 had diagnoses including major depressive disorder and macular degeneration, with records showing impaired vision, moderately impaired cognitive skills for daily decision making, dependence for ADLs, and hospice care. The care plan indicated the resident required maximum assistance from one staff member with personal hygiene and oral care. During observation, Resident 5 was lying in bed with dry, flaky, peeling lips, drool with food debris on the right side of the mouth, and brownish-black substance under the fingernails. CNA 3 stated the resident was fed by facility staff and that CNA 3 would give the resident a bath. CNA 3 also stated the family did not want hospice to provide bathing and wanted the facility to provide the shower and everything. Staff interviews stated oral care should be provided right after meals and that chapped lips could crack and bleed. Resident 46 had diagnoses including cerebral ischemia and end stage renal disease, with records showing the resident was alert and oriented to person, place, and time but had moderately impaired cognitive skills and required substantial to maximal assistance for ADLs. The care plan directed staff to provide assistance with oral hygiene and personal care. During observation, Resident 46 was lying in bed with food debris drool on the right side of the mouth and whitish creamy discharge from the inner corner of the left eye. The resident stated staff helped feed the resident “here and there.” Staff interviews indicated that after meal trays were collected, residents should be checked for dirt or residue after eating, and that oral care, cleanliness, and grooming were part of ADLs.
Controlled Medication Disposal and Storage Deficiencies
Penalty
Summary
Controlled medications that had been discontinued were deposited into the MedSafe in their original packaging, including blister packs, and were left whole, identifiable, and retrievable. During observation in the medication room, the MedSafe was seen with three separate locks, and the LVN stated that discontinued medications were placed there by the DON in original medication packaging. The DON stated that the process was for a nurse and the DON to reconcile the number of discontinued controlled medications by verifying and signing the Controlled Drug Record, then depositing the medications into the MedSafe without removing them from their packaging. The DON and the CP described a process in which, when the MedSafe was full, they opened it, removed the inner plastic liner containing the medications, secured the liner with a zip tie, and placed it in a hard cardboard box for pickup by a contracted waste company. The CP stated that the CP only reviewed the Controlled Drug Records and did not physically check or verify the contents in the MedSafe. The CP also stated that the CP did not physically inspect the contents because it was against protocol, and that in the past the CP had removed the discontinued controlled medications from their original packaging and wasted them at the facility in the presence of the DON. Record review showed that the facility’s protocol required the consultant pharmacist or a pharmacist from the contracted pharmacy to verify accuracy of the controlled medication disposition log, but the DON stated that 17 of 27 reviewed Controlled Drug Records did not have the CP’s signature and were not reviewed by the CP. The CP stated that the CP monitored the records by signing the margin but did not physically check the contents of the MedSafe and could not ensure the medications inside matched the records. In addition, the cardboard box containing the MedSafe waste was stored in the DON’s office next to the DON’s desk from one date to another, and the DON stated the office did not have a double lock. The DON also stated the box was not picked up until later, and the facility policy required controlled substances remaining after discontinuation to be retained in a securely double locked area until destroyed.
Infection Control Supplies Not Available at Entrance and EBP Rooms
Penalty
Summary
The facility failed to implement infection prevention and control practices by not ensuring masks were readily available at the entrance and by not ensuring gloves were readily available outside two resident rooms for residents on Enhanced Barrier Precautions (EBP). During observation, a large freestanding sign outside the entrance stated, "No Mask! No Entry! No Exemption!" but no masks were available upon entry, even though hallway signage stated that masks were being requested to help keep everyone safe and healthy and to prevent the spread of respiratory infections. Resident 3 was admitted and readmitted with diagnoses including a history of UTI, ESBL resistance, and sepsis. The resident's H&P stated the resident did not have the capacity to understand and/or sign forms, and the MDS indicated severely impaired cognitive skills for daily decision making and dependence for ADLs. The resident had an active order for EBP every shift for wound, GT, history of ESBL, and Providencia Stuartii. During observation of the room, EBP signage was posted and a PPE cart was outside the room, but there were no gloves in or on the cart. A CNA stated there was usually a box of gloves there because the resident was on EBP. Resident 46 was admitted and readmitted with diagnoses including cerebral ischemia and ESRD with dependence on renal dialysis. The resident's H&P stated the resident was AOx3, and the MDS indicated moderately impaired cognitive skills and dependence for ADLs. The resident had an active order for EBP every shift due to hemodialysis. During observation of the room, EBP signage was posted and a PPE cart was outside the room, but there were no gloves in or on the cart. A CNA stated staff should ensure PPE supplies were available before entering the room in order to follow EBP and the signage. The Infection Preventionist stated masking was required during respiratory virus season and that having masks and PPE readily available was important for compliance with masking and EBP.
Failure to Assist Resident With Toileting Dignity
Penalty
Summary
The facility failed to treat one resident with respect and dignity when CNA 2 did not assist the resident to the restroom after the resident requested toileting assistance. The resident, who had diagnoses including glaucoma, irritable bowel syndrome, and spinal stenosis, was admitted as wheelchair bound, alert, and able to understand and be understood by others. The resident’s bowel and bladder screening indicated the resident was always mentally aware of the need to toilet and needed one-person assistance to get to the bathroom, and the care plan stated the resident was totally dependent on one staff member for toilet use and should be encouraged to participate to the fullest extent possible with each interaction. During interview, the resident stated that on several occasions when asking CNA 2 to take the resident to the restroom, CNA 2 said the resident did not need to go and did not provide a reason. The resident stated this made the resident feel bad, like a fireman dummy being thrown around, or like a child asking permission to use the restroom. The AD confirmed the resident had reported that CNA 2 did not take the resident to the toilet when asked. LVN 2 and CNA 7 stated the resident preferred commode assistance for dignity and that staff were expected to take a resident to the restroom when requested or seek help if unable to do so. The DON stated that when a resident had the urge to have a bowel movement, it was personal and needed to be taken seriously because not attending to this need affected the resident’s psychosocial well-being and dignity.
Failure to Complete PASARR Level II Screening After Positive Level I
Penalty
Summary
The facility failed to complete a PASARR Level II screening for one sampled resident after the resident’s PASARR Level I screening indicated serious mental illness. The resident was admitted with diagnoses including orthostatic hypotension and unspecified dementia, and later records showed the resident was alert and oriented to name only. The resident’s MDS indicated severely impaired cognitive skills for daily decision making, with the resident never or rarely making decisions. A DHCS notification letter documented an attempted evaluation and stated that a PASARR Level II mental health evaluation was not scheduled because facility staff were unresponsive to two or more separate attempts of communication within 48 hours of the Level I screening. During interview, the DON stated the facility did not respond to the DHCS notification letter and stated the facility should have responded to verify the resident was receiving proper care and services. The facility’s admission criteria policy stated that residents with a positive Level I screening were to be referred for the Level II screening process.
OTC Eye Wash Stored in Resident Room Without Order
Penalty
Summary
The facility failed to ensure that Resident 5’s eye wash irrigating solution and a non-legend OTC medication were not stored inside the resident’s room. Resident 5 was admitted and later readmitted with diagnoses including major depressive disorder and unspecified macular degeneration. The resident’s H&P dated 7/2/2025 indicated the resident was alert, oriented to person, place, and time with normal cognition, while the MDS dated 10/29/2025 indicated impaired vision, moderately impaired cognitive skills for daily decision making, dependence for ADLs, need for supervision or touching assistance, and hospice care. The OSR active orders as of 1/2/2026 did not show an order for the eye wash irrigating solution to be used or stored in Resident 5’s room. During observation on 12/30/2025 at 9:37 AM, a 4 fl oz bottle of Walgreens Soothing Eye Wash Eye Irrigating Solution was found on the sink counter in Resident 5’s restroom, and the container box was marked with the resident’s name. During interview, LVN 5 stated the eye wash irrigating solution was an OTC medication used for eye treatment, that it should not be left in the resident’s room because it was considered a medication and only licensed staff could administer it, and that it did not come from the facility pharmacy.
Missing Monthly Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure a medication regimen review (MRR) was completed for one of five sampled residents, Resident 11, because there was no documented evidence of an MRR for November and December 2025. Resident 11 was originally admitted on 6/17/2024 with diagnoses including major depressive disorder and unspecified dementia. A History and Physical dated 7/20/2025 indicated Resident 11 had the capacity to understand and sign any form, and a Minimum Data Set dated 9/17/2025 indicated the resident's cognitive skills for daily decision making were moderately impaired. Resident 11's care plan for depression, with Lexapro as the antidepressant medication, was revised 10/24/2025 and included an intervention that pharmacy review would be done monthly or per protocol. During a concurrent interview and record review on 1/2/2026, the DON reviewed the facility's 2025 MRR binder and stated Resident 11's MRRs for November and December 2025 were not done. The facility's Drug Regimen Review policy stated the drug regimen review program would include a monthly review of all medication orders and the documented medication administration process, and that the DON was responsible for scheduling and maintaining monthly drug regimen reviews.
Failure to Administer Hospice-Ordered Nutrition and Pain Management Therapies
Penalty
Summary
The facility failed to provide care and services as ordered by a hospice physician for a resident with a history of a displaced intertrochanteric fracture of the left femur and dysphagia, who was admitted with moderate cognitive impairment and required significant assistance with mobility. The facility did not include an order for Boost, a nutritional supplement, in the resident's active orders, despite it being present on the hospice agency's treatment list. There was no documentation that the Boost order was discontinued or placed on hold, and the omission was confirmed by nursing staff. The resident experienced a notable weight loss over a short period, and the care plan indicated the resident was on hospice for expected weight loss and overall decline. Additionally, the facility failed to include an order for diclofenac sodium topical gel, prescribed for osteoarthritis pain management, in the resident's drug therapy orders. The omission was identified during a review of the hospice agency's treatment list and confirmed by the MDS nurse. The resident, who had dementia and may not have been able to verbally report pain, was observed guarding the affected leg, which could indicate pain. The medication administration record showed the resident received morphine sulfate for severe pain on multiple occasions, but there was no evidence that the diclofenac was administered as ordered. Facility policy required coordination with hospice to meet the resident's care needs, including administering prescribed therapies.
Delayed Call Light Response for Residents Requiring Assistance
Penalty
Summary
The facility failed to ensure that call lights were answered immediately for two of three sampled residents. One resident, admitted with a right humerus fracture and a history of falls, required maximal assistance for mobility and was dependent for certain movements. The resident's family member reported that staff sometimes took up to an hour to respond to call lights, leading the family member to assist the resident with bathroom needs when staff were delayed. Another resident, admitted with a spinal fusion and muscle weakness, reported two separate incidents where it took staff an hour to respond to the call light, both during the day and at night. The resident stated that on those occasions, no staff came to check on their needs, which typically involved assistance to the bathroom. Interviews with facility staff, including a CNA and an LVN, confirmed that call lights are expected to be answered immediately due to the potential for emergencies. Resident Council Meeting minutes from two separate dates indicated ongoing concerns from residents about untimely responses to call lights, particularly during the overnight shift, and instances where residents' needs were not met even when call lights were answered. The facility's policy requires immediate response to call lights and completion of requests within five minutes if possible, but this standard was not consistently met as evidenced by resident and family reports.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for two residents, as required by their policy and procedure. Resident 23, who was admitted with multiple diagnoses including shortness of breath and anxiety disorder, did not have an activities care plan developed, which was necessary to guide the activities staff on the appropriate activities for the resident. Additionally, the resident's Minimum Data Set (MDS) indicated a moderately impaired cognition status, and the resident did not receive the influenza vaccine in the facility. The facility's policy required that a comprehensive care plan be developed within seven days of the MDS assessment and no more than 21 days after admission, which was not adhered to in this case. Similarly, Resident 6, admitted with a displaced intertrochanteric fracture of the left femur and other conditions, did not have a care plan addressing their edema, despite a physician's order for the application of elastic stockings to manage swelling. Observations revealed that Resident 6 had swollen and dependent legs, and the Licensed Vocational Nurse (LVN) confirmed that a care plan should have been in place to address the edema. The Director of Nursing (DON) acknowledged that a care plan should have been created to include the problem, goal, and interventions for Resident 6's edema. This oversight had the potential to result in the residents not receiving necessary care and services according to their specific needs.
Failure to Use Alternatives Before Bedrail Use
Penalty
Summary
The facility failed to use appropriate alternatives before resorting to the use of bedrails for two residents, which could potentially lead to accidents. Resident 12, who was admitted with dementia, muscle weakness, and difficulty walking, was observed with quarter siderails up on both sides of the bed. The Minimum Data Set (MDS) indicated that Resident 12 was unable to express ideas and understand verbal content. Similarly, Resident 23, admitted with multiple diagnoses including shortness of breath, anxiety disorder, and psychosis, was observed with upper side rails up on both sides of the bed. The MDS for Resident 23 showed moderately impaired cognition and a need for moderate assistance with bed mobility. The facility's Siderail Evaluation forms indicated that alternatives such as the use of a low bed should be attempted before using siderails. However, there was no documentation showing how the low bed was ineffective for Residents 12 and 23, nor were other alternatives attempted. The facility's policy required attempts to use alternatives and an interdisciplinary evaluation before the use of bedrails, which was not followed. The MDS Nurse acknowledged the lack of documentation and stated that siderails could pose hazards, especially for residents with dementia, due to the risk of entrapment.
Inaccurate Medical Records and Undocumented Change in Condition
Penalty
Summary
The facility failed to ensure the accuracy of medical records for a resident, specifically regarding the Medication Administration Record (MAR) and documentation of a change in condition. The resident's Controlled Drug Record indicated that Hydrocodone-Acetaminophen was removed on several occasions, but the MAR did not reflect the administration of this medication on certain dates. This discrepancy was acknowledged by the Director of Nursing (DON) during a review, who noted that licensed nurses are required to document medication administration in the MAR. The facility's policy mandates that the individual administering the medication must record specific details in the resident's medical record, which was not adhered to in this case. Additionally, the facility failed to document a change in the resident's condition regarding the development of a skin rash. The resident was observed with a red scabbed rash on the right arm and elbow, which was itchy and had spread from the elbow to the lower arm. Despite this, there was no change of condition evaluation form in the resident's medical record, and the Long Term Evaluation Progress Notes did not mention the rash. The Treatment Nurse (TN) stated that a new rash should be assessed, and the physician and Infection Prevention Nurse (IPN) should be notified, but this process was not followed. The facility's policies on administering medications and charting and documentation require that all services provided to the resident, including any changes in their medical condition, be documented in the medical record. The failure to document the administration of medication and the change in the resident's condition resulted in an inaccurate MAR and the potential for medication errors and inadequate care for the resident's skin rash.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain its infection prevention and control program, as evidenced by several deficiencies observed during a survey. In one instance, two maintenance technicians entered a room with signage indicating enhanced barrier precautions (EBP) without wearing personal protective equipment (PPE) or performing hand hygiene. While inside, one technician adjusted a resident's bed, coming into direct contact with the bed linens, and both technicians exited the room without performing hand hygiene. This failure to adhere to EBP and hand hygiene protocols was acknowledged by the technicians and the infection preventionist, who emphasized the importance of these measures in preventing the transmission of infections. Additionally, the facility did not ensure the cleanliness of shared restrooms used by residents. In one restroom, a certified nursing assistant observed a large brownish fecal smear on the toilet seat, which was acknowledged as a health risk and cross-contamination concern. Another restroom contained an unlabeled bottle of cleansing cream, which a licensed vocational nurse confirmed should have been labeled to prevent cross-contamination. These observations highlight lapses in maintaining sanitary conditions and proper labeling of personal items in shared spaces. The facility also failed to handle clean linen properly in the laundry room. During an observation, laundry aides were seen removing dried laundry from dryers and placing it into hampers, with some linens touching and dragging on the floor. This was noted as a breach of infection control practices, as the floor was considered dirty. The infection preventionist reiterated the importance of maintaining hygienically clean linen to prevent environmental contamination. These deficiencies collectively indicate a lack of adherence to established infection control policies and procedures, potentially compromising resident safety.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for two residents, which is a violation of their policy and procedure titled 'Answering Call Light.' For Resident 39, the call light was found looped around the G-tube feeding pump, out of the resident's reach, during an observation with the Director of Staff Development. The Director confirmed that the call light should be within reach to allow the resident to call for help when needed. Resident 39's care plan also specified that the call light cord should be placed within easy reach, but this was not adhered to. Resident 39 was admitted with multiple diagnoses, including anxiety disorder and a need for assistance with personal care. The resident's Minimum Data Set (MDS) indicated moderate cognitive impairment and a dependency on assistance for all activities of daily living. Despite these needs, the call light was not accessible, potentially delaying necessary care and services. Similarly, Resident 300's call light was not within reach, as it was observed hanging from the upper bed rail, tucked between the wall and the bed mattress. Resident 300, who had severe cognitive impairment and required substantial assistance with activities of daily living, was unaware of the call light system and relied on staff entering the room for assistance. Interviews with staff, including a Certified Nursing Assistant and the Director of Nursing, emphasized the importance of call lights for resident safety and communication, yet the facility's policy to ensure call lights are accessible was not followed.
Failure to Provide Adequate Grooming for a Resident
Penalty
Summary
The facility failed to ensure proper grooming for a resident, identified as Resident 18, who was observed with a dark brown substance under three fingernails of the left hand. This observation was made during a survey, and the resident was noted to have been admitted to the facility with diagnoses including anxiety and osteoarthritis. The Minimum Data Set (MDS) assessment indicated that Resident 18 had severely impaired cognitive skills and was dependent on staff for all activities of daily living (ADLs). Despite this dependency, the resident's grooming needs were not adequately met, as evidenced by the condition of the fingernails. During an interview, a Certified Nursing Assistant (CNA) suggested that the substance under the fingernails could be due to the resident scratching staff. The Director of Staff Development confirmed that daily ADL care should include nail care, among other personal hygiene activities. The facility's policy on ADLs, dated March 2018, stated that residents unable to perform these activities independently should receive necessary services to maintain grooming and hygiene. The failure to provide adequate nail care for Resident 18 represents a deficiency in meeting the resident's grooming needs.
Failure to Provide Activities for Resident's Needs
Penalty
Summary
The facility failed to provide activities to meet the needs of a resident, identified as Resident 23, which potentially affected their emotional and psychosocial wellbeing. Resident 23 was admitted with multiple diagnoses, including shortness of breath, anxiety disorder, and psychosis. The Minimum Data Set (MDS) indicated that Resident 23 had moderately impaired cognition but was usually able to understand and express ideas. The resident expressed a high interest in activities such as listening to music, going outside for fresh air, and participating in religious services. However, observations from November 12 to November 14, 2024, showed that Resident 23 was mostly lying in bed, either asleep or watching TV, with no engagement in preferred activities. The Activity Program Attendance records from November 1 to November 12, 2024, revealed that no activities were provided to Resident 23 from November 1 to November 9, 2024. The Activities Staff (AS) acknowledged that activities should be provided at least three times a week and that they were responsible for visiting residents who did not attend group activities. However, during the absence of the Activities Director, the AS was responsible for group activities, and Resident Assistant 1 (RA 1) was tasked with room visits, which included handing out chronicles and turning on TVs. The facility's policy indicated that activities should reflect resident interests, but this was not adhered to, leading to the deficiency in meeting Resident 23's activity needs.
Failure to Follow Physician's Orders for Edema Management
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident with edema in accordance with the physician's order. The resident, who was admitted with multiple diagnoses including a displaced intertrochanteric fracture of the left femur and essential primary hypertension, had a physician's order for the application of elastic stockings to both lower extremities once a day for compression. However, during observations on two separate occasions, the resident was found wearing regular socks instead of the prescribed elastic stockings, and both legs were swollen and dependent. Interviews with the resident and staff revealed that the facility did not discuss the resident's swollen legs with them, and the resident had to request staff assistance to elevate their legs. A Licensed Vocational Nurse confirmed that the resident had pitting edema and that the physician's order for elastic stockings was not followed. The Director of Nursing acknowledged that one of the interventions for edema was to elevate the extremities and follow the physician's orders. The facility's policy on applying anti-emboli stockings was not adhered to, which was intended to minimize edema and improve circulation.
Failure to Implement Fall Prevention Measures for High-Risk Resident
Penalty
Summary
The facility failed to ensure that floor mats were in place for a resident identified as high risk for falls, as indicated in the resident's physician's order, care plan, and the facility's policy and procedure on managing falls and fall risk. The resident, who was admitted with diagnoses including malignant neoplasm of the ascending colon, difficulty walking, and muscle weakness, was observed without floor mats in their room, despite being at high risk for falls. This oversight was confirmed during an interview with a CNA, who acknowledged that the resident should have had floor mats in place as part of their fall prevention interventions. The Director of Nursing (DON) also confirmed that staff should follow physician orders regarding safety equipment like floor mats to ensure resident safety and reduce the potential for fall-related trauma. The resident's care plan and physician's order both specified the use of floor mats, and the facility's policy emphasized implementing a resident-centered fall prevention plan. Despite these directives, the absence of floor mats in the resident's room was a clear deviation from the established care plan and facility policy, potentially compromising the resident's safety.
Failure to Implement Gradual Dose Reduction for Antipsychotic Medication
Penalty
Summary
The facility failed to follow the pharmacist's recommendation to perform a gradual dose reduction (GDR) for Seroquel, an antipsychotic medication, for a resident diagnosed with dementia, muscle weakness, and difficulty in walking. The resident was admitted on 5/10/2024, and the Minimum Data Set (MDS) dated 8/15/2024 indicated severe cognitive impairment. Observations revealed the resident was frequently asleep in bed, and staff noted the resident slept all the time, even when seated in a chair. The resident's care plan for behavior related to psychosis indicated the last GDR was on 6/17/2024, when the Seroquel dose was reduced from 37.5 mg to 25 mg. The Medication Regimen Review (MRR) conducted between 9/1/2024 and 9/17/2024 recommended evaluating the current dose and considering a dose reduction, but there was no documentation of the physician's response to this recommendation. The Infection Prevention Nurse (IPN) confirmed the lack of documentation and stated that the Director of Nursing was responsible for following up on the MRR recommendations. The facility's policy on psychotropic medication use, dated July 2022, required gradual dose reductions unless clinically contraindicated, but this was not adhered to in this case.
Improper Administration of Potassium Chloride ER
Penalty
Summary
The facility failed to ensure the correct administration of Potassium Chloride ER for one resident, which was not in accordance with the facility's policy and procedure. The resident, who was alert and oriented, had a medical history including anemia, hypertension, and GERD. The facility's Consultant Pharmacist recommended that the potassium supplement be administered with food or after meals with a full glass of water or fruit juice to minimize gastrointestinal upset. However, the Medication Administration Record indicated that the medication was administered daily at 9 a.m. without ensuring the resident had eaten. During an observation, a Licensed Vocational Nurse administered the medication to the resident while they were in bed with an untouched breakfast tray, indicating the resident had not eaten. The nurse acknowledged that the medication should have been given with food to prevent stomach irritation. The Director of Nursing confirmed that medications should be administered as ordered by the physician to ensure their effectiveness. The facility's policy on administering medications emphasized that medications should be given safely, timely, and as prescribed, which was not followed in this instance.
Improper Storage and Labeling of Medications in Med Cart
Penalty
Summary
The facility failed to ensure proper storage and labeling of drugs and biologicals in one of the medication carts, Med Cart 2. During an observation, it was found that several medications and biologicals were not labeled with the opened date, which is crucial for determining their expiration. Specifically, an opened bottle of Magnesium Citrate and PreserVision Eye Vitamin & Mineral were found with opened dates but were past the one-year usage period. Additionally, containers of test strips and a glucose control solution were found without opened dates, contrary to the manufacturer's instructions to discard them six months after opening. The report highlights that two unopened Insulin Aspart Flexpens, which require refrigeration, were found inside Med Cart 2 with a sticker indicating they should be refrigerated. LVN 1 acknowledged the importance of labeling and proper storage, stating that the insulin should have been refrigerated to maintain its effectiveness. The lack of proper labeling and storage could potentially lead to the administration of ineffective medications, compromising the health and safety of residents, including Resident 33, who was receiving insulin from this cart. Resident 33, who was affected by this deficiency, had multiple diagnoses, including type 2 diabetes mellitus with diabetic polyneuropathy, COPD, and unspecified dementia. The resident's cognitive skills were moderately impaired, requiring supervision for daily decision-making. The facility's policies and procedures were reviewed, indicating that medications should be labeled with expiration dates and stored according to guidelines, including refrigeration when necessary. However, these procedures were not followed, leading to the identified deficiency.
Failure to Administer Influenza Vaccine to Consenting Resident
Penalty
Summary
The facility failed to administer the influenza vaccine to a resident who was eligible and had consented to receive it. The resident, identified as Resident 23, was admitted with multiple diagnoses, including shortness of breath, anxiety disorder, and unspecified fever. Despite having the capacity to understand and sign forms, as indicated in the resident's History and Physical, and a physician's order allowing the administration of the flu vaccine, the resident did not receive the vaccine. This oversight was confirmed during a review of the resident's Minimum Data Set and the facility's vaccination log, which showed that the resident had not been vaccinated. The facility's policy and procedure on vaccination, revised in October 2019, stated that all residents should be offered vaccines unless medically contraindicated or already vaccinated. The policy allowed for the administration of vaccines per physician-approved protocols after assessing medical contraindications. However, despite these guidelines, the resident did not receive the flu vaccine, as confirmed by the Infection Prevention Nurse during an interview and record review. This failure to administer the vaccine placed the resident at greater risk for acquiring or experiencing complications from the flu.
Failure in Pain Management for Resident
Penalty
Summary
The facility failed to provide appropriate pain management for a resident who was experiencing significant pain. The resident, admitted with a displaced intertrochanteric fracture of the right femur and dementia, was observed crying out in pain multiple times. Despite the resident's clear expressions of pain, the Certified Nursing Assistant (CNA) did not report the resident's condition to the Licensed Vocational Nurse (LVN), as the resident had previously stated they did not want pain medication. This lack of communication resulted in the LVN being unaware of the resident's pain until later, when the resident rated their pain as 10 out of 10. Upon being informed, the LVN administered morphine sublingually but admitted to forgetting to assess the location of the pain, which is crucial for understanding its cause. The Director of Nursing (DON) emphasized the importance of prioritizing pain assessment and management, indicating that the CNA should have informed the nurse immediately. The facility's policy on pain management stresses the need for a multidisciplinary approach, recognizing and addressing pain based on professional standards and the resident's care plan, which was not adhered to in this instance.
Failure to Provide Adequate Assistance During Transfer Leads to Resident Injury
Penalty
Summary
The facility failed to provide adequate care and services to prevent a fall for a resident by not ensuring that a Certified Nursing Assistant (CNA) provided two-person physical assistance during a transfer using a mechanical lift. The resident, who had a history of seizures and chronic atrial fibrillation, required extensive assistance with bed mobility and transfers due to decreased functional mobility and impaired balance. Despite the care plan indicating the need for two-person assistance, the CNA attempted the transfer alone, resulting in the resident falling forward from the lift and sustaining a fracture in the neck of the humerus, causing severe pain and requiring hospital transfer for further evaluation and treatment. The incident occurred when the CNA used the Sara lift to transfer the resident from the toilet to the wheelchair without the assistance of another staff member. The CNA admitted to routinely performing such transfers alone, contrary to the facility's policy and procedures, which mandate the use of two staff members for mechanical lift transfers. The resident's knees buckled during the transfer, leading to the fall and subsequent injury. Interviews with other staff members, including another CNA and a Licensed Vocational Nurse (LVN), confirmed that the standard practice and facility policy required two staff members to operate the Sara lift safely. The Director of Nursing (DON) reiterated the importance of following the facility's policy for using the Sara lift with two staff members to ensure resident safety and prevent injuries. The facility's policies on using mechanical lifting devices and managing fall risks clearly stated the need for two nursing assistants to safely move a resident with a mechanical lift. The failure to adhere to these policies directly contributed to the resident's fall and injury, highlighting a significant deficiency in the facility's adherence to safety protocols and staff training.
Failure to Implement Care Plan for Resident with Dementia
Penalty
Summary
The facility failed to ensure that a resident diagnosed with dementia and assessed at high risk for falls and elopement received appropriate care and services to prevent a fall. The resident's care plan interventions related to repetitive wandering behavior and attempts to leave the facility unattended were not implemented. Additionally, the care plan was not updated when staff recognized the need for one-to-one supervision due to frequent elopement attempts and the facility's fear that the resident might leave unnoticed. On the day of the incident, the resident fell while running toward the front lobby and attempting to leave the facility, resulting in a left distal radius fracture and a right humerus fracture. The resident was transferred to a general acute care hospital, where a cast was placed on the left arm and a sling on the right arm. Despite the resident's known high risk for falls and elopement, interventions such as frequent visual checks and outdoor walks were not consistently implemented. Interviews with staff revealed that the resident was known to be very confused and frequently wandered, making it difficult to monitor the resident when staff were busy with other tasks. The Director of Nursing confirmed that the resident's care plan interventions were not documented as implemented. The facility's policies and procedures for safety and supervision of residents and dementia care were not followed, leading to the resident's fall and subsequent injuries.
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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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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Duarte
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Royal Terrace Healthcare | 0.4 mi | ★★★★★ | 7 | 0 |
| Monte Vista Healthcare Center | 0.6 mi | ★★★★★ | 8 | 0 |
| Monrovia Post Acute | 0.6 mi | ★★★★★ | 14 | 0 |
| Community Care Center | 1.9 mi | — | 30 | 0 |
| Monrovia Gardens Healthcare Center | 2.4 mi | ★★★★★ | 34 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release June 2026) and official state health department websites.