Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Royal Terrace Healthcare during CMS and state inspections, most recent first.
Two residents had inaccurate MDS assessments. One resident’s MDS did not code depression despite an admission diagnosis of depression, an active order for mirtazapine, and MAR documentation showing all doses were given. Another resident’s MDS did not code antipsychotic use despite an order for quetiapine fumarate and MAR documentation showing a dose was administered. The MDSD and DON acknowledged the assessments were not accurate.
A facility failed to develop individualized CPs for two residents with depression and dementia. One resident had intact cognition but depressed mood and multiple ADL assistance needs, while another had severely impaired cognition, lacked decision-making capacity, and needed help with several ADLs. The MDSD and DON confirmed no specific CPs were in place to address the residents’ diagnoses, despite the facility policy requiring person-centered CPs with measurable goals, interventions, and resident-specific needs.
Failure to document blood sugar checks, rotate insulin injection sites, and complete psychotropic monitoring. A resident with DM received bedtime Lantus without blood sugar documentation on multiple occasions, and insulin was repeatedly given in the same abdominal site. Another resident with psychosis and depression received citalopram and quetiapine, but the MAR lacked every-shift psychotropic monitoring documentation. A third resident with DM also received insulin at the same sites instead of site rotation, contrary to the physician orders and facility policy.
Expired and improperly stored food items were found in Kitchen Refrigerator 1, including spilled vanilla ice cream cups and a pitcher of prune juice past its use-by date. The DS and DON stated expired food should not be kept in the refrigerator, and the facility policy required refrigerators to be maintained in a safe, clean, and sanitary condition to prevent foodborne illness.
Unlabeled food was found in a resident refrigerator located in the staff break room, including frozen dessert, strawberry ice cream, and a sealed cup of vanilla ice cream with no name or expiration date. Cook 1, the DS, LVN 3, and the DON all stated outside food should be labeled with the resident's name and date information, and that expired or unlabeled items should be discarded. The facility policy also required outside food to be labeled and unsafe or unlabeled items to be discarded.
Infection control practices were not followed when two unlabeled wash basins were left stacked on the floor in a shared bathroom between two rooms, rather than labeled and kept at a resident’s bedside. The facility also allowed a resident’s urinal to be stored on a nightstand and side table, including one observation where it contained urine and dripped onto the table. Staff and the DON stated these items should be labeled and kept in appropriate holders or bedside areas, and the resident involved had impaired cognition and needed help with toileting and personal hygiene.
Feeding a resident while standing instead of at eye-level. An LVN fed a resident with dysphagia, malnutrition, and generalized weakness while standing beside the bed instead of sitting in a chair at eye-level during lunch. The resident was awake in bed with a tray table across the chest and no chair nearby. The LVN acknowledged the expected practice was to sit when feeding at eye-level, and the DON stated staff should sit next to residents to respect dignity.
Incorrect Low Air Loss Mattress Settings for Resident With Pressure Injury: A resident admitted with dementia and pressure induced deep tissue damage had a low air loss mattress ordered to be set according to weight and checked each shift, but observations showed the mattress was set inconsistently at about 160-170 lbs. and later about 100 lbs. Staff, including the TN and DON, stated the mattress should match the resident’s current weight and the MD order, and the facility policy required settings appropriate for the resident’s weight and condition.
The facility did not have a full-time RN serving as DON for an extended period, instead relying on RN consultants who visited part-time and floor RNs/LVNs to provide oversight. This was contrary to facility policy, which requires a full-time DON to oversee nursing services and ensure regulatory compliance.
Two residents were not adequately protected from accident hazards when a bed sensor alarm failed to alert staff as one resident got up unassisted, and another resident experienced multiple falls with head injuries due to inaccurate or missing fall risk assessments and lack of updated care plan interventions by the IDT.
A resident with severe dementia and psychosis, known for hypersexual and inappropriate public behavior, was placed in a shared room and engaged in indecent exposure and masturbation in front of another resident. Despite the affected resident expressing fear and discomfort to nursing staff, the only response was to advise use of the call light, and the incident was not reported or investigated as required by facility policy. Staff were aware of the ongoing behavior but did not take adequate steps to protect the resident or follow abuse reporting protocols.
A resident with dementia and psychosis repeatedly exposed himself and engaged in inappropriate sexual behavior in the presence of another resident who required substantial assistance with daily activities. Despite staff awareness of the ongoing behavior, it was not reported as sexual abuse to the administrator or authorities, as required by facility policy. Staff later acknowledged the failure to recognize and report the incidents appropriately.
A resident with severe dementia and psychosis exhibited inappropriate sexual behaviors, including exposing himself and masturbating in the presence of another resident and in the hallway. Although staff were aware of and reported the behavior, no care plan was developed to address or manage it, and the affected resident reported feeling unsafe. Facility policy required care planning for significant behavioral changes, but this was not followed.
A resident with multiple chronic conditions expressed a desire to leave the facility but did not receive a new elopement risk assessment or increased supervision as required by policy. After the resident verbalized wanting to leave, staff did not implement additional monitoring or interventions, resulting in the resident leaving the facility unsupervised.
The facility did not ensure that two residents had properly completed and accessible Advance Directives and Acknowledgement Forms in their medical records, despite both having significant medical conditions and cognitive impairments. Staff interviews and record reviews confirmed that required documentation was either missing or incomplete, contrary to facility policy.
Surveyors found that kitchen staff failed to label and date leftover food from outside the facility stored in the refrigerator, and did not label or discard expired items in the dry storage area. The Dietary Supervisor and Lead Cook confirmed these practices were not in line with facility policy, which requires all food to be labeled with delivery, opened, and used by dates, and prohibits storage of outside food in the kitchen.
A resident with a G-tube and severe cognitive impairment was exposed when a staff member checked the G-tube site without closing the privacy curtain, leaving the resident's abdomen and lower extremities visible to others. Both the DSD and DON acknowledged that privacy should have been maintained during care, in accordance with facility policy.
A resident with muscle weakness and contractures was unable to reach the call light, which was found behind the resident and out of reach while in bed. Staff confirmed the call light should have been accessible, and facility policy required it to be within reach. This failure had the potential to delay assistance for the resident.
A resident admitted with cirrhosis, hepatic encephalopathy, and CHF was placed on hospice care, but neither the hospice provider nor facility staff developed or initiated a coordinated hospice care plan as required. Interviews with the SSD and DON confirmed that a comprehensive, individualized plan was not created, despite facility policy mandating such collaboration.
A resident with a Stage 4 sacral pressure ulcer and morbid obesity was found lying on a low air loss (LAL) mattress that was not set according to their actual weight, as required by the care plan, physician orders, and the manufacturer's instructions. Staff confirmed the mattress was set incorrectly, and the resident reported a change in bed firmness. The deficiency was identified through observation, record review, and staff and resident interviews.
A resident dependent on hemodialysis, with end stage renal disease and moderately impaired cognition, did not have a required dialysis emergency kit (E-kit) at the bedside. Observation and staff interviews confirmed the absence of the E-kit, despite facility policy and the resident's care plan specifying its necessity for immediate intervention in case of bleeding from the dialysis access site.
A resident with rib fractures and intact cognition was assessed with severe pain, but a nurse administered Dilaudid as ordered for moderate pain instead of notifying the physician for appropriate orders. Facility policy required medications to be given per prescriber orders, and the DON confirmed the parameters were not followed, resulting in a medication error.
Surveyors found that the medication refrigerator was not consistently maintained within the required temperature range of 36 to 46°F, with temperature logs showing readings both above and below this range. Staff, including an LVN and the DON, confirmed the importance of proper temperature control for medication efficacy, and facility policy also required daily monitoring and adjustment.
Two resident rooms were found to have less than the required 80 square feet per resident, with each room measuring 156 square feet and housing two beds. Staff reported that care could be provided safely and residents had adequate space for mobility and equipment use, and no concerns were raised by residents regarding room size. The facility had requested a waiver for these rooms, and no changes to occupancy were made.
The facility failed to properly handle Advance Directives for two residents, risking treatment against their wishes. One resident's AD was not screened or documented upon admission, while another's AD Acknowledgement form was incomplete. The Social Service Director and Director of Nursing confirmed these oversights, which contradict the facility's policy.
The facility failed to manage and label IV lines appropriately for three residents, leading to potential infection risks. A resident's PICC line port was left uncapped, another's peripheral IV site was unlabeled, and a third's PICC line dressing lacked date labeling. These actions were contrary to the facility's policies, as confirmed by staff interviews.
The facility failed to provide necessary respiratory care and services for four residents receiving oxygen therapy, as per the facility's Policy and Procedure on Respiratory Therapy - Prevention of Infection. A resident was observed not using oxygen, with the oxygen tubing found on the floor. Another resident was using oxygen therapy without the oxygen tubing and humidifier bottle being labeled with the date of change. A third resident used a facemask for breathing therapy that was not labeled with the date of use. Additionally, a fourth resident had oxygen tubing touching a trash bin, which was identified as a contamination risk.
A facility failed to create an individualized care plan for a resident with chronic cystitis, who was prescribed Bactrim. Despite the resident's moderate cognitive impairment and dependency on staff for daily activities, no care plan was documented to guide treatment. This deficiency was confirmed by the RN Supervisor and DON, who acknowledged the oversight in care planning.
A facility failed to perform a smoking assessment for a newly admitted resident with a history of smoking, as required by their policy. The resident, who had acute respiratory failure and hypertension, was observed smoking in the designated area without prior assessment. An LVN confirmed the oversight, highlighting a deficiency in adhering to the facility's smoking policy.
A resident with hemiplegia and hemiparesis required a plate guard and supervision during meals. Despite orders and care plans indicating the need for assistance, the resident was observed eating alone with the plate guard improperly positioned, leading to food spillage. Interviews confirmed the need for proper supervision and positioning to maintain the resident's independence and nutritional status.
A resident's POLST inaccurately indicated the presence of an Advance Directive, leading to potential miscommunication among healthcare providers. The Social Service Director admitted to incorrect documentation, which could result in inconsistent care during emergencies. The resident required substantial assistance and had diagnoses of hydrocephalus and hypertension.
The facility failed to meet the required square footage per resident in two rooms, each housing two residents, which were found to be 156 square feet instead of the required 160 square feet. Despite this, residents were able to move freely, and staff had enough space to provide care. The Administrator acknowledged the issue and planned to submit a room waiver request.
The facility failed to accommodate a resident's needs by not ensuring timely responses to call lights, not assisting with ADLs as per the care plan, and leaving the resident soiled in urine for prolonged periods. Staffing shortages led to delays in care and unmet needs.
The facility failed to implement individualized care plans for six residents, including not performing prescribed ROM exercises and not applying a left elbow splint, potentially diminishing their quality of life.
The facility failed to provide restorative nursing services as ordered by the physician for six residents, leading to potential declines in their range of motion and mobility. Staffing shortages caused RNAs to be reassigned to CNA duties, resulting in missed RNA services for multiple days in April 2024.
The facility failed to ensure sufficient nursing staff, resulting in unmet resident needs and inconsistent RNA services. Multiple residents did not receive timely care or physician-ordered RNA services due to staffing shortages and inadequate responses from the Director of Staff Development.
The facility failed to verify the competencies and skill sets of the nursing staff, leading to several deficiencies, including expired CNA certifications, lack of Skills Competency tests for newly hired CNAs, and missing CPR/BLS certifications. Additionally, the facility did not address staffing shortages, affecting the quality of care provided to residents.
Inaccurate MDS Coding for Depression and Antipsychotic Use
Penalty
Summary
The facility failed to ensure Resident 23’s MDS accurately reflected a diagnosis of depression. Resident 23 was admitted with diagnoses including secondary malignant neoplasm of the brain and depression, lacked capacity to make and understand medical decisions, and had an active order for mirtazapine 7.5 mg at bedtime for depression. The resident’s MAR showed 20 of 20 doses of mirtazapine were administered in May 2026, and the care plan included interventions related to depression and behavioral episodes. During record review and interview, the MDS Director stated the MDS dated [DATE] did not indicate depression and should have, and that the assessment was not accurate. The facility also failed to accurately code Resident 36’s antipsychotic medication use on the MDS. Resident 36 was admitted with diagnoses including psychosis and depression, lacked capacity to make and understand medical decisions, and had an order for quetiapine fumarate 25 mg at bedtime for depression. The MAR showed one dose of quetiapine fumarate was given on 3/10/2026, but the MDS dated [DATE] did not indicate antipsychotic medication use. During interview, the MDS Director stated quetiapine fumarate is an antipsychotic medication and that the MDS should have indicated antipsychotic use even though only one dose was administered. The DON stated the MDS should be accurate and acknowledged the inaccurate assessment was a discrepancy.
Failure to Develop Individualized Care Plans for Depression and Dementia
Penalty
Summary
The facility failed to develop specific, comprehensive, and individualized person-centered care plans for two sampled residents. Resident 2 was admitted with diagnoses including DM and depression. The H&P documented that Resident 2 had full decision-making capacity and depression, and the MDS indicated intact cognition, depressed mood at least half of the look-back period, and assistance needs for eating, oral hygiene, personal hygiene, toileting hygiene, showering/bathing, and bed-to-chair transfers. During record review, the MDSD stated there was no care plan developed to address Resident 2’s depression, and stated that even if the resident was not taking medication for depression, a specific and individualized care plan should still have been developed so staff would know the goal and intervention to address the depression. The DON also stated there should be a specific care plan to address Resident 2’s depression. Resident 36 was admitted with diagnoses including dementia and depression. The H&P documented that Resident 36 lacked the capacity to make and understand medical decisions and had dementia. The MDS indicated severely impaired cognition and assistance needs for eating, oral hygiene, personal hygiene, toileting hygiene, showering/bathing, and bed-to-chair transfers. During record review, the MDSD stated there was no care plan developed to address Resident 36’s dementia and stated the licensed nurse should develop and initiate the care plan for new diagnoses, medications, treatments, and services, no later than the end of the shift. The MDSD further stated the care plan needed to identify the resident’s problems, goals, and interventions, and that staff could not meet the resident’s goal without a specific care plan. The DON also stated there should be a specific care plan to address dementia care for Resident 36.
Failure to document blood sugars, rotate insulin sites, and monitor psychotropic medications
Penalty
Summary
The facility failed to meet professional standards of care for three sampled residents involving insulin administration, blood sugar documentation, and psychotropic medication monitoring. Resident 2 was admitted with diagnoses including diabetes mellitus and depression, had intact cognition, and had an active order for Lantus at bedtime with instructions to hold the insulin when blood sugar was less than 100. Review of the resident’s blood sugar summary and MAR showed no blood sugar reading documented at bedtime on multiple dates in May 2026, and the DON and MDSD confirmed the missing documentation. The DON stated the blood sugar level should be checked and documented before insulin administration and that documentation was proof of action. Resident 2’s insulin administration history also showed repeated use of the left lower abdomen for consecutive days rather than rotation of the injection site. The MDSD stated the resident received Lantus in the left lower abdomen for three consecutive days on two separate occasions and for two consecutive days on another occasion. The MDSD stated the facility’s practice was to rotate insulin administration sites to minimize discoloration, pain, and wound formation. Resident 36 was admitted with diagnoses including psychosis and depression, lacked capacity to make and understand medical decisions, and had severely impaired cognition. The resident had orders for citalopram hydrobromide daily and quetiapine fumarate at bedtime. Review of the MAR showed the resident received the ordered doses, but there was no documentation for psychotropic medication monitoring on the MAR for the month reviewed. The MDSD and DON stated staff were expected to monitor behavior every shift and document it on the MAR, including monitoring for therapeutic effectiveness, behavioral response, adverse reactions or side effects, and changes in cognition, mood, appetite, sleep, functional status, and signs of over-sedation. Resident 7 had diagnoses including type 2 diabetes mellitus, chronic kidney disease, and hemiplegia. The resident had an order for insulin asparte before meals and at bedtime depending on blood sugar levels, with instructions to rotate the injection site each time insulin was given. Review of the Location of Administration Reports for March and May 2026 showed insulin was administered at the same injection sites on multiple dates without rotation. The DON and RN stated that insulin sites should be rotated after each injection to prevent bruising and hardening of subcutaneous tissue and that repeated injections at the same site could cause irritation, pain, or swelling.
Expired and Spilled Food Left in Kitchen Refrigerator
Penalty
Summary
Safe food storage practices were not maintained in the facility kitchen refrigerator. During observation, five cups of vanilla ice cream dated 5/18/26 were found spilled over in Kitchen Refrigerator 1, and a pitcher containing brown liquid identified as prune juice with a use-by date of 5/14/26 was also observed in the same refrigerator. The items were present during surveyor observation and interview, and the dietary staff member stated the overflowing ice cream cups should have been removed and thrown out, while the prune juice should not have been stored in the refrigerator because it was expired. During interviews, the Dietary Supervisor stated there should not be any expired food items inside the kitchen refrigerators because it could make residents sick, and that all kitchen staff were responsible for checking for expired items. The DON also stated expired food should not be in the kitchen refrigerator and should be thrown out. The facility policy titled Kitchen Refrigerator and Freezer Policy stated kitchen refrigerators and freezers are to be maintained in a safe, clean, and sanitary condition to ensure proper food storage and prevent foodborne illness.
Unlabeled food left in resident refrigerator
Penalty
Summary
The facility failed to ensure safe handling and storage of food brought into the facility for a resident by family or other visitors. During observation in the employee lounge where the resident refrigerator was located, one container of peanut butter and chocolate chip frozen dessert and one container of strawberry ice cream were found with no name or expiration date. A cup of vanilla ice cream sealed with plastic wrap was also observed with no name or expiration date. Cook 1 stated the resident refrigerator should not have items without a name and expiration date, and stated nursing staff were responsible for checking and cleaning out the refrigerator. The Dietary Supervisor stated nursing staff collected food brought in by family and placed it in the resident refrigerator, and that food brought in by family should be labeled with the resident's name, room number, and expiration date or date placed in the refrigerator. The Dietary Supervisor and DON both stated expired or non-labeled foods should be discarded. LVN 3 stated outside food should be labeled with the resident's name, room number, and date placed in the refrigerator, and that food in the resident refrigerator should have an expiration date. The facility policy required food brought in from outside sources to be labeled with the resident's name, date received, and food item description, and stated expired, spoiled, unlabeled, or unsafe food items shall be discarded.
Infection Control Lapses With Shared Wash Basins and Resident Urinal Storage
Penalty
Summary
The facility failed to implement infection control practices when two unlabeled wash basins were found stacked together on the floor under the sink in the shared bathroom between Rooms A and B. During observation, the basins were empty and placed in a common bathroom used by residents from both rooms. A CNA stated the basins should have been labeled with a resident’s name and kept at the resident’s bedside, and should not have been left on the bathroom floor because they could be contaminated with germs and spread infection. The DON stated personal items such as wash basins were assigned to one resident, should be labeled with the resident’s name or initials and room number, and should be kept at the bedside rather than in a shared bathroom. The facility also failed to manage a urinal used by Resident 58 in a sanitary manner. Resident 58 was admitted with diagnoses including encephalopathy, respiratory failure, and UTI, and was described as alert but intermittently confused and dependent for toileting hygiene and personal hygiene. During observation, the resident’s urinal was seen hanging from an opened nightstand drawer with food items inside the drawer, and the resident stated the urinal was placed there because there was no urinal holder and one had not been offered. On a later observation, the urinal was on the resident’s side table and contained yellow liquid, with some liquid dripping onto the table. Staff interviews confirmed the urinal placement was not sanitary. An LVN stated the urinal should not be on the side table or hanging from the drawer and that it could spread bacteria to the resident’s food or drink. The IPN stated the urinal should be kept in a blue holder hanging from the side of the bed and that staff should request one from central supply if missing. The DON stated the urinal should not be on the nightstand, should be kept in the holder attached to the bed, and should be emptied after use; the DON also stated urinals should be labeled with the resident’s room number and removed if soiled. The facility’s policy stated it was committed to implementing infection prevention and control practices to reduce the risk of transmission of infections, and its urinal policy stated urinals shall not be stored on floors, bedside meal trays, windowsills, or other inappropriate surfaces.
Feeding a resident while standing instead of at eye-level
Penalty
Summary
The facility failed to provide care in a manner that maintained Resident 4’s dignity and respect when LVN 3 fed the resident while standing instead of sitting at eye-level during the lunch meal. Resident 4 was admitted on 3/14/2026 and readmitted on [DATE] with diagnoses including protein-calorie malnutrition, dysphagia, and generalized muscle weakness. The resident’s 3/16/2026 DPN indicated full decision-making capacity, and the 3/21/2026 MDS indicated moderately impaired cognition and dependence for eating, toileting hygiene, and upper/lower body dressing. During observation on 5/19/2026 at 12:50 PM, Resident 4 was awake and sitting in bed with a tray table across the chest while LVN 3 stood at the left side and fed the resident with a spoon; no chair was observed near the bedside. In interview, LVN 3 stated the resident was fed while standing because the resident needed standby assist, and acknowledged the nurse was supposed to sit in a chair when feeding at eye-level. The DON stated nursing staff needed to sit next to residents when feeding them to respect dignity and that feeding while standing above or over a resident could make the resident feel intimidated or disrespected. The facility’s Dignity Policy stated residents are to be treated with dignity, respect, compassion, and individuality at all times.
Incorrect Low Air Loss Mattress Settings for Resident With Pressure Injury
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not met when the facility failed to ensure Resident 60’s low air loss mattress was accurately monitored and set according to the resident’s weight. Resident 60 was admitted with diagnoses that included dementia, pressure induced deep tissue damage of the sacral region, and contracture of the forearm. The record showed Resident 60 weighed 118 lbs., and the physician order directed the low air loss mattress to be set according to resident weight, checked every shift for proper setting and function, and adjusted to resident comfort level every shift for wound management. The care plan also identified impaired skin integrity and included the low air loss mattress as ordered. During observation, Resident 60 was resting in bed on the low air loss mattress, which was set at approximately 160-170 lbs. normal pressure, and later the setting had been changed to approximately 100 lbs. The H&P stated Resident 60 lacked full medical decision-making capacity due to cognitive impairment. Staff interviews confirmed the mattress should be set to the resident’s current weight and according to the MD order, and that the treatment nurse and licensed nurses were responsible for ensuring the correct settings were in place. The DON also stated the mattress should be set to the resident’s weight and that staff needed to follow the doctor’s orders. The facility policy stated low air loss mattress settings are to be appropriate for the resident’s weight and condition.
Failure to Designate Full-Time Director of Nursing
Penalty
Summary
The facility failed to designate a registered nurse (RN) to serve as the Director of Nursing (DON) on a full-time basis, as required, from December 9, 2025, to December 23, 2025. During this period, there was no RN working as a full-time DON, despite a census of 52 residents. Observations on December 22 and 23, 2025, confirmed the absence of a designated full-time DON. Interviews with the former DON, the Administrator, and several RNs revealed that the previous DON had resigned in early December, and since then, no RN had been assigned to the full-time DON role. Instead, oversight was provided by RN consultants who visited the facility only 8 to 24 hours per week, and floor RNs and LVNs were considered to be acting as DONs in their absence. Facility policy and job descriptions reviewed during the survey indicated that the DON must be a state-licensed RN with experience in nursing service administration and must be employed full-time (40 hours per week). The policies also specified that RNs report to the DON, and the DON is responsible for overseeing nursing services and ensuring compliance with regulations. Despite these requirements, the facility did not have a full-time DON in place during the specified period, as confirmed by staff interviews and policy review.
Failure to Prevent Accidents and Inadequate Fall Risk Management
Penalty
Summary
The facility failed to maintain an environment free from accident hazards and did not provide adequate supervision to prevent accidents for two residents. For one resident with a history of falls, dementia, and impaired cognition, a physician order required the use of a bed sensor pad alarm for safety. However, during observation, the resident was able to get up from bed and walk unassisted to the bathroom without the alarm sounding or staff responding. The resident reported multiple prior falls and stated she was not supposed to walk alone, but did so because staff did not always respond promptly when she needed to use the toilet. Another resident, admitted with diagnoses including metabolic encephalopathy and seizures, experienced multiple falls resulting in head lacerations. Documentation showed that after each fall, the facility's licensed nursing staff either failed to conduct a fall risk assessment or completed it inaccurately, incorrectly assessing the resident as low risk despite repeated incidents. The Director of Nursing confirmed that required fall risk evaluations were not completed or were inaccurate, and acknowledged that this increased the likelihood of further falls. Additionally, the facility's Interdisciplinary Team did not conduct comprehensive root cause analyses following the resident's falls, nor did they update the resident's care plan interventions to address the ongoing risk. The care plan was not reviewed or revised after repeated falls, and the team did not consider the resident's diagnoses as contributing factors. The facility's own policy required post-fall management, including care plan updates and multidisciplinary review, but these steps were not followed after the incidents.
Failure to Protect Resident from Sexual Abuse Due to Inadequate Response to Inappropriate Sexual Behavior
Penalty
Summary
The facility failed to protect a resident from sexual abuse, resulting in one resident being subjected to indecent exposure by another resident. Specifically, a resident with severe dementia, psychosis, and a history of bizarre and hypersexual behavior, including public masturbation and exposing himself in hallways, was placed in a shared room. Despite staff being aware of this resident's ongoing inappropriate sexual behavior, including an incident where he masturbated in the presence of his roommate, the facility did not take adequate measures to prevent further exposure or ensure the safety of the roommate. The affected roommate, who had a history of acute subdural hemorrhage and mobility difficulties but was cognitively intact, reported feeling unsafe and unable to sleep due to fear of what might happen. The roommate communicated his discomfort and concerns to nursing staff, who only advised him to use the call light if something happened, rather than taking immediate protective action or removing him from the situation. Staff interviews confirmed that the inappropriate behavior was known and had been reported to the previous DON, but the behavior was attributed to the resident's dementia and not recognized as sexual abuse. Facility policy required prompt reporting and thorough investigation of all abuse allegations, but the incident was not reported to the administrator as required. Staff interviews indicated a lack of clarity regarding which residents were exposed and whether the situation was safe, with one RN supervisor acknowledging that it was not safe for the roommate to be alone with the resident exhibiting inappropriate sexual behavior. The facility's failure to act on known risks and to follow abuse reporting protocols resulted in a resident being subjected to sexual abuse and feeling unsafe in his living environment.
Failure to Report and Supervise Sexual Abuse Incidents
Penalty
Summary
The facility failed to ensure residents' right to be free from sexual abuse, specifically in the case involving one resident with a history of dementia, psychosis, and hypersexual behavior. This resident was observed exposing himself and masturbating in the presence of another resident, despite prior knowledge by staff of similar inappropriate behavior occurring in the hallways. Staff interviews and record reviews revealed that the behavior was ongoing, with nursing staff noting repeated incidents and acknowledging that the resident would only stop the behavior when prompted. The staff associated the behavior with the resident's dementia but did not recognize or report it as sexual abuse at the time. The incident involved another resident who required significant assistance with daily activities and had the capacity to understand and make medical decisions. The facility's policy required prompt reporting and investigation of abuse, but the RN Supervisor only reported the behavior to the previous DON and not to the administrator or external authorities. The staff later acknowledged that the behavior constituted sexual abuse and should have been reported according to policy, but this was not done at the time of the incidents.
Failure to Initiate Care Plan for Inappropriate Sexual Behavior
Penalty
Summary
The facility failed to initiate a care plan for a resident who exhibited inappropriate sexual behaviors, including exposing himself and masturbating in the presence of another resident and in the hallway. The resident had a history of severe dementia with psychotic disturbance, unspecified psychosis, depression, and delirium, and was admitted to the facility following psychiatric evaluation for bizarre behavior and significant cognitive impairment. Despite these behaviors being observed and reported by nursing staff, no care plan was developed to address or manage the resident's hypersexual behavior. Interviews with staff revealed that the inappropriate behavior was known to the nursing team, and it was reported to the previous Director of Nursing. Staff acknowledged the behavior as related to the resident's dementia diagnosis but did not consider it sexual abuse. The affected resident who witnessed the behavior reported feeling uncomfortable and unsafe, and communicated these concerns to the nursing staff, who advised using the call light if further incidents occurred. However, there was no evidence in the medical record that a care plan was initiated to address the behavior or to protect other residents. Facility policies required that significant changes in a resident's condition, including behavioral changes, be assessed and addressed through interdisciplinary care planning. The policies also specified that such changes should be documented and that a comprehensive assessment should be conducted. Despite these requirements, the facility did not develop or implement a care plan for the resident's inappropriate sexual behavior, resulting in a deficiency related to the failure to meet the resident's needs and ensure the safety and well-being of other residents.
Failure to Reassess and Intervene After Resident Expressed Intent to Leave
Penalty
Summary
A deficiency occurred when a resident, admitted with diagnoses including cirrhosis of the liver, chronic congestive heart failure, and hepatic encephalopathy, expressed a desire to leave the facility but did not receive appropriate interventions for elopement risk. The resident had previously been assessed as not at risk for elopement upon admission, with the initial evaluation indicating no verbalization of wanting to leave. However, on the day of the incident, the resident told RN 1 that he wanted to leave and go to a friend's house but was unable to provide an address. Despite this verbalization, RN 1 did not complete a new elopement risk evaluation as required by facility policy, nor were additional monitoring or interventions implemented. Subsequently, the resident was discovered missing from the facility, prompting staff to search both inside and outside the premises and in the surrounding community. The Director of Nursing confirmed that the facility's policy required a new elopement risk assessment and closer monitoring when a resident verbalizes intent to leave. The failure to reassess and implement interventions after the resident expressed a desire to leave resulted in the resident leaving the facility unsupervised.
Failure to Complete and Maintain Advance Directive Documentation
Penalty
Summary
The facility failed to ensure that Advance Directives (AD) and AD Acknowledgement Forms were properly completed and included in the medical records for two residents. For one resident with end stage renal disease, hydronephrosis, and dependence on hemodialysis, there was no copy of an AD or AD acknowledgement form in either the paper chart or electronic medical record. The Social Services Director confirmed that these documents should be updated and accessible with each admission or readmission to inform staff of the resident's wishes and preferences. The Director of Nursing also stated that all residents should have updated AD and ADA forms in their records, completed and signed upon admission or readmission, to ensure residents and their representatives are informed of their rights regarding medical treatment and advance directives. Another resident, admitted with type 2 diabetes mellitus and unspecified dementia, had an AD Acknowledgement Form that was not filled out completely. The Social Worker and Director of Nursing both confirmed that the form was incomplete and emphasized the importance of having it fully and accurately completed to reflect the resident's medical wishes. The facility's policy and procedure required inquiry about advance directives and provision of written information about the right to refuse or accept treatment prior to or upon admission, but this was not followed for the sampled residents.
Deficient Food Storage and Labeling Practices in Kitchen and Dry Storage
Penalty
Summary
Surveyors observed that the facility failed to maintain safe and sanitary food storage practices in the kitchen. Specifically, leftover food from outside the facility, including beef, chicken, macaroni salad, and rice, was found in the kitchen refrigerator in unmarked to-go boxes. These items were not labeled or dated and were stored alongside food intended for residents. The Lead Cook confirmed that all food items in the kitchen refrigerator should be labeled with the date received, opened, and used by date, and that food from outside the facility should not be stored in the kitchen refrigerator for infection control purposes. Further observations in the dry storage area revealed multiple food items, such as an open box of chocolate powder, unopened boxes of thickened lemon-flavored water, a bag of hotdog buns, and cans of chocolate pudding, that were not labeled with delivery, opened, or used by dates. Additionally, an opened gallon of teriyaki sauce with a use-by date that had already passed was found on the rack. The Dietary Supervisor acknowledged that all food items should be properly labeled and expired items discarded, in accordance with facility policy. Review of facility policies confirmed requirements for labeling, dating, and discarding expired or partially eaten food, which were not followed in these instances.
Failure to Provide Privacy During G-Tube Care
Penalty
Summary
Staff failed to provide privacy for a resident with a gastrostomy tube during a care procedure. During an observation, the Director of Staff Development (DSD) entered the resident's room and pulled up the resident's gown to check the G-tube site without closing the privacy curtain. This action exposed the resident's abdominal area and lower extremities to both the roommate and the hallway. The resident was noted to have severely impaired cognition and was dependent on staff for all activities of daily living, including personal hygiene and dressing. Interviews with the DSD and the Director of Nursing (DON) confirmed that the privacy curtain should have been closed during care and activities of daily living to maintain the resident's dignity and privacy. The facility's policy on dignity and quality of life also required staff to promote and protect resident privacy during personal care and treatment procedures. The failure to close the privacy curtain resulted in unnecessary exposure of the resident's body during a medical check.
Call Light Inaccessible to Resident with Limited Mobility
Penalty
Summary
The facility failed to ensure that a call light was within reach and appropriate to the physical abilities of a resident with significant mobility limitations. The resident, who had muscle weakness and contractures affecting both hips, both knees, and the left elbow, was found lying on his left side and unable to locate or reach his call light. A CNA confirmed that the call light was positioned behind the resident's right backside, making it inaccessible, and handed it to the resident. The resident stated he was unable to reach the call light on his own. The resident's care plan and occupational therapy evaluation documented limited mobility, decreased strength, and the need for assistance with activities of daily living. Interviews with staff, including an LVN and the DON, confirmed that the call light should have been within the resident's reach to allow for timely assistance. The facility's policy also required that the call light be accessible to residents when in bed. The failure to ensure the call light was within reach had the potential to delay meeting the resident's needs for assistance.
Failure to Develop Comprehensive Hospice Care Plan
Penalty
Summary
The facility failed to develop an individualized and comprehensive hospice plan of care for a resident who was admitted with diagnoses including cirrhosis, hepatic encephalopathy, and congestive heart failure. The resident was admitted to hospice care upon entry to the facility, as indicated in the Order Summary Report. However, upon review of both the hospice medical record and the facility's electronic medical record, it was found that no hospice care plan had been developed or initiated by either the hospice provider or the facility. Interviews with the Social Services Director and the Director of Nursing confirmed that a coordinated hospice care plan should have been created upon admission to address the resident's specific needs, goals, and interventions. The facility's policy and procedures also require collaboration between facility staff and the hospice agency to establish a care plan based on the resident's assessment. Despite these requirements, the necessary hospice care plan was not in place for the resident.
Failure to Set Low Air Loss Mattress According to Resident Weight
Penalty
Summary
The facility failed to ensure that a low air loss (LAL) mattress was set up accurately according to the manufacturer's instructions for a resident with a history of a Stage 4 sacral pressure ulcer and morbid obesity. The resident's care plan and physician orders specified that the LAL mattress settings should be adjusted based on the resident's weight and personal preference. However, during observation, the mattress was found to be set at a weight setting between 350 lbs to firm, while the resident's actual weight was 144 lbs. Multiple staff members, including the Director of Staff and Development and the Infection Prevention Nurse, confirmed that the mattress was not set according to the resident's actual weight, as required by both the care plan and the manufacturer's user manual. The resident was dependent on staff for most activities of daily living and had impaired skin integrity related to a sacral coccyx Stage 4 pressure injury. During interviews, the resident reported that the bed was not as firm as before, indicating a change in the mattress setting. The Director of Nursing also acknowledged that the LAL mattress needed to be set based on the resident's weight and comfort level to prevent deterioration of wounds or development of new pressure injuries. The user manual for the mattress confirmed that the pressure should be adjusted using the patient's weight as a guide.
Failure to Provide Dialysis Emergency Kit at Bedside
Penalty
Summary
The facility failed to ensure that a resident requiring hemodialysis had a dialysis emergency kit (E-kit) at the bedside, as required for immediate intervention in case of complications such as unexpected bleeding from the hemodialysis access site. Observation and interview confirmed that the resident, who had diagnoses including end stage renal disease, hydronephrosis, and dependence on hemodialysis, did not have an E-kit available at the bedside. The resident's care plan specified the need for immediate intervention for dialysis-related complications, and the Director of Nursing confirmed that all dialysis residents should have an E-kit readily accessible. The deficiency was identified during a review of the resident's records, care plan, and through direct observation and staff interviews. The resident was noted to have moderately impaired cognition and required varying levels of assistance with daily activities. The facility's policy and procedures indicated the need for immediate action and supplies in the event of bleeding from the dialysis access site, but these supplies were not present at the resident's bedside at the time of the survey.
Failure to Administer Pain Medication According to Physician Orders
Penalty
Summary
A deficiency occurred when a resident with multiple left-sided rib fractures and high blood pressure, who was cognitively intact and able to make decisions, did not receive pain medication in accordance with physician orders. The resident had an active order for Dilaudid 1 mg by mouth every four hours as needed for moderate pain (pain scale 4-6). During a medication administration observation, a nurse assessed the resident's pain at a level of seven, which is categorized as severe pain, but still administered Dilaudid as ordered for moderate pain. The nurse stated that pain medication for severe pain was unavailable and planned to reassess and contact the physician for further orders. The facility's care plan indicated that Dilaudid should be administered as ordered by the physician, and facility policy required medications to be given in accordance with prescriber orders. The DON confirmed that the physician should have been notified to obtain appropriate orders for severe pain and acknowledged that the ordered parameters were not followed. Facility policy also defined a medication error as administering drugs not in accordance with physician orders or accepted professional standards.
Failure to Maintain Medication Refrigerator Within Required Temperature Range
Penalty
Summary
The facility failed to maintain the medication refrigerator (MR) within the required temperature range of 36 to 46 degrees Fahrenheit, as evidenced by temperature logs and direct observation. The MR temperature log showed that on two consecutive days, the temperature was recorded at 48 degrees Fahrenheit, which is above the recommended range. Additionally, during an observation in the medication room, the MR temperature was found to be 34 degrees Fahrenheit, which is below the required minimum. Both the Licensed Vocational Nurse and the Director of Nursing confirmed that maintaining the MR temperature within the specified range is necessary to ensure the efficacy and stability of stored medications. A review of the facility's policy and procedure on temperature control confirmed that drugs requiring refrigeration must be stored between 36 and 46 degrees Fahrenheit, and that daily temperature logs should be maintained to ensure compliance. The failure to keep the MR within the recommended temperature range was directly observed and acknowledged by facility staff, with no indication in the report of corrective actions taken at the time of the survey.
Resident Rooms Below Minimum Square Footage Requirement
Penalty
Summary
The facility failed to provide the required minimum of 80 square feet per resident in two out of twenty-three resident rooms, as determined by observation, interview, and record review. The Client Accommodations Analysis indicated that the identified rooms had a total of 156 square feet of floor area and housed two beds, which does not meet the regulatory requirement for space per resident. The facility had submitted a waiver request for these rooms, stating that the space was sufficient for safe resident mobility and accessibility, and that care and services would not be impeded. During the health recertification survey, it was observed that the rooms in question allowed for adequate nursing care, comfort, and privacy. Staff, including a CNA and an LVN, reported that there was enough space to use necessary equipment such as Hoyer lifts and walkers, and residents were able to move freely within the rooms. No residents expressed concerns about the room sizes, and staff confirmed that care could be provided without issue. The facility administrator confirmed that a waiver had been requested for these rooms and that there had been no changes to bed occupancy.
Failure to Properly Handle Advance Directives
Penalty
Summary
The facility failed to ensure proper handling of Advance Directives (AD) for two residents, which could lead to treatment against their wishes. For Resident 99, the facility did not perform a screening for an AD upon admission, nor did they obtain a copy of the AD to maintain in the resident's medical record. This oversight was confirmed during an interview with the Social Service Director (SSD), who acknowledged that the screening for ADs is part of the facility's admission process. Additionally, Resident 99's family member confirmed that the resident had an AD, but the facility did not request a copy for the medical record. For Resident 9, the facility failed to ensure that the AD Acknowledgement form was filled out completely. The form lacked checks in the boxes indicating whether the resident had executed an AD. This was noted during a review of the resident's medical record and confirmed by the SSD, who stated that it was necessary to complete the form to respect the resident's treatment preferences. The Director of Nursing also acknowledged the incomplete form, emphasizing the need for it to be filled out by the SSD. The facility's policy requires that ADs be inquired about and documented upon admission, but this was not adhered to in these cases.
Deficiencies in IV Line Management and Labeling
Penalty
Summary
The facility failed to provide appropriate care and services for intravenous (IV) lines for three residents, leading to potential risks of infection and complications. For one resident, a PICC line port was observed to be exposed and not covered with a cap, contrary to the facility's policy on preventing intravenous catheter-related infections. This resident was admitted with sepsis and cellulitis, requiring IV medications via a PICC line, and the care plan aimed to avoid complications related to IV therapy. Interviews with the Infection Preventionist Nurse and the Director of Nursing confirmed that all PICC line ports should be capped when not in use to prevent infection. Another resident had a peripheral IV site that was not labeled with the date of insertion, which is against the facility's policy requiring labeling with the date, time, and nurse's initials. This resident was admitted with cellulitis and had a physician's order for the peripheral site dressing to be changed every 72 hours. Observations and interviews with nursing staff revealed that the lack of labeling made it difficult to determine when the dressing was last changed, increasing the risk of infection. A third resident had a PICC line dressing that was not labeled with the date of insertion or change. This resident was admitted with acute osteomyelitis and anemia and required assistance with personal hygiene and transfers. The facility's policy mandates that PICC line dressings be labeled and changed every 5-7 days to prevent bacterial accumulation and infection. The Infection Preventionist Nurse confirmed that the dressing should be labeled to ensure timely changes, highlighting a lapse in adherence to infection prevention protocols.
Deficiencies in Respiratory Care and Infection Control
Penalty
Summary
The facility failed to provide necessary respiratory care and services for four residents receiving oxygen therapy, as per the facility's Policy and Procedure on Respiratory Therapy - Prevention of Infection. Resident 151, who was admitted with conditions including hemiplegia, hemiparesis, and pneumonitis, was observed not using oxygen, with the oxygen tubing found on the floor. Interviews with staff, including the Licensed Vocational Nurse and the Infection Preventionist Nurse, confirmed that the oxygen tubing should have been placed in a transparent bag when not in use to prevent contamination and infection. Resident 27, admitted with acute respiratory failure and pneumonitis, was observed using oxygen therapy without the oxygen tubing and humidifier bottle being labeled with the date of change. This labeling is crucial to ensure timely changes and prevent infection. Interviews with the Infection Preventionist Nurse and the Registered Nurse Supervisor highlighted the importance of labeling to maintain infection control standards. Resident 25, diagnosed with hydrocephalus and hypertension, used a facemask for breathing therapy that was not labeled with the date of use. The Infection Preventionist Nurse indicated that the facemask should be labeled and changed every seven days to prevent bacterial accumulation. Additionally, Resident 199, with pulmonary hypertension, had oxygen tubing touching a trash bin, which was identified as a contamination risk by the Licensed Vocational Nurse and the Director of Nursing. The facility's policy requires oxygen equipment to be stored properly to prevent infection, which was not adhered to in these cases.
Failure to Develop Individualized Care Plan for Resident with Cystitis
Penalty
Summary
The facility failed to develop and implement an individualized person-centered care plan for Resident 19, who was diagnosed with chronic cystitis and was prescribed Bactrim. Despite the facility's policy requiring a comprehensive care plan to be developed within seven days of the Minimum Data Set (MDS) assessment and no more than 21 days after admission, there was no clinical documentation of a care plan addressing Resident 19's cystitis or the use of Bactrim. This oversight was identified during a review of Resident 19's medical records, which revealed the absence of a care plan to guide staff in providing appropriate treatment. Resident 19 was admitted to the facility with diagnoses including chronic cystitis and overactive bladder. The resident's cognitive abilities were moderately impaired, and they were dependent on staff for various activities of daily living. Despite these needs, the facility did not create a care plan to address the resident's specific medical condition and medication regimen. Interviews with the Registered Nurse Supervisor and the Director of Nursing confirmed the lack of a care plan, acknowledging that it should have been developed to ensure the resident received necessary care and treatment.
Failure to Conduct Smoking Assessment for New Resident
Penalty
Summary
The facility failed to conduct a smoking assessment for a newly admitted resident, identified as Resident 100, who had a history of smoking for more than a specified number of years. This oversight was discovered during an observation in the facility's designated smoking area, where Resident 100 was seen smoking with a visitor. The resident's admission record indicated diagnoses of acute respiratory failure and hypertension, and the history and physical examination confirmed the resident's capacity to understand and make decisions. However, the medical record lacked any documentation of a smoking assessment. During an interview with Licensed Vocational Nurse 5, it was revealed that the facility was unaware of Resident 100's smoking status upon admission, and no smoking assessment was performed. The facility's policy, revised in October 2023, mandates that residents be informed of the smoking policy and evaluated for smoking status upon admission. The failure to adhere to this policy resulted in a deficiency, as the necessary assessment to ensure safe smoking practices was not conducted.
Failure to Supervise Resident Using Plate Guard
Penalty
Summary
The facility failed to provide adequate supervision to a resident who required the use of a plate guard during meals. The resident, who was admitted with diagnoses of hemiplegia and hemiparesis, had an order for a plate guard at mealtime and required supervision or assistance with eating. Despite these requirements, observations revealed that the resident was eating alone with the plate guard improperly positioned, leading to food spillage. Interviews with the Director of Nursing and a Certified Nurse Assistant confirmed that the resident needed assistance to use the plate guard effectively, and the Dietary Supervisor indicated that the plate guard should be positioned to accommodate the resident's dominant hand. The resident's care plan and order summary report indicated the need for supervision during meals, yet the resident was observed eating without the necessary assistance. The facility's policy on assistive devices emphasized the importance of maintaining and supervising the use of such equipment to support resident independence and safety. However, the lack of proper supervision and incorrect positioning of the plate guard during meals demonstrated a failure to adhere to these guidelines, potentially impacting the resident's nutritional status and independence during mealtime.
Inaccurate POLST Documentation for a Resident
Penalty
Summary
The facility failed to ensure accurate documentation of the Physician Orders for Life-Sustaining Treatment (POLST) for a resident, identified as Resident 25. The POLST, which is crucial for recording a patient's treatment preferences in emergencies, inaccurately indicated that the resident had an Advance Directive (AD). However, upon review, it was found that the resident did not execute an AD, as confirmed by the AD acknowledgment form and the Social Service Director (SSD). This inconsistency between the POLST and the AD acknowledgment form was acknowledged by the SSD, who admitted to incorrect documentation. Resident 25 was admitted with diagnoses including hydrocephalus and hypertension and required substantial assistance for personal hygiene and transfers. The inaccurate documentation in the POLST had the potential to cause miscommunication among healthcare providers, leading to inconsistent care and possibly administering treatment against the resident's wishes during emergencies. The facility's policy on charting and documentation emphasizes the need for objective, complete, and accurate records, which was not adhered to in this case.
Room Size Deficiency in Two Resident Rooms
Penalty
Summary
The facility failed to ensure that two of its rooms met the required square footage per resident in multiple resident rooms. Specifically, rooms 12 and 32, each housing two residents, were found to be 156 square feet, falling short of the 160 square feet minimum requirement. Despite this deficiency, observations indicated that residents in these rooms were able to ambulate freely and maneuver in their wheelchairs without difficulty. Nursing staff also had sufficient space to provide care with dignity and privacy, and there was adequate room for beds, side tables, dressers, and other medical equipment. During an interview, the Administrator acknowledged the deficiency and indicated plans to submit a room waiver request for the affected rooms. The waiver request letter stated that there was ample room to accommodate wheelchairs and other medical equipment, and that the health and safety of residents were not compromised. Interviews with residents revealed no concerns regarding the size of their rooms, suggesting that the deficiency did not adversely affect their well-being or the provision of care.
Failure to Accommodate Resident Needs and Preferences
Penalty
Summary
The facility failed to accommodate the needs and preferences of a resident by not ensuring timely responses to the resident's call light, not assisting with activities of daily living (ADL) as per the care plan, and leaving the resident soiled in urine for prolonged periods. The resident, who had multiple diagnoses including a history of stroke, osteoarthritis, epilepsy, and mobility impairments, was totally dependent on staff for personal and toileting hygiene. Despite the care plan indicating the need for substantial assistance and frequent incontinence care, the resident reported having to wait for assistance to get out of bed and being left soiled due to staff shortages. Interviews with Certified Nursing Assistants (CNAs) revealed that due to staffing shortages, they were unable to change incontinence briefs and reposition residents every two hours as required. The CNAs admitted to only being able to change residents twice per shift and acknowledged delays in answering call lights. The facility's policies on answering call lights and supporting ADLs were not adhered to, leading to the resident's needs not being met in a timely and appropriate manner.
Failure to Implement Individualized Care Plans
Penalty
Summary
The facility failed to develop and implement individualized care plans for six residents in accordance with physician's orders. For Resident 7, the care plan did not include a physician's order for Assisted Active Range of Motion (AAROM) exercises to both lower extremities. Additionally, the facility did not perform Passive Range of Motion (PROM) exercises for Resident 9's right upper extremity, Resident 10's lower extremities and right upper extremity, and Resident 11's lower extremities as indicated in their care plans. Furthermore, Active Range of Motion (AROM) exercises were not performed for Resident 13's lower extremities, and Resident 14 did not receive the prescribed left elbow splint and PROM exercises for the left upper extremity as indicated in the care plan. Resident 7 was admitted with multiple diagnoses including dementia and morbid obesity and required assistance with mobility and personal care. The care plan for Resident 7 included AAROM exercises for both lower extremities, but there was no corresponding physician's order. Resident 9, who had a history of cerebral infarction and severe cognitive impairment, did not receive PROM exercises for the right upper extremity on several documented dates. Similarly, Resident 10, who had hemiplegia and hemiparesis, did not receive PROM exercises for the lower extremities and right upper extremity on multiple occasions. Resident 11, with a history of falling and a displaced bimalleolar fracture, did not receive PROM exercises for the lower extremities as ordered. Resident 13, who had a right femoral neck fracture and other mobility issues, did not receive AROM exercises for the lower extremities on several dates. Lastly, Resident 14, who had hemiplegia and contractures, did not receive the prescribed left elbow splint and PROM exercises for the left upper extremity on multiple occasions. These failures had the potential to diminish the residents' quality of life related to a further decline in their physical and psychosocial well-being.
Failure to Provide Restorative Nursing Services
Penalty
Summary
The facility failed to provide restorative nursing services (RNS) as ordered by the physician for six residents. For Resident 7, who had multiple diagnoses including dementia and morbid obesity, RNA services were not provided for five days in April 2024. The resident required assistance with mobility and personal care, and the lack of RNA services was confirmed through interviews and record reviews. Similarly, Resident 9, who had a history of cerebral infarction and severe cognitive impairment, did not receive RNA services for four days in April 2024. The resident was dependent on staff for most self-care activities and mobility, and the absence of RNA services was also confirmed through documentation review and interviews. Resident 10, diagnosed with hemiplegia and hemiparesis, did not receive RNA services for six days in April 2024. The resident was dependent on staff for toileting hygiene, showering, and mobility. The lack of RNA services was confirmed through record reviews and interviews. Resident 11, who had a history of falling and a displaced bimalleolar fracture, did not receive RNA services for three days in April 2024. The resident had severe cognitive impairment and was dependent on staff for all self-care activities and mobility. The absence of RNA services was confirmed through documentation review and interviews. Resident 13, who had multiple diagnoses including a right femoral neck fracture and heart failure, did not receive RNA services for three days in April 2024. The resident was dependent on staff for various self-care activities and transfers. The lack of RNA services was confirmed through record reviews and interviews. Lastly, Resident 14, diagnosed with hemiplegia and contractures, did not receive RNA services for four days in April 2024. The resident was dependent on staff for most self-care activities and mobility. The absence of RNA services was confirmed through documentation review and interviews. The Director of Nursing acknowledged that RNA services must be provided consistently to prevent further decline in residents' range of motion and mobility, but staffing shortages led to RNAs being reassigned to CNA duties, resulting in the failure to provide the necessary services.
Staffing Shortages Lead to Inadequate Resident Care
Penalty
Summary
The facility failed to ensure sufficient nursing staff, including CNAs and RNAs, to provide care for seven of 15 sampled residents. This deficiency was observed through various interviews and record reviews, revealing that residents' needs and preferences were not met, and physician-ordered RNA services were not consistently provided. For instance, Resident 1 had to wait until 10 AM to get out of bed due to a lack of staff, and incontinence brief changes were not performed as frequently as required. Multiple CNAs reported being overworked and unable to respond to call lights promptly, leading to delays in care and resident dissatisfaction. The report also highlighted that RNA services were not provided as ordered by the physician for several residents. Resident 7, for example, did not receive RNA services on multiple days in April 2024, as documented in the facility's records. Similar deficiencies were noted for Residents 9, 10, 11, 13, and 14, who did not receive their prescribed RNA services on various dates. Interviews with RNAs confirmed that they were often reassigned to perform CNA duties due to staffing shortages, leaving them unable to fulfill their RNA responsibilities. Interviews with facility staff, including CNAs, LVNs, and the DON, revealed a consistent theme of staffing shortages and inadequate responses from the Director of Staff Development (DSD). Staff reported that the DSD did not call for additional help or use registry staff effectively, leading to an overwhelming workload and insufficient care for residents. The facility's policy on staffing emphasized the need for sufficient numbers of skilled staff to meet residents' needs, but this was not adhered to, resulting in significant care deficiencies.
Failure to Verify Competencies and Address Staffing Shortages
Penalty
Summary
The facility failed to verify the competencies and skill sets of the nursing staff, leading to several deficiencies. Three of nine sampled CNAs did not have active CNA certifications. Interviews revealed that errors in filling out certification renewal paperwork and providing required in-services delayed the renewal process. Despite expired certifications, some CNAs continued to work in non-resident care-related duties. The facility's policy required maintaining current certifications, but this was not adhered to, as evidenced by the employee files and timecards reviewed by the Director of Nursing (DON). Additionally, the facility's DSD job description mandated maintaining employee files and health records, which was not followed in this case. The facility also failed to conduct Skills Competency tests for newly hired CNAs before they began working independently. Performance evaluations and Skills Competency tests were supposed to be conducted upon hire and annually, but there was no documented evidence that these tests were performed for two newly hired CNAs. The DON confirmed the absence of these tests and noted that the Pre-Employment Reference Verification Checklist for one CNA was questionable. The facility's DSD job description required assessing the learning needs of personnel and monitoring continuity between classroom and clinical application, which was not done. Furthermore, the facility did not ensure that all nursing staff had current CPR/BLS certifications. Four sampled nursing staff members lacked documented evidence of current CPR/BLS certifications. The DSD was responsible for verifying these certifications upon hiring and organizing renewal classes if needed, but this was not done. Interviews with staff revealed that the DSD did not address staffing shortages, which affected the quality of care provided to residents. Staff reported being overwhelmed with the workload, unable to take breaks, and struggling to provide adequate care due to insufficient staffing. The facility's policy required providing sufficient numbers of staff with the necessary skills and competency, which was not met.
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What surveyors actually found near you
We read the 5,268 citations issued within 25 miles in the last 12 months — including the 23 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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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 Oaks Manor-bradbury Oaks | 0.4 mi | ★★★★★ | 11 | 0 |
| Monrovia Post Acute | 0.6 mi | ★★★★★ | 26 | 0 |
| Monte Vista Healthcare Center | 0.7 mi | ★★★★★ | 34 | 0 |
| Community Care Center | 1.6 mi | — | 1 | 0 |
| Monrovia Gardens Healthcare Center | 2.3 mi | ★★★★★ | 31 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.