Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Royal Vista Care Center during CMS and state inspections, most recent first.
Failure to timely report alleged verbal abuse: A resident with Parkinson’s disease and spinal stenosis reported that the DSD called him “Pinche Chimoso.” Staff members heard the statement, but one did not report it because he expected the resident to do so, and another did not report it until the next day. The Administrator stated the incident was reported the following day, despite the facility policy requiring suspected abuse, including verbal abuse, to be reported within 2 hours.
Surveyors found that the facility failed to follow its scabies infection control policy for two residents with suspected and confirmed scabies. One resident returned from dermatology with suspected scabies, and another had biopsy-confirmed scabies, yet the IPN did not initiate required contact tracing, staff screening, or six-week surveillance monitoring. The confirmed case did not receive timely Permethrin 5% treatment and was not placed on contact isolation until many days after the positive result, despite dependence on staff for most ADLs. CNAs who provided hands-on care were not informed of the diagnosis or instructed to monitor for symptoms, and no line lists or documentation of surveillance or contact tracing were produced, in contrast to both facility policy and CDC scabies guidance.
Psychotropic medication orders for three residents were not properly monitored or documented on the MAR. One resident on olanzapine for striking out and grabbing staff had no behavior documentation despite staff reporting aggressive episodes, another resident on divalproex for mood swings had yes-or-no entries instead of tally counts, and a third resident on quetiapine and Depakote had vague behavior targets and incomplete care plan documentation. Staff and the DON/ADON confirmed the missing or nonspecific behavior tracking.
The facility failed to ensure PASRR Level 1 screening was completed and accurate for two residents with mental health and cognitive diagnoses. One resident with major depressive disorder and unspecified intellectual disabilities had no PASRR documented for readmission, and another resident with Alzheimer’s disease, psychosis, and dementia had a PASRR that was marked negative even though the resident was later shown to be receiving quetiapine for psychosis. The DON stated the PASRR was incorrectly filled out.
A resident with dementia and dependence for hygiene was observed with long, jagged fingernails and scratch marks on the arm after stating he scratched himself. Staff interviews confirmed that CNAs/RNAs were responsible for nail trimming and that long nails could injure skin. Another resident with spinal stenosis, PVD, and DM reported requesting showers for two weeks but said staff limited showers to certain times and instead gave intermittent bed baths that did not meet his needs. The ADON confirmed there was no ADL care plan and no documentation for multiple dates showing a shower or bed bath was provided.
A facility failed to provide ordered pressure ulcer care for three residents. One resident with DM and existing heel and sacrococcyx pressure injuries did not have the ordered LALM in place and was observed without heel or elbow protectors. Another resident at high risk for pressure injuries was observed on a LALM set above the resident’s weight, and the skin care plan did not include the LALM. A third resident with a history of skin breakdown was also observed on a LALM set far above the resident’s weight, despite staff stating the setting should match the resident’s weight and be checked each shift.
An LVN incorrectly administered an inhaled COPD medication, a resident’s 9 AM medications were given late and several delayed-release tablets were crushed, another resident received meds without two identifiers being used, and an LVN prepared the wrong supplement by placing Rena Vite in a cup labeled for Vitamin C. The events involved residents with COPD, DM, HTN, dementia, mood disorder, and severe cognitive impairment, and staff acknowledged the medications were not handled according to orders or policy.
Surveyors found a 50% medication error rate after observing med passes for four residents. Errors included incorrect administration of Combivent for a resident with COPD, 16 late 9 AM medications for a resident with dementia and DM, crushing three medications ordered not to be crushed, and preparing Rena Vite instead of Vitamin C for another resident.
A resident with COPD received Combivent Respimat incorrectly during a med pass when an LPN placed the inhaler in the resident’s mouth, pressed the dose-release button, and had the resident take repeated breaths without holding the breath after inhalation. In a separate event, an LPN crushed multiple medications ordered as do not crush, including delayed-release divalproex and aspirin and extended-release metoprolol, despite the MAR and orders indicating the medications should not be crushed. The DON and ADON confirmed the medications were not administered according to the ordered formulations or inhaler instructions.
Medication Storage and Labeling Deficiencies: An unopened insulin pen was found in a med cart drawer instead of being refrigerated, and opened Ipratropium-Albuterol and Albuterol Sulfate foil packets were found in the cart with one packet undated and others past their opened expiration dates. In the med storage room, an opened syringe was mixed with sealed syringes, along with expired safety needles, alcohol prep pads, and large bags of expired needles and syringes. The DON/ADON and LVN stated the items were not stored or labeled correctly and that expired meds/supplies should not remain available for use.
Kitchen staff failed to follow hair restraint, food labeling, storage, and handling practices. A cook and the DSS were observed without proper hair or beard nets, multiple food items in refrigerators and freezers were unlabeled or expired, a staff member's personal strawberries were stored in a kitchen refrigerator, and a DSA handled water cups by the rim during tray line preparation without gloves. Facility policy required proper hair restraints, labeling with preparation/opening dates and discard dates, and sanitary food handling.
Infection control practices were not followed during medication administration when an LPN picked up a dropped tablet and continued giving meds without changing gloves or performing hand hygiene, and another LPN placed a dirty lancet in a med tray, reused the tray without sanitizing it, and handled a dropped medication cup with bare hands before preparing meds. The facility also failed to process linens per policy, with washer and dryer cycles not matching the required temperature and time parameters for washing and drying sheets, pillowcases, blankets, and other linens.
Failure to document VIS education before flu and pneumococcal vaccine consent: Two residents did not have record evidence that they or their RP received education or a CDC VIS before vaccine consent was obtained. One resident had intact cognition, while the other had severely impaired cognition and required assistance with ADLs. The IPN stated facility protocol required providing and documenting the VIS before consent for influenza and pneumococcal vaccines.
Missing COVID-19 Vaccine Education and VIS Documentation: The facility failed to document that two residents were given COVID-19 vaccine education or a CDC VIS before consent decisions were made. One resident had intact cognition and diagnoses including COPD and spinal fusion, while the other had severely impaired cognition and diagnoses including acute/chronic respiratory failure, COPD, and depression. The IPN confirmed the facility’s protocol was to provide VIS forms and document the education or consent in the chart, but no such documentation was found.
Incomplete Advance Directive Documentation for a Resident with Impaired Decision-Making: The facility failed to document that advance directives were discussed and written information was provided to a resident with severely impaired cognitive skills and dependence for multiple ADLs. The chart lacked a completed advance directive acknowledgment, social services notes did not show whether an AD was in place or whether information was given to the RP, and a prior acknowledgment form was incomplete and not updated after readmission.
A resident who used a manual wheelchair was observed sitting in a chair with a missing right armrest pad that exposed the metal frame and a left armrest pad with peeling, cracked leather. The resident said the exposed metal was hard and uncomfortable and that the damaged covering scratched the left arm. An LVN, ADON, and MTD all stated the wheelchair should have been in good condition and have armrests for support and comfort.
Failure to Monitor for Hypo/Hyperglycemia Signs After Insulin Use A resident with DM was receiving insulin aspart before meals and at bedtime, and the care plan identified risk for hypo- and hyperglycemia with specific signs and symptoms to monitor and document. However, the MAR and NPN showed no documentation that staff assessed the resident for these signs after insulin administration, and the ADON confirmed there was no monitoring recorded despite the resident’s reported blurred vision when blood sugar is high.
A resident with cataracts, eye pain, and blurred vision missed a scheduled pre-op ophthalmology appt for cataract surgery evaluation. The chart did not show the reason for the missed appt, any refusal, or MD notification, and an RN confirmed there was no progress note or documentation of what occurred after the appt was missed.
Failure to implement bladder training for a resident with urinary incontinence. A resident with severely impaired cognition and dependence for toileting had a fall after trying to go to the bathroom, and the care plan called for bladder training followed by scheduled toileting. However, staff reported the program was not carried out, one LVN believed bladder training applied only to residents with catheters, and chart review found no documentation of hourly or scheduled toileting assistance or bladder training.
Nebulizer Mask Not Stored Properly: A resident with COPD and cognitive impairment had an order for PRN albuterol nebulizer treatments, and staff observed the nebulizer mask stored in the resident’s bedside drawer attached to tubing but not placed in a clean plastic bag. An LVN and the DON stated the mask should have been stored in a labeled clean plastic bag to prevent contamination, and the facility P&P required nebulizer equipment to be stored clean, dry, and labeled for resident-specific use.
A resident with chronic respiratory failure, ORIF of the left hip, gout, and OA had an order for Cyclobenzaprine for left thigh spasm/pain, but doses were not administered when the med was unavailable and marked HO on the MAR. Staff said the med was waiting on pharmacy delivery, there was no order to hold it, and there was no documentation of alternative pain interventions or a care plan for the resident’s ongoing 7/10 left thigh pain.
Failure to monitor fluid intake for a resident on dialysis fluid restriction: A resident with ESRD and dependence on renal dialysis had a physician-ordered 1500 cc/day fluid restriction and a care plan for I&O monitoring, but a full pitcher of water was placed at bedside and intake was not measured or documented in the MAR/task record. CNA staff stated they did not check how much the resident drank, and the MDS Coordinator, ADON, and DON confirmed the lack of shift-by-shift fluid intake documentation.
Missing Medication Administration Competency for Newly Hired LVN: The facility failed to ensure an LVN had the required medication administration competency completed upon hire. The LVN's competency folder did not contain the new hire pre-checklist skills form, and the ADON stated that if there was no record, the competency was not done. The ADON also stated the LVN missed the pharmacy consultant medication pass evaluation, and basic med administration was not included on the orientation competency checklist even though the facility assessment identified med administration competencies as necessary.
A resident with spinal stenosis, PVD, and DM did not receive prompt dental follow-up despite reporting broken teeth buried in the gums, food trapping, and intermittent pain. The resident said the dentist came once and took pictures but did not return, and the chart lacked nursing and social services documentation of dental visits; the dental note only referenced X-rays and did not include the resident's tooth concerns.
Inaccurate TAR Documentation for Pressure-Relief Mattress: A resident with DM, bipolar disorder, depression, impaired cognition, and multiple pressure ulcers was observed in bed without the ordered low air loss mattress, while the pump was powered off at the foot of the bed. An LVN stated the resident had a regular mattress, and a TN confirmed the TAR incorrectly documented that the low air loss mattress had been provided even though it had not been, contrary to the facility’s documentation policy.
A resident with a right hip chronic ulcer was given Bactrim DS for delayed wound healing even though the surveillance review showed only 1 of 4 required criteria for cellulitis, soft tissue, or wound infection was met. The IPN confirmed no wound culture was documented and the MD was not notified that criteria were not met, while the MAR showed the resident completed a 10-day course of the antibiotic. The facility’s antibiotic stewardship policy required review of clinical documentation and use of McGeer criteria to determine whether antibiotics were clinically indicated.
A resident with severe cognitive impairment, dependence for multiple ADLs, and a history of fractures had two falls in the facility and was later assessed as high risk for falls. Staff did not have the resident’s red star fall risk identifier posted, and the assigned LVN and CNA were not aware of the resident’s fall history or the resident-specific frequent visual checks listed in the care plan. The care plan also called for education of the resident, family, and caregiver regarding the cause of falls, but staff interviews showed the fall prevention measures were not consistently known or implemented.
Resident rooms failed to meet the required square footage per resident in multiple-occupancy rooms. Surveyors observed 10 of 36 rooms below the 80 sq. ft. standard, and the facility’s accommodation analysis documented several 2-bed and 4-bed rooms measuring less than the minimum per-resident space. A resident interviewed stated he was comfortable in his room, had space for his belongings and wheelchair, and staff could move around his bed during care.
The facility failed to maintain clear exit doors and hallways, with multiple obstructions such as wheelchairs, linen bins, and carts noted during observations. Staff interviews confirmed awareness of the need for clear egress paths, but the policy was not effectively implemented, posing risks to emergency evacuation and safety.
A resident with dementia and high fall risk sustained a fracture from an unwitnessed fall. The facility failed to report this unusual occurrence to the State Agency within 24 hours as required by their policy. The incident was only discovered upon the resident's readmission from a hospital.
A resident with dementia and muscle weakness, assessed as high risk for falls, experienced a deficiency in care when the facility failed to implement a care plan intervention of placing a floor mat at the bedside after an unwitnessed fall. The mat was found under the bed, contrary to the care plan, as confirmed by an RN.
A staff member failed to follow hand hygiene protocols while assisting a resident with chronic kidney disease, UTI, and diabetes. The staff member fed the resident with bare hands, touched another resident, and returned to assist the first resident without performing hand hygiene, contrary to the facility's policy.
A resident with dementia and a high risk for falls was left unattended in a wheelchair by the Director of Activities, resulting in a fall and rib fractures. The care plan lacked specific interventions for wheelchair safety, and staff interviews confirmed the need for constant supervision. The facility's fall risk policy was not adequately followed, leading to this deficiency.
A resident reported alleged rough handling by staff, but the facility failed to implement the care plan, including 72-hour monitoring for psychosocial wellbeing. Despite having a care plan addressing emotional distress and safety, there was no documentation or monitoring by licensed nurses, as confirmed by staff interviews. This oversight contravened facility policies requiring ongoing assessments and care plan revisions.
A resident on enhanced barrier precautions (EBP) did not receive care with proper PPE use, as staff failed to wear gowns during high-contact activities like diaper changes and medication administration via gastrostomy tube. Despite EBP signage, there was no PPE cart available, and staff were unaware of the requirements. The Director of Nursing confirmed the resident's care plan lacked EBP, and the facility's policy was not followed.
A resident with a history of chronic conditions developed a worsening pressure ulcer due to the facility's failure to assess, document, and communicate changes in the resident's skin and wound condition. The facility did not use the SBAR tool to document changes on multiple occasions, leading to the ulcer progressing to stage 4. The resident was later hospitalized with an infected ulcer and required surgical intervention.
A facility failed to ensure accurate documentation of a resident's skin condition and wound care. The resident, with chronic kidney disease and coordination issues, was at risk for pressure ulcers. Despite ongoing treatments for MASD and a stage 2 pressure ulcer, nurses' notes and weekly summaries did not consistently reflect these conditions. Interviews confirmed the documentation inconsistencies, and facility policies on pressure ulcer assessment and documentation were not followed.
A facility failed to maintain the dignity and privacy of several residents. A resident was fed by a CNA standing over them, contrary to policy. Two residents were changed with curtains and doors open, exposing them to passersby. Another resident was repeatedly called "Mama" against her preference, and a resident was fed without a chair for the CNA to sit, compromising a dignified dining experience.
The facility failed to provide communal dining, impacting residents' social interactions and emotional well-being. Since 2020, residents have been eating in their rooms, leading to feelings of loneliness and dissatisfaction. Despite residents expressing their desire for communal dining, the facility has not resumed this practice, which is essential for a homelike environment and resident dignity.
The facility failed to provide communication boards in the appropriate language for three residents, hindering their ability to communicate with staff. One resident with severe cognitive impairment had a board in a non-English language, while another resident's board was only recently placed in their room. A third resident, who does not speak English, reported that staff did not use a communication board, relying instead on his sister for communication. The facility's policies on communication needs were not effectively implemented.
Two residents in an LTC facility were not provided with activities based on their preferences and needs, leading to a deficiency. One resident, with intact cognitive skills, was not offered his preferred activity of listening to the radio, while another resident expressed dissatisfaction with the limited activities available, such as Bingo and exercise videos. The facility's policy on activity programs, which requires a variety of activities to meet individual needs, was not followed.
The facility failed to ensure appropriate use and monitoring of psychotropic medications for four residents. One resident was prescribed two anxiety medications without specific behavior monitoring, while another received an antipsychotic without justified need. A third resident's antidepressant use lacked behavior monitoring, and a fourth resident did not receive a recommended dose reduction for an antipsychotic. Staff interviews and record reviews highlighted inadequate documentation and communication regarding medication effectiveness and necessity.
A LTC facility experienced a 16% medication error rate during a med pass, involving two residents. Errors included improper insulin administration by an LVN and missed and delayed doses by an IPN. The residents had significant medical histories, requiring precise medication management, which was not adhered to, potentially impacting their health.
The facility failed to properly label and store medications, leaving them unattended and improperly stored, risking resident safety. Unopened insulin pens were not refrigerated, an opened Ipratropium-Albuterol solution was not labeled with an open date, and expired Mometasone spray was not removed. Additionally, opened medications in the storage room lacked proper labeling, leading to potential medication errors.
The facility failed to follow proper food handling practices, including not discarding expired food, improper labeling, and unclean kitchen equipment. Additionally, dietary staff did not consistently perform hand hygiene or change gloves during food preparation, increasing the risk of food contamination.
The facility staff failed to follow infection control protocols, including improper handling of soiled linens, inadequate disinfection of a glucometer, lack of proper signage for isolation precautions, and failure to perform hand hygiene during medication administration. These deficiencies involved residents with various medical conditions, posing a risk of infection spread.
The facility failed to ensure a safe environment by allowing a wheelchair to block an emergency exit and cluttering hallways with equipment, posing risks to a resident with mobility issues. Staff interviews confirmed the hazards, and facility policies emphasized the need for clear exits and safe environments.
The facility failed to obtain informed consent for two residents. One resident was admitted without completing the necessary Admission Consent Forms, which include consent for treatment and disclosure of medical records. Another resident was prescribed Seroquel, an antipsychotic medication, without obtaining informed consent, despite the resident's severe cognitive impairment. The facility's policies require informed consent for treatment and medication, which was not adhered to in these cases.
A facility failed to follow its policy on self-administration of medications for a resident by not obtaining a physician's order and not conducting an assessment to determine the resident's capability. The resident had moderately impaired cognitive skills and was found with unprescribed medications at her bedside, which were not reported to the physician as required by the facility's policy.
A resident with multiple diagnoses, including dementia and total dependency on staff, was unable to reach their call light, which was found under the draw sheet. This was against the facility's policy and care plan, which required the call light to be within reach to ensure the resident could call for assistance when needed.
Failure to Timely Report Alleged Verbal Abuse
Penalty
Summary
The facility failed to report an alleged verbal abuse to the State Agency within 2 hours after the resident reported it to staff. Resident 1 was admitted and later readmitted with diagnoses including Parkinson’s disease and spinal stenosis. The resident’s MDS dated 2/24/2026 indicated he was independent in cognitive skills for daily decision making but dependent for multiple activities of daily living, including eating, oral hygiene, toileting hygiene, bathing, dressing, footwear, and personal hygiene. On 5/7/2026, Resident 1 stated that the DSD called him “Pinche Chimoso.” RNA 1 stated the resident told him about the allegation at 2:50 PM, but he did not report it because he believed the resident would report it. CNA 3 stated she heard the DSD say “Pinche Chimoso” while walking by with Resident 1 at 2:15 PM, but she did not report it until the next day. The Administrator stated the incident was reported on 5/8/2026. The facility’s policy required suspected or known abuse, including verbal abuse, to be reported immediately and within 2 hours.
Failure to Implement Scabies Infection Control Measures for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to follow its own infection prevention and control policy for suspected and confirmed scabies cases involving two residents. For Resident 1, who had moderate cognitive impairment and required assistance with most ADLs, a dermatology report dated 4/8/2026 documented a diagnosis of suspected scabies affecting the neck, trunk, back, and extremities. Nursing notes indicated that Resident 1 was transported to and from the dermatology appointment via the facility van with a CNA, and returned with the suspected scabies diagnosis. Despite this, the Infection Prevention Nurse (IPN) acknowledged that she did not perform contact tracing, surveillance monitoring, or staff management measures as required by the facility’s Scabies Prevention and Control policy for this suspected case. For Resident 3, who had diagnoses including severe protein calorie malnutrition and adult failure to thrive and was dependent or required substantial assistance with most ADLs, a skin biopsy of the left upper chest dated 2/27/2026 with a report date of 3/6/2026 confirmed scabies by identifying Sarcoptes scabiei body parts in the stratum corneum. Nursing progress notes on 3/6/2026 documented that staff were informed by the dermatologist’s office that the biopsy result was scabies. The IPN later stated that the licensed staff who received the result did not notify her of the positive scabies diagnosis on 3/6/2026, and that if she had been informed at that time, she could have initiated contact tracing and surveillance. The IPN also stated that Resident 3 did not receive ordered Permethrin 5% cream treatment from 3/6/2026 through 3/15/2026, and physician orders reviewed for 3/6/2026 to 3/16/2026 did not include contact isolation until an order dated 3/17/2026, meaning Resident 3 was not on contact precautions from 3/6/2026 to 3/16/2026. The facility’s Scabies Prevention and Control policy, dated 3/2026, required contact tracing of roommates, caregivers, and staff with direct contact within six weeks of a suspected or confirmed case, screening of staff for symptoms, and surveillance monitoring for six weeks after the last case with maintenance of line lists. The IPN and a registered nurse both confirmed that these policy requirements were not implemented for Residents 1 and 3. The IPN stated she did not perform contact tracing, surveillance, or staff management for either resident and was unable to provide documentation of surveillance, line lists, staff symptom screening, or contact tracing. CNAs who provided direct care to Resident 3 reported they were not informed of the resident’s scabies diagnosis and were not instructed to monitor themselves for symptoms. The surveyors also referenced CDC guidance on public health strategies for scabies outbreaks in institutional settings, which emphasizes early detection, treatment, isolation, surveillance, and systematic tracking of cases, contrasting with the facility’s documented inaction. The deficiency further included the facility’s failure to conduct required surveillance monitoring and screening of all residents and staff with direct contact with Residents 1 and 3 for new signs of scabies infestation within six weeks after the last suspected case on 4/8/2026. The IPN stated that six weeks of surveillance monitoring after the last case should have been done and that a line list should have been maintained to track whether cases were decreasing and whether additional residents or staff were affected, but no such documentation was available. Additionally, the facility did not perform contact tracing on caregivers and staff with direct contact with Resident 1 for six weeks before 4/8/2026 and with Resident 3 for six weeks before 3/6/2026, as required by the policy. These combined failures to promptly identify, isolate, treat, and systematically monitor suspected and confirmed scabies cases constituted the infection prevention and control deficiency cited by the surveyors.
Psychotropic Medication Behavior Monitoring Not Documented
Penalty
Summary
The facility failed to ensure that psychotropic medications were monitored and documented according to the ordered behavior targets for three residents. The deficiency involved Resident 7, Resident 2, and Resident 68, each of whom had orders tied to specific behaviors that were supposed to be tracked on the MAR every shift. Surveyors reviewed records, care plans, MARs, and physician orders, and interviewed nursing and administrative staff about the missing documentation and the specificity of the behavior-monitoring orders. For Resident 7, the record showed diagnoses including pneumonia, depression, and dementia, with severely impaired cognitive skills and dependence for several activities of daily living. The resident had an order for olanzapine 2.5 mg at bedtime for psychosis manifested by striking out and grabbing staff, with instructions to monitor and tally behavior episodes on the MAR every shift. The care plan also identified periods of striking out or grabbing staff. During interviews, CNA staff reported aggressive behaviors such as scratching, spitting, and hitting, and stated they informed nurses when these behaviors occurred. The LVN stated the resident had aggressive behavior at least weekly and admitted not documenting the behavior in the MAR because he forgot. The ADON reviewed the MARs and confirmed that no aggressive behaviors were documented despite the order to monitor them. For Resident 2, the record showed diagnoses including type 2 diabetes, bipolar disorder, and depression, with severely impaired cognitive skills and need for assistance with personal care. The resident had an order for divalproex sodium 250 mg twice daily for mood stabilizer/bipolar disorder manifested by changes in mood from happy to anger, with instructions to monitor and tally episodes on the MAR every shift. The MAR was reviewed and showed only yes-or-no documentation rather than tally hashmarks. The ADON stated the MAR should have been tallied to show the number of episodes, and an LVN stated nursing documentation should be tallied to accurately reflect the resident’s mood symptoms. Facility policies reviewed stated that psychotropic medication use requires adequate monitoring and documentation of behavior, mood, function, and effectiveness. For Resident 68, the record showed diagnoses including Alzheimer’s disease, psychosis, and dementia, with severely impaired cognitive skills and dependence for multiple ADLs. The resident had orders for quetiapine fumarate 25 mg at bedtime for psychosis manifested by aggressive behavior and for Depakote sprinkles for mood disorder manifested by aggressive towards others by hitting, both with instructions to monitor and tally behavior episodes on the MAR every shift. The MDS coordinator stated the quetiapine order was incomplete because the behavior was not specific enough, and also stated the behavior-monitoring orders for quetiapine and Depakote were too similar and should identify different, specific behaviors for each medication. The care plan intervention was described as not specific, incomplete, and not person centered, and the facility policy on antipsychotic medication use was noted to address side effects and adverse consequences but not the specific behavior monitoring tied to the medication orders.
PASRR Screening Not Completed or Accurate for Two Residents
Penalty
Summary
The facility failed to ensure that Level 1 PASRR screening was completed and accurate for two sampled residents with mental health and cognitive diagnoses. For one resident, the admission record showed a readmission with diagnoses including major depressive disorder and unspecified intellectual disabilities, but the medical record did not show a PASRR Level 1 screening completed for the readmission. The resident’s MDS dated 1/13/2026 showed intact cognitive skills for daily decision making, while also showing dependence for multiple activities of daily living and independence with eating. For the second resident, the admission record showed diagnoses including Alzheimer’s disease, psychosis, and dementia. The resident’s MDS showed severely impaired cognitive skills for daily decision making and dependence for multiple ADLs. A PASRR dated 10/3/2025 was reviewed and indicated Level 1 was negative, stating the resident was not diagnosed with serious mental illness and was not taking psychotropic medications. However, the resident’s order summary dated 2/11/2026 showed quetiapine 25 mg by mouth at bedtime for psychosis manifested by aggressive behavior. During interview and record review, the DON stated the PASRR was incorrectly filled out because it should have indicated the diagnosis of psychosis and the use of quetiapine. The DON also stated that if the PASRR was incorrectly done, the facility would not be able to provide the right level of care that the resident possibly needed.
Failure to Provide Nail Care and Requested Showers
Penalty
Summary
Resident 38 was admitted and later readmitted to the facility with diagnoses including dementia, muscle disorders, and lack of coordination. The MDS dated 1/13/2026 indicated the resident had intact cognitive skills for daily decision making but was dependent for oral care, toileting, personal hygiene, showering, upper and lower body dressing, and putting on and taking off footwear. During a concurrent observation and interview on 2/9/2026 at 10:42 AM, Resident 38 was seen sitting in a wheelchair in the hallway with multiple scattered reddened scratch marks on the right forearm and long, untrimmed, jagged nails on both hands. The resident stated he scratched his arm with his nails. During interviews, the ADON stated Resident 38's nails should be trimmed by CNAs or charge nurses to prevent injuries from scratching. CNA 3 stated CNAs and RNAs are assigned to trim residents' nails and explained that long nails can get dirty, break skin, and potentially cause infection; CNA 3 also stated Resident 38 could bleed if he scratched his skin too much. RN 1 stated residents with long, jagged nails could break their skin, injure themselves, and potentially bleed, especially if they take blood thinners. CNA 4 stated the CNA assigned to the resident should cut long nails to prevent residents from injuring themselves. The facility's policy stated residents shall receive appropriate fingernail and toenail care as part of routine personal hygiene. Resident 3 was admitted and re-admitted to the facility with diagnoses including lumbar spinal stenosis, peripheral vascular disease, and diabetes mellitus. The MDS indicated the resident had intact cognitive skills for daily decision making and required substantial to maximal assistance with showering/bathing and partial to moderate assistance with several other ADLs. During an observation and interview on 2/9/2026 at 8:24 AM, Resident 3 stated he had been requesting a shower for two weeks on both morning and evening shifts, but staff told him they could not give showers because they were only allowed at certain times. He stated he was receiving a bed bath every two days, but this did not work for his hair and made him feel uncomfortable; he said a shower made him feel fresher and better. The ADON later stated there was no care plan for Resident 3's ADLs, no interventions addressing shower or bed bath needs, and no documentation on multiple dates showing that a shower or bed bath was provided. The DSD stated that if Resident 3 refused a shower, staff should have documented the refusal, informed the charge nurse, and charted it in the nurses' progress notes, and also stated the resident had the right to take a shower whenever he requested one.
Pressure Ulcer Care and Support Surfaces Not Implemented as Ordered
Penalty
Summary
The facility failed to ensure that pressure ulcer treatments and pressure-relieving devices were provided as ordered for three residents reviewed for pressure injuries. Resident 2 had diagnoses including type 2 DM, bipolar disorder, and depression, and was documented with non-blanchable redness to both heels and a stage 3 sacrococcyx pressure ulcer. The resident’s orders and care plans included use of a low air loss mattress (LALM) and heel/elbow protectors, but during observation the resident’s bed had a regular mattress with a powered-off low air loss pump at the foot of the bed, and the resident was observed without heel or elbow protectors. Staff interviews and record review showed no documentation explaining why the LALM or protectors were not in use as ordered. Resident 3 had diagnoses including spinal stenosis, peripheral vascular disease, and DM, and was assessed as high risk for pressure ulcers. The resident was observed lying on a LALM that was set at 270 lbs, while the resident’s recorded weight was 199 lbs. The ADON stated the mattress should have been set based on the resident’s weight and that the setting was too high. The physician’s order called for LALM skin management every shift, and the DON stated the skin management care plan did not include the use of the LALM even though it should have. Staff stated the mattress setting should be checked every shift. Resident 42 had diagnoses including epilepsy, major depressive disorder, and a mental disorder, and was assessed as dependent for many activities of daily living and at risk for pressure injuries. The resident’s order indicated use of a low air loss mattress for wound management, and the resident weighed 140 lbs. During observation, the LALM was set at 240 lbs. Staff interviews confirmed that the mattress setting should be based on the resident’s weight and that licensed nurses were responsible for checking the setting each shift. The ADON stated the setting was wrong and should have been adjusted according to the resident’s weight.
Medication Administration Errors and Identification Failures
Penalty
Summary
Pharmaceutical services were not provided in accordance with prescriber orders and the facility’s medication administration policy for four sampled residents. The report documents multiple medication administration events observed by surveyors, along with record review and staff interviews, showing failures in how medications were prepared, timed, identified, and administered. For one resident with COPD, the inhaled Combivent Respimat was administered incorrectly. During observation, an LVN placed the inhaler in the resident’s mouth, pressed the dose-release button, and instructed the resident to take five breaths while the inhaler remained in place. The resident was not instructed to hold his breath after inhaling, which did not match the package insert instructions. The resident’s record showed diagnoses including COPD, and staff acknowledged the medication was not given correctly. For another resident with multiple chronic conditions including DM, dementia, hypertension, mood disorder, and wound-related supplementation needs, 16 medications scheduled for 9 AM were administered after 10 AM. The medications included divalproex delayed release, gabapentin, aspirin EC, Eliquis, acetaminophen, hydralazine, losartan, metformin, Pacerone, sertraline, Vitamin C, Zetia, zinc sulfate, metoprolol succinate ER, multivitamin-minerals, and amlodipine. The same resident’s divalproex, aspirin EC, and metoprolol succinate ER were crushed even though the orders indicated do not crush and the medications were delayed-release or extended-release formulations. The LVN stated the medications were late because of the number of scheduled medications and other tasks, and stated the delayed-release medications were crushed without notifying the RN supervisor, pharmacy, or physician. The report also documents that an LVN administered medications to another resident without using two identifiers, relying only on the MAR and not checking the resident’s name, DOB, MR number, or armband. In a separate event, an LVN preparing medications for a resident with severe cognitive impairment selected Rena Vite instead of Vitamin C and placed the wrong medication into the cup labeled for Vitamin C after already preparing Rena Vite for the same resident. The LVN acknowledged the wrong medication had been prepared and that the medication pack had not been checked carefully enough.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to keep its medication error rate below 5 percent. Surveyors identified 18 medication errors out of 36 observed opportunities, resulting in a 50% medication error rate for four sampled residents during medication administration observations. For one resident with COPD, hypertension, and metabolic encephalopathy, an LVN administered Combivent Respimat incorrectly. The resident’s order was for one inhalation twice daily, and the package insert instructed the user to breathe out, place the mouthpiece correctly, inhale slowly while pressing the dose-release button, and then hold the breath for 10 seconds or as long as comfortable. During observation, the LVN placed the inhaler in the resident’s mouth, pressed the dose-release button, instructed the resident to take a deep breath, counted to five while the resident inhaled and exhaled five times, and did not instruct the resident to hold his breath after inhaling. The LVN stated the medication was not given correctly, and the ADON stated the resident should have been instructed to hold his breath after inhalation. For another resident with dementia, encephalopathy, and diabetes, an LVN administered 16 scheduled 9 AM medications after 10 AM, including hydralazine, metformin, multivitamin-minerals, Eliquis, zinc sulfate, losartan, sertraline, metoprolol succinate, gabapentin, Zetia, vitamin C, acetaminophen, amlodipine, aspirin EC, divalproex sodium, and Pacerone. The LVN stated the medications were late because of the number of medications scheduled, the need to replace the blood pressure cuff, and checking blood sugar before the medication pass. The same resident also received three medications that were ordered not to be crushed: divalproex sodium delayed release, aspirin EC delayed release, and metoprolol extended release. The LVN stated the medications were crushed and that she did not inform the RNS, pharmacy, or physician. For a third resident with anemia, adult failure to thrive, and major depressive disorder, an LVN prepared Rena Vite instead of Vitamin C during medication pass. The LVN stated she had placed the wrong medication in the cup labeled Vitamin C and should have checked the bubble pack more than once to ensure the correct medication was prepared.
Medication Administration Errors Involving Inhaler Technique and Crushing of Extended-Release Medications
Penalty
Summary
Resident 38 was admitted and readmitted with diagnoses including metabolic encephalopathy, COPD, and essential hypertension. The resident’s MDS indicated intact memory and cognitive skills for daily decision making, with dependence for several activities of daily living. A physician order dated 8/9/2025 prescribed Combivent Respimat inhalation aerosol, 1 inhalation twice daily for COPD prevention, and the MAR showed the medication scheduled for administration at 5 PM. During a medication pass observation, LVN 4 administered Resident 38’s Combivent Respimat incorrectly. LVN 4 placed the inhaler in the resident’s mouth, pressed the dose-release button, and instructed the resident to take a deep breath while counting to five as the resident inhaled and exhaled five times. LVN 4 did not instruct the resident to hold his breath after inhaling the medication. In interview, LVN 4 stated the resident did not receive the Combivent correctly. The ADON stated the resident should have been instructed to hold his breath for at least 5 seconds after inhaling and stated the medication was not administered correctly. Resident 2 was admitted with diagnoses including encephalopathy, DM, and dementia, and the MDS indicated severely impaired cognitive skills for daily decision making and dependence for multiple transfers and self-care tasks. The order summary listed divalproex sodium delayed-release 250 mg twice daily, aspirin 81 mg delayed-release daily, and metoprolol tartrate 50 mg extended-release every 12 hours, each marked do not crush. LVN 3 stated there were three medications for the resident that indicated do not crush, did not know they could not be crushed, and crushed the medications without informing the RNS, pharmacy, or physician. LVN 3 acknowledged that crushing delayed-release medications affects the slow-release mechanism and stated the physician’s orders were not followed.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to label and store medications and biologicals in accordance with its policies and accepted medication storage practices. During a concurrent medication inspection of Medication Cart 1, an unopened Humalog insulin pen was found in the top left drawer instead of being refrigerated after delivery. The insulin was in a clear plastic bag with a blue sticker stating, "Refrigerate Until Opened," and the LVN stated it was new and unused and should have been refrigerated after delivery. The ADON later stated unopened insulin should always be stored in the refrigerator and that the licensed staff receiving it were responsible for placing it there. During the same inspection, multiple opened inhalation medication foil packets were found in the medication cart. One Ipratropium-Albuterol solution packet had an opened date of 2/1/2026 and another packet was not dated, while one Albuterol Sulfate solution packet had an opened date of 1/27/2026. The LVN stated the Ipratropium-Albuterol packet expired 7 days after opening and should have been discarded on 2/8/2026, and the Albuterol Sulfate packet expired 2 weeks after opening and should have been discarded on 2/9/2026. The LVN also stated expired medications should not remain in the medication cart and that it was the responsibility of licensed nurses assigned to the cart to check that medications were not expired and were labeled with opened dates. In the medication storage room, the ADON observed one opened 3 mL syringe with a capped needle in a box of sealed syringes, 33 safety needles with an expiration date of 12/20/2025, one bag of alcohol prepping pads with an expiration date of 10/2023, and two 5-gallon size bags of expired needles and syringes with expiration dates of 7/31/2025 and 6/28/2025. The ADON stated the opened syringe was not safe to have in the box of sealed syringes, the expired needles might be dull or cause possible reactions, the alcohol pads would no longer be effective, and expired supplies could possibly injure residents or cause infection because staff would not know if they were still good to use. The facility's policies stated that medications requiring refrigeration are stored in a secured refrigerator, opened multi-dose containers are dated when opened, and outdated or deteriorated medications are returned or destroyed through the dispensing pharmacy.
Kitchen Food Handling and Storage Deficiencies
Penalty
Summary
Food service personnel were observed failing to follow the facility's hair restraint policy in the kitchen. On 2/9/2026, a cook was seen wearing a hat with the back of his hair exposed, and the Dietary Service Supervisor was observed without a beard net, exposing facial hair. On 2/11/2026, a Dietary Service Aide was again observed without a hair net and wearing only a hat while preparing rice soup for residents. The Dietary Service Supervisor stated that hair and beard nets should be used to keep hair out of food and prevent contamination. The facility's Hair Net policy required all food service personnel, including cooks, dietary aides, and dishwashers, to wear effective hair restraints when preparing, handling, or serving non-prepackaged food or clean utensils. Multiple food items were observed stored without proper labeling or with expired use-by dates in several refrigerators and freezers. These included a beef patty box without a use-by date, trays of gelatin without preparation or use-by dates, expired pumpkin soup, expired chorizos, cucumbers past their use-by date, uncovered and unlabeled ice cream, unlabeled dinner rolls and French fries, an unknown food item with an old use-by date, unlabeled yogurt, open milk and almond milk without open dates or use-by dates, and pitchers of cranberry juice, thickened water, and thickened hydrolyte water with expired or missing dates. During interview, the cook stated expired food should be discarded, and the Dietary Service Supervisor stated food items should be labeled to track expiration and that residents could get food borne illness if expired items are consumed. The facility's Food Labeling and Storage policy required food removed from original packaging or prepared in-house to be labeled with the common name and date of preparation or opening, with discard dates not to exceed 7 days for perishable ready-to-eat foods. Staff personal food was also found stored in the kitchen refrigerator, including a bag of strawberries belonging to a cook. In addition, during tray line preparation, a Dietary Service Aide was observed preparing multiple cups of water and grabbing each cup around the mouthpiece without gloves while placing plastic covers on the cups. Another staff member stated it was important to wear gloves when filling water cups and to keep everything clean for residents. The facility's Food Handling and Safety policy stated that resident safety is ensured through strict temperature control, sanitation, and adherence to physician-ordered diets.
Infection Control and Laundry Processing Failures
Penalty
Summary
The facility failed to follow infection prevention and control practices during medication administration for a resident with encephalopathy, DM, and dementia who was dependent for multiple activities of daily living and had severely impaired cognitive skills for daily decision making. During one observation, an LVN was administering medications when a tablet fell to the floor. The LVN picked up the medication, discarded it, and then dispensed another medication from the medication cart without changing gloves. The LVN then placed the medication into the resident’s mouth while still wearing the same gloves. In interview, the LVN stated she forgot to change her gloves and perform hand hygiene, and the Infection Preventionist stated the gloves should have been changed and hand hygiene performed before preparing the new medication. During another observation, a different LVN checked the resident’s blood sugar and placed the dirty lancet into the medication tray. The LVN then used the same tray to store medicine cups without sanitizing the tray. The LVN later picked up a medication cup from the floor with bare hands, discarded it, and began preparing the resident’s medication without performing hand hygiene. In interview, the LVN stated the tray was not sanitized after the blood sugar check and acknowledged the tray should have been cleaned because it was dirty. The Infection Preventionist stated the tray should have been disinfected before placing medication cups in it and that hand hygiene should have been performed after touching anything on the floor and before preparing medication. The facility also failed to ensure linens were washed and dried at the temperatures and time lengths required by its policies. In the laundry room, staff used washer cycles for colored and white linens but were unable to state the water temperatures for those cycles, and management was unable to state the set temperatures. The facility’s laundry document listed recommended washer temperatures below the minimum stated in the facility’s Washer and Dryer policy, which required linens to be exposed to water at a minimum of 160 degrees F for at least 24 minutes during the wash cycle. During drying, sheets, pillowcases, and blankets were removed from dryers after running at temperatures and times that did not match the facility’s drying procedures. Management stated the linens did not run at the appropriate temperatures for the full indicated time frame and that the drying times and temperature ranges were important to prevent mold and bacteria accumulation and to ensure linens were dried and disinfected properly.
Failure to Document VIS Education Before Flu and Pneumococcal Vaccine Consent
Penalty
Summary
The facility failed to ensure that two sampled residents were provided education or a Vaccine Information Statement (VIS) for influenza and pneumococcal vaccinations before consent was obtained. For one resident, the record showed intact cognitive skills for daily decision making, but the medical chart from the review period did not document that the resident was given education or a VIS for the influenza vaccine. The resident’s electronic record and Vaccine Consent Form also did not show that education or a VIS was provided before consent for the flu and pneumococcal vaccines was obtained. For the second resident, the record showed severely impaired cognitive skills for daily decision making, and the resident required varying levels of assistance with eating, oral hygiene, toileting hygiene, bathing, and personal hygiene. The medical chart did not document that the resident’s responsible party was provided education or a VIS for the influenza and pneumococcal vaccines. The resident’s electronic record and undated Vaccine Consent Form also did not show that a VIS was provided for either vaccine. During interview, the Infection Preventionist Nurse stated the facility protocol was to provide residents and/or responsible parties with VIS forms to explain the risks and benefits before they decide whether to consent to or decline influenza and pneumococcal vaccinations, and that this should be documented in the medical record or progress notes. The Infection Preventionist Nurse further stated there was no documentation in either resident’s record or consent form showing that education or VIS forms were provided, and that if it had been provided, it should have been documented.
Missing COVID-19 Vaccine Education and VIS Documentation
Penalty
Summary
The facility failed to ensure two sampled residents, Resident 72 and Resident 4, were provided education or a Vaccine Information Statement (VIS) for the COVID-19 vaccine in accordance with facility policy and procedure. The report states the facility’s protocol was to provide residents and/or their responsible parties with VIS forms to explain the risks and benefits of the vaccine, then document the education and the resident’s decision in the medical record or a progress note. Resident 72 was admitted with diagnoses including fusion of the spine, COPD, and difficulty walking, and the MDS indicated intact cognitive skills for daily decision making. Review of the resident’s medical chart from 8/1/2025 to 2/11/2026 and the Vaccine Consent Form dated 10/1/2026 did not show documentation that education or a VIS form for the COVID-19 vaccine was provided. Resident 4 was readmitted with diagnoses including acute and chronic respiratory failure, COPD, and depression, and the MDS indicated severely impaired cognitive skills for daily decision making. Review of Resident 4’s medical chart from 7/4/2025 to the date of survey did not show documentation that education or a VIS form for the COVID-19 vaccine was provided.
Incomplete Advance Directive Documentation for Resident with Impaired Decision-Making
Penalty
Summary
The facility failed to ensure Resident 78’s medical record was updated to show that advance directives were discussed upon admission and that written information was provided to the resident and/or responsible party. Resident 78 was originally admitted and later readmitted to the facility with diagnoses including a wedge compression fracture of the first lumbar vertebra, spinal stenosis, and hepatomegaly. The admission record showed a blank entry for an advance directive. Resident 78’s MDS dated 1/27/2026 indicated severely impaired cognitive skills for daily decision making. The assessment also showed the resident was dependent for toileting, showering/bathing, and dressing, and required partial/moderate assistance with eating, oral hygiene, and personal hygiene. Social Services Assessments dated 1/22/2026 and 2/6/2026 did not indicate whether Resident 78 had an advance directive or whether written information had been provided to the resident or the responsible party. Review of the physical medical chart from 2/4/2026 to 2/10/2026 did not show an advance directive acknowledgment form or documentation that the resident and responsible party were informed and given written material regarding advance directives. During interviews, the Director of Social Services stated the facility’s process was to complete an advance directive acknowledgment form within 72 hours of admission and to inquire about any existing advance directive or provide information to the resident or representative. A later review produced an advance directive acknowledgment dated 1/21/2026, but it did not indicate whether Resident 78 had an advance directive or whether the responsible party wanted more information, and the Director of Social Services stated it was incomplete and should have been completed again upon readmission.
Wheelchair Missing Armrest Pad and Damaged Armrest Covering
Penalty
Summary
The facility failed to provide a safe and comfortable wheelchair for Resident 38. Resident 38 was admitted and later readmitted with diagnoses including difficulty walking and lack of coordination. The MDS dated 1/13/2026 indicated the resident had intact cognitive skills for daily decision making, was dependent for oral care, toileting, personal hygiene, showering, upper and lower body dressing, and putting on and taking off footwear, and used a manual wheelchair for mobility. During a concurrent observation and interview on 2/10/2026, Resident 38 was sitting in a wheelchair that was missing the right armrest pad and exposed the metal frame, and the left armrest pad had peeling and cracked leather covering. The resident stated he could not place his right arm on the exposed metal because it was hard and uncomfortable, and that the cracks and peeling on the left armrest scratched his left arm. An LVN stated cracked and worn-out wheelchairs could cause discomfort and potentially irritate the resident's skin. The ADON stated wheelchairs should be in good condition without tears and peeling to prevent skin injuries and that Resident 38's wheelchair should have armrests for comfort and to prevent the right arm from dangling. The MTD stated the armrest is for arm support and comfort and that the left armrest should have been replaced and the right armrest provided for proper support.
Failure to Monitor for Hypoglycemia and Hyperglycemia After Insulin Administration
Penalty
Summary
The facility failed to monitor signs and symptoms of hypoglycemia and hyperglycemia for one resident who was receiving insulin aspart by sliding scale before meals and at bedtime. The resident’s record showed diagnoses including diabetes mellitus, spinal stenosis, and peripheral vascular disease, and the MDS indicated the resident had intact cognitive skills and received seven insulin injections. During an interview, the resident stated that their eyes became blurry when blood sugar was high and that they did not feel good. The resident’s physician orders included insulin aspart subcutaneously before meals and at bedtime, but the Assistant Director of Nursing stated there was no order to monitor for signs and symptoms of hypoglycemia and hyperglycemia while using insulin. The resident’s care plan, dated 10/8/2025, identified the resident as at risk for hypoglycemia or hyperglycemia and directed staff to monitor, document, and report signs and symptoms of both conditions, including sweating, tremors, tachycardia, pallor, nervousness, confusion, slurred speech, lack of coordination, staggering gait, increased thirst, headaches, trouble concentrating, blurred vision, frequent urination, fatigue, and weight loss. Record review of the MAR and nurses’ progress notes showed the resident received insulin before meals and at bedtime from 2/1/2026 to 2/10/2026, but there was no documentation that staff monitored the resident for signs and symptoms of hypoglycemia or hyperglycemia after insulin administration. The ADON stated the staff should have documented whether the resident exhibited these signs and symptoms and that licensed staff do not check the resident after giving insulin. The facility policies on hypoglycemia, hyperglycemia, and diabetes mellitus management also required assessment, monitoring, documentation, and recording of blood glucose values, symptoms, interventions, resident response, and provider notifications.
Missed Ophthalmology Appointment Not Documented
Penalty
Summary
The facility failed to ensure that Resident 72 maintained a scheduled ophthalmology appointment. Resident 72 was admitted with diagnoses including fusion of the spine, COPD, and difficulty walking. An ophthalmology consultation dated 10/7/2025 documented complaints of cataract, eye pain, and blurrier vision in the left eye, and noted a history of cataracts in both eyes with physician recommendations to refer the resident to a cataract surgeon for surgery evaluation for quality-of-life enhancement. The resident’s MDS dated 11/18/2025 indicated intact cognitive skills for daily decision making and need for assistance with some activities of daily living. Physician orders dated 12/5/2025 included a preoperative ophthalmology appointment scheduled for 1/29/2026 at 8:00 AM. During interview, Resident 72 stated the appointment was missed and was important because they were going to measure her eyes for surgery. Review of the medical chart from 1/14/2026 through 2/12/2026 did not show the reason for the missed appointment, whether the resident refused, or that the physician was notified. RN 2 stated there was no documentation of the missed appointment, no progress note, and no MD notification, and confirmed the appointment was for surgery needed for both eyes.
Failure to Implement Ordered Bladder Training for an Incontinent Resident
Penalty
Summary
The facility failed to ensure that a resident who was incontinent of bladder was provided a bladder retraining and/or toileting program in accordance with the resident care plan and the facility’s Bowel and Bladder Program policy. Resident 78 was admitted and later readmitted with diagnoses including wedge compression fracture of the first lumbar vertebra, spinal stenosis, displaced fracture of the left ulna, and hepatomegaly. The resident’s MDS dated 1/27/2026 indicated severely impaired cognitive skills for daily decision making and dependence with toileting, bathing, dressing, walking, and transfers. After an unwitnessed fall on 1/31/2026 that occurred when the resident attempted to go to the bathroom, the SBAR/COC documented that Resident 78 was incontinent of bowel and bladder. The care plan dated 2/2/2026 stated that a bladder training program was to be initiated for two weeks and then transitioned to scheduled toileting using a bedside commode as tolerated. During interview, the resident stated she wore a diaper and urinated in it instead of going to the restroom. Staff interviews and record review showed the bladder training program was not implemented. An LVN stated she had not carried it out because she believed bladder training was only for residents with urinary catheters, and the resident did not have one. A CNA stated the resident was using incontinent briefs and was not on a bladder training program. The MDS coordinator stated the program had been initiated so CNAs could check hourly and document toileting needs, but review of the resident’s paper and electronic records from 2/5/2026 through 2/12/2026 showed no documentation of hourly or scheduled toileting assistance, initiation of bladder training, or tolerance of the program. The MRD also stated there was no paper documentation of bowel and bladder training, and the ADON confirmed that CNAs were to check residents hourly and offer restroom assistance.
Nebulizer Mask Not Stored in Clean Plastic Bag
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not followed for Resident 55. Resident 55 was admitted with COPD and had moderate cognitive impairment, was dependent for several activities of daily living, and required assistance with dressing, eating, and hygiene. The resident had an order for Albuterol Sulfate inhalation nebulization solution every 4 hours as needed for shortness of breath or wheezing, and the MAR showed the medication was administered on multiple dates in February 2026. During an observation in the resident’s room, the nebulizer mask was attached to oxygen tubing connected to the nebulizer machine and placed inside the bedside drawer, but it was not stored in a plastic bag. LVN 6 stated the nebulizer mask should have been placed inside a labeled clean plastic bag to prevent contamination that could potentially cause respiratory infection. The DON also stated nebulizer masks should be placed in a clean plastic bag to prevent the mask from getting dirty and contaminated, which could prevent respiratory infection. The facility policy stated nebulizer equipment shall be stored clean, dry, and labeled for resident-specific use.
Missed Pain Medication and Lack of Pain Care Planning
Penalty
Summary
The facility failed to manage pain timely and effectively for one resident who had chronic respiratory failure with hypoxia, ORIF of the left hip fracture, gout, and osteoarthritis of the knee, and who was assessed as having severely impaired cognitive skills and dependence in multiple activities of daily living. The resident had a physician’s order dated 12/15/2025 for Cyclobenzaprine HCl 5 mg by mouth twice daily for left thigh spasm/pain, but the medication was not administered on 1/13/2026 at 9:00 AM and on 1/20/2026 at 9:00 AM and 5:00 PM, with the MAR showing HO for those doses. During record review and interviews, staff stated the medication was unavailable and was being awaited from the pharmacy, but there was no order to hold the medication on those dates. The progress notes documented that the medication was not on hand and that pharmacy was contacted, but there was no documentation that the medication was given or that other interventions were provided for the resident’s left thigh pain/spasm. The resident stated he always had pain rated 7/10 in his left thigh and that staff did not inform him that a dose of his pain medication had been missed. The record also showed no care plan had been developed for the resident’s left thigh pain/spasm.
Failure to Monitor Fluid Intake for Resident on Dialysis Fluid Restriction
Penalty
Summary
Resident 92, who was admitted with end stage renal disease and dependence on renal dialysis, had a physician order dated 2/4/2026 for a 1500 cc/day fluid restriction divided into 500 cc at breakfast, lunch, and dinner. The resident’s care plan, initiated on 2/5/2026, also addressed the fluid restriction and included monitoring intake and output. During observation on 2/9/2026, a pitcher that was half full of water, approximately 500 cc, was seen on the resident’s bedside table while the resident was awake and lying in bed. Record review showed the resident had moderate impairment in cognitive skills for daily decision making and required varying levels of assistance with activities of daily living, including setup assistance with eating. CNA 5 stated she had placed a full pitcher of water in the room and did not check or measure how much water the resident drank from it. The MDS Coordinator stated there was no documentation of fluid intake monitoring in the MAR and no amounts of fluid intake documented by CNAs on the task section since 2/5/2026. The ADON stated the resident’s fluid intake should have been documented every shift, and the DON stated the CNA should have asked licensed nursing staff if the resident was allowed fluids and should not keep water at bedside for residents on fluid restrictions.
Missing Medication Administration Competency for Newly Hired LVN
Penalty
Summary
The facility failed to ensure that appropriate competencies and skill sets were completed for one of four sampled employees when LVN 3 did not have a medication administration competency completed upon hire. A review of LVN 3's employment application showed the LVN was hired on 3/10/2025. During interview and record review with the ADON, the employee competency folder for LVN 3 did not contain a new hire competency pre-checklist skills form, and the ADON stated that if there was no record, it meant the competency was not done. The ADON also stated that LVN 3 did not have the opportunity to be evaluated by the facility's pharmacy consultant for medication pass/administration because the LVN was sick on the days scheduled for evaluation. During review of LVN 3's orientation competency checklist, the ADON stated that basic medication administration was not included and should have been included in the skills checklist to verify that LVN 3 had completed the medication administration competency. The facility assessment identified medication administration competencies as part of the staff training and competencies needed to provide care for the resident population.
Delayed Dental Follow-Up and Incomplete Documentation
Penalty
Summary
Provide routine and 24-hour emergency dental care for each resident was not promptly carried out for one resident who was reviewed for dental care. The resident was admitted and later re-admitted to the facility, had diagnoses including spinal stenosis, peripheral vascular disease, and diabetes mellitus, and was assessed as having intact cognitive skills with partial to moderate assistance needed for several activities of daily living. A physician order dated 7/8/2025 allowed dental consultations and treatment as indicated. During an observation and interview, the resident stated the dentist had come in the prior year and took pictures but did not return. The resident reported broken teeth buried in the upper gums, food getting stuck when eating, and that it sometimes hurt. The resident was observed with only 2 to 3 teeth in the upper mouth and 6 to 8 teeth in the lower mouth. Record review and interviews with the DSS showed the dental note from 10/22/2025 documented only tooth 8 X-rays, with no documentation of the resident's tooth concerns. The DSS stated the dentist also came to the facility in 11/2025 and 1/2026 but did not check the resident, and there was no nursing progress note or social services note documenting dental visits for the resident. The facility policy stated oral healthcare and dental services would be provided to each resident and that social services was responsible for making necessary dental appointments.
Inaccurate TAR Documentation for Pressure-Relief Mattress
Penalty
Summary
The facility failed to maintain accurate medical records for one sampled resident, identified in the report as Resident 2, in accordance with its policy and procedure for clinical documentation and charting. Resident 2 was admitted with diagnoses including type 2 diabetes mellitus, bipolar disorder, and depression. The Minimum Data Set dated 1/14/2026 indicated the resident had severely impaired cognitive skills for daily decision making, needed partial/moderate assistance with eating, oral and personal hygiene, and was dependent for toileting, self-showering/bathing, and lower body dressing. The assessment also documented two stage 1 pressure ulcers and one stage 3 pressure ulcer with treatment including a pressure reducing device for bed and pressure ulcer/injury care. During observation on 2/10/2026, Resident 2 was seen lying in bed with a low air loss pump at the foot of the bed that was powered off. Later that day, the bed was observed without a low air loss mattress, and the pump remained powered off at the foot of the bed. An LVN stated the current mattress was a regular mattress, not a low air loss mattress, and said the last time he saw Resident 2 with a low air loss mattress was on 2/7/2026. The Treatment Nurse reviewed the TAR and stated it documented that a low air loss mattress was provided on 2/10/2026, but that documentation was not accurate because Resident 2 did not have a low air loss mattress. The facility policy stated records must be complete, accurate, timely, legible, and authenticated, and that TAR documentation is to be done after completing the treatment and never pre-charted.
Failure to Follow Antibiotic Stewardship Criteria for Wound-Related Antibiotic Use
Penalty
Summary
The facility failed to implement its antibiotic stewardship protocol for one resident who was prescribed Bactrim DS for delayed wound healing even though the documented criteria for cellulitis, soft tissue infection, or wound infection were not met. The resident had been admitted with diagnoses including fusion of the spine, COPD, and difficulty walking, and the MDS indicated intact cognitive skills with assistance needed for some activities of daily living. A weekly skin condition record showed a non-pressure chronic ulcer on the right hip that was progressing positively, with less drainage and weekly debridement being completed and tolerated without complications. During review of the surveillance data collection form, the Infection Preventionist Nurse confirmed that only one of the required four criteria for antibiotic use had been met. The form did not document that a wound culture was collected, and it did not show that the physician was notified that the criteria for antibiotic use were not met. The same form documented Bactrim DS was to start for 10 days for delayed wound healing, and the MAR showed the resident received Bactrim DS twice daily for 10 days. The IPN stated the resident did not qualify for Bactrim DS because only one of four criteria were met and that the doctor should have been notified. The IPN also stated the facility used McGeer criteria during antibiotic surveillance to determine whether antibiotics were necessary and that when criteria are not met, the doctor should be notified. The ADON stated antibiotic stewardship is important to ensure antibiotics are necessary and to prevent unnecessary medication use and antibiotic resistance. The facility policy stated the Infection Preventionist monitors resident antibiotic regimens and that antibiotics should be prescribed only when clinically indicated and monitored as part of the stewardship program.
Failure to Implement Fall Risk Identification and Monitoring
Penalty
Summary
The facility failed to ensure a fall risk identifier, frequent visual checks, and caregiver education were implemented for one sampled resident with a history of falls. The resident was admitted and readmitted with diagnoses including a wedge compression fracture of the first lumbar vertebra, spinal stenosis, a displaced fracture of the left ulna, and hepatomegaly. The resident’s care plan for being at risk for falls, dated 1/22/2026, directed staff to review information on past falls and educate the resident, family, and caregiver as to the cause of falls. The resident’s MDS, dated 1/27/2026, indicated severely impaired cognitive skills for daily decision making and dependence with toileting, showering/bathing, dressing, walking, and transfers, with partial/moderate assistance needed for eating, oral hygiene, and personal hygiene. The medical record from 1/21/2026 through 2/12/2026 showed the resident had two falls while in the facility on 1/31/2026 and 2/4/2026. A fall risk assessment dated 2/4/2026 identified the resident as high risk for falls, and a care plan dated 2/5/2026 included frequent visual checks. During interview and observation on 2/12/2026, the assigned LVN stated she was unable to state the resident-specific intervention of frequent visual checks and was not aware of the resident’s full fall history because it was her first time working with the resident. At the same time, the resident’s room door name plate did not have a red star fall risk identifier, and the LVN stated it should have because the resident had a recent fall and was at high risk for falls. A CNA assigned to the resident stated he was not aware of the resident’s fall history or cause of previous falls and said he provided rounding and visual checks every 2 hours, more often only if the resident had the red star sign. The ADON stated staff should be aware of assigned residents’ fall risks and history and that fall prevention measures should be implemented.
Resident Rooms Did Not Meet Required Square Footage Standards
Penalty
Summary
The facility failed to ensure that 10 of 36 resident rooms met the required square footage standard of 80 sq. ft. per resident in multiple resident rooms. During observation of the facility and resident rooms from 2/9/2026 to 2/12/2026, Rooms 17, 42, 43, 44, 51, 52, 53, 54, 62, and 63 were identified as not meeting the minimum space requirement. The facility's Client Accommodations Analysis form, dated 2/10/2026, documented that several bedrooms measured less than the required 80 sq. ft. per resident, including rooms measured at 153.28 sq. ft. for 2 beds and multiple 4-bed rooms measured between 311.12 sq. ft. and 319.88 sq. ft., resulting in per-resident space below the standard. During an interview on 02/11/2026 at 4:22 PM, Resident 38 stated he was comfortable in his room, had space for his belongings and wheelchair, and that staff were able to move around his bed when providing care. During observation, residents in the affected rooms were seen to have enough space to move freely inside the rooms, and each room had beds and side tables with drawers. The report also states there was adequate room for the operation and use of wheelchairs, walkers, or canes, and that the room variance did not affect the care and services provided to the residents when nursing staff were observed providing care.
Obstructed Exit Doors and Hallways in Facility
Penalty
Summary
The facility failed to ensure that exit doors and hallways were free from obstruction and clutter, which could potentially impede emergency evacuation and increase the risk of accidents. During observations on March 13, 2025, multiple instances were noted where wheelchairs, soiled linen bins, a bed, drawer carts, and a linen cart were blocking exit doors in various hallways. These obstructions were observed at different times in the morning, indicating a consistent issue with maintaining clear egress paths. Interviews with facility staff, including the Interim Director of Nursing (IDON), a Certified Nurse Assistant (CNA), and the Director of Staff Development (DSD), confirmed that staff were aware of the requirement to keep hallways and exit doors clear. The IDON acknowledged that objects should be placed three feet away from exit doors, and only one side of the hallway should be used for storage. The CNA and DSD reiterated the importance of keeping pathways clear for safety and emergency evacuation. The facility's policy, reviewed with the Administrator, also emphasized the need for unobstructed hallways and exits, yet the policy was not being effectively implemented, as evidenced by the observed obstructions.
Failure to Timely Report Resident's Fracture from Fall
Penalty
Summary
The facility failed to report an unusual occurrence to the State Agency within 24 hours as required by their policy. This deficiency involved a resident who sustained a fracture from an unwitnessed fall. The resident, who had a history of dementia, muscle weakness, and was at high risk for falls, was admitted to the facility and later readmitted with a fracture of the left ilium. The facility became aware of the fracture upon the resident's readmission from a general acute care hospital. Despite the facility's policy requiring unusual occurrences to be reported within 24 hours, the incident was not reported in a timely manner. Interviews with the Registered Nurse and Director of Nursing confirmed that the fall and resulting fracture were considered unusual occurrences that should have been reported. The facility's policy, revised in February 2025, mandates that such incidents be reported to appropriate agencies as required by law, but this was not adhered to in this case.
Failure to Implement Fall Prevention Care Plan
Penalty
Summary
The facility failed to implement a care plan for a resident who was at high risk for falls. After an unwitnessed fall on January 26, 2025, which resulted in a fracture, the care plan for the resident included placing a floor mat at the bedside to prevent further injury. However, during an observation on March 3, 2025, the floor mat was found placed under the bed, contrary to the care plan's instructions. This oversight was confirmed by a registered nurse who acknowledged that the facility was not adhering to the resident's plan of care for fall risk. The resident involved had a history of dementia, muscle weakness, and a fracture of the left ilium. The resident was assessed as being at high risk for falls and required substantial assistance with daily activities, including hygiene and transfers. The facility's policy required the interdisciplinary team to develop and implement a comprehensive, person-centered care plan, which was not followed in this instance, leading to the potential for further falls and injury.
Failure to Adhere to Hand Hygiene Protocols
Penalty
Summary
The facility failed to ensure proper hand hygiene practices were followed by staff, as observed during an interaction involving Resident 3. Resident 3, who has chronic kidney disease, a urinary tract infection, and diabetes mellitus, was dependent on staff for various activities, including eating. During an observation, Activities 1 was seen feeding Resident 3 with bare hands and subsequently touching another resident's hair and ears without performing hand hygiene. Activities 1 then touched a third resident's shoulder and wheelchair before returning to assist Resident 3 with meals, again without performing hand hygiene. Interviews with the Activities Director and the Infection Preventionist Nurse confirmed that Activities 1 should have worn gloves and performed hand hygiene before and after assisting each resident to prevent the spread of infection. The facility's policy on hand hygiene, revised in October 2023, clearly states that hand hygiene is required immediately before and after touching a resident and after touching a resident's environment. The failure to adhere to these policies had the potential to spread infection among staff and residents.
Failure to Supervise High-Risk Resident Leads to Fall and Injury
Penalty
Summary
The facility failed to ensure adequate supervision for a resident assessed as high risk for falls, leading to an incident where the resident fell and sustained injuries. The resident, who had a history of dementia, cerebral infarction, lack of coordination, and repeated falls, was left unattended in a wheelchair in the hallway outside the activity room by the Director of Activities (DOA). This lack of supervision resulted in the resident attempting to turn the wheelchair, slipping, and falling, which caused redness on the forehead and later revealed rib fractures. The resident's care plan, dated a day before the incident, identified the resident as at risk for falls but did not include specific interventions to prevent falls while in a wheelchair. The incident occurred when the DOA left the resident unattended to attend to other residents, without informing another staff member to supervise the resident. Interviews with staff, including the DOA, a Certified Nursing Assistant (CNA), and a Registered Nurse (RN), confirmed that the resident required constant monitoring due to the high risk of falls, and the fall could have been prevented with proper supervision. The facility's policy and procedure for fall risk assessment, reviewed with the Director of Nursing (DON), emphasized the need for identifying and documenting resident risk factors for falls and establishing a resident-centered falls prevention plan. However, the lack of specific interventions in the care plan and the failure to supervise the resident adequately led to the fall and subsequent injuries, highlighting a deficiency in the facility's adherence to its fall prevention policies.
Failure to Implement Care Plan for Alleged Rough Handling
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident who reported alleged rough handling by a staff member. The resident, who was moderately impaired in cognitive skills and dependent on assistance for daily activities, reported the incident on January 7, 2025. Despite having a care plan that included interventions for addressing physical pain, emotional distress, and ensuring a safe environment, the facility did not place the resident on the required 72-hour monitoring for psychosocial wellbeing. Licensed nurses were expected to monitor and document the resident's status every eight hours, but this was not done. Interviews with facility staff, including a Licensed Vocational Nurse, MDS nurse, and the Director of Nursing, confirmed the lack of documentation and monitoring following the resident's report of alleged abuse. The facility's policies required ongoing assessments and revisions of care plans based on changes in the resident's condition, but these were not adhered to. The absence of documentation and monitoring meant that the resident's emotional distress and potential changes in psychosocial state were not assessed, which was crucial for determining the need for further treatment.
Infection Control Deficiency Due to Improper PPE Use
Penalty
Summary
The facility failed to adhere to its infection control policy for a resident who was on enhanced barrier precautions (EBP). The resident, who had a gastrostomy tube and was dependent on staff for various activities, was not provided care with the appropriate use of personal protective equipment (PPE). During observations, staff members were seen providing incontinent care and administering medication via the gastrostomy tube without wearing gowns, which is a requirement under EBP. The deficiency was observed when Certified Nurse Assistants (CNAs) and a Licensed Vocational Nurse (LVN) did not wear gowns while performing high-contact activities with the resident. Despite the presence of EBP signage outside the resident's room, there was no PPE cart available to remind or provide staff with the necessary equipment. Interviews with the staff revealed a lack of awareness and adherence to the EBP requirements, as they acknowledged the need for gowns but failed to use them during care. The Director of Nursing confirmed that the resident's care plan did not include EBP, and the facility's policy on EBP was not followed. The policy clearly stated that gowns and gloves should be worn during high-contact activities, such as diaper changes and medication administration through a gastrostomy tube, to prevent the transmission of infections. The absence of a PPE cart and the failure to include EBP in the resident's care plan contributed to the deficiency in infection control practices.
Failure to Monitor and Document Pressure Ulcer Progression
Penalty
Summary
The facility failed to provide care consistent with professional standards of practice to prevent the worsening of a pressure ulcer for a resident. The resident, who was at risk of developing pressure ulcers, had a history of chronic obstructive pulmonary disease and type 2 diabetes mellitus. The facility did not assess and document detailed observations of the resident's skin and wound condition changes using the SBAR communication tool on multiple occasions, including 10/17/2024, 10/24/2024, 11/14/2024, and 11/30/2024. This lack of documentation and communication led to the resident's pressure ulcer worsening from moisture-associated skin damage to a stage 4 pressure ulcer. The facility also failed to monitor the resident's wound condition every shift after noting a foul odor on 11/25/2024 and an increase in wound size on 11/27/2024. The resident developed a fever and was admitted to a general acute care hospital with an infected sacral decubitus ulcer, fever, and leukocytosis. The resident required broad-spectrum antibiotic treatment and underwent excisional debridement of the sacral pressure ulcer. Interviews with facility staff, including the Wound Treatment Nurse, MDS Nurse, Registered Nurse Supervisor, and Director of Nursing, revealed that there was no documented evidence of SBAR completion or interdisciplinary team notification regarding the resident's wound condition changes. The facility's policies and procedures required prompt notification of changes in a resident's condition, detailed observations, and documentation in the resident's medical record, which were not followed in this case.
Inaccurate Documentation of Wound Care and Skin Condition
Penalty
Summary
The facility failed to ensure that licensed nurses documented accurate information regarding a resident's skin condition and wound care treatment. Specifically, the documentation in the Skilled Nursing Assessment form and the Weekly Summary form did not accurately reflect the resident's condition on several occasions. The resident, who had chronic kidney disease and lack of coordination, was at risk for developing pressure ulcers and had a stage 2 pressure ulcer that was not present upon admission. The review of the resident's medical records revealed inconsistencies in the documentation of wound treatments. The Treatment Administration Record (TAR) indicated ongoing treatments for Moisture Associated Skin Damage (MASD) and later a stage 2 pressure ulcer, but these were not consistently documented in the nurses' notes or weekly summaries. The Wound Care Doctor's communication log confirmed the presence of MASD and later a stage 2 pressure ulcer, but the nurses' documentation failed to reflect these findings accurately. Interviews with the Director of Nursing (DON) and the Administrator confirmed that the documentation was not consistent with the resident's actual condition. The DON acknowledged that the nurses should have conducted and documented complete and accurate weekly skin assessments. The facility's policies on pressure ulcer assessment and documentation were not followed, leading to inaccurate representation of the resident's skin condition and wound treatment in the medical records.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to uphold the dignity and privacy of several residents, as evidenced by multiple observations and interviews. Resident 47, who was severely cognitively impaired and dependent on assistance for eating, was fed by a CNA who stood over the resident, contrary to the facility's policy that staff should sit at eye level to provide a dignified dining experience. This practice was confirmed by the Registered Nurse Supervisor, who acknowledged that sitting while feeding residents is respectful and indicates that staff are not rushed. Residents 59 and 73 experienced breaches of privacy during personal care. Resident 59, who had severe cognitive impairment and required assistance with personal hygiene, was changed by a CNA with the curtain and door open, exposing the resident to passersby. Similarly, Resident 73, who also had severe cognitive impairment and required substantial assistance, was changed with the curtain and door open. Both CNAs admitted to not closing the curtain or door, acknowledging that this was against the facility's policy to maintain resident privacy. Resident 25, who had a preference to be called by her name, was repeatedly addressed as "Mama" by staff, despite expressing irritation and requesting to be called by her name. This disregard for the resident's preference was confirmed by both the resident and staff interviews. Additionally, Resident 75, who was dependent on assistance for eating, was fed by a CNA standing up, as there was no chair available, which did not align with the facility's policy for a dignified dining experience. These actions and inactions by the facility staff failed to respect the residents' rights to dignity and privacy, as outlined in the facility's policies.
Lack of Communal Dining Affects Resident Well-being
Penalty
Summary
The facility failed to provide a comfortable and homelike environment by not offering communal dining to its residents, which was a concern raised by five of the seven sampled residents during a Resident Council meeting. The absence of communal dining has been ongoing since 2020, following the closure of the dining room during the COVID-19 pandemic. Residents expressed their desire for communal dining, highlighting its importance for social interaction and emotional well-being. Resident 8, who requires assistance with eating, expressed a desire for communal dining, noting its absence since 2020. Resident 22, who also requires supervision with eating, emphasized the social benefits of communal dining and reported having raised the issue with the Activity Director multiple times without resolution. Resident 43, who has hemiplegia and requires supervision with eating, mentioned the logistical benefits of dining in the activity room to avoid congestion and potential accidents. Resident 44, diagnosed with major depressive disorder, and Resident 72, who does not require supervision with eating, both expressed feelings of loneliness when eating alone in their rooms and a preference for communal dining. The Activity Director acknowledged the lack of communal dining since 2020 and recognized its importance for creating a homelike environment and supporting residents' psychosocial well-being. The facility's policies emphasize providing a homelike environment and dignified dining experiences, which were not upheld in this instance.
Failure to Provide Appropriate Communication Boards
Penalty
Summary
The facility failed to provide communication boards in the appropriate language for three residents, which hindered their ability to communicate effectively with staff. Resident 41, who has severe cognitive impairment and physical disabilities, was observed with a communication board in a non-English language, which she could not understand. Her responsible party expressed concerns about the communication barrier, stating that the resident often resorted to pointing at objects to express her needs. The Activity Director admitted that communication binders were not consistently available in residents' rooms until the day before the surveyor's visit. Resident 42, who has severely impaired cognitive skills and prefers a non-English language, was found with a communication folder in her room for the first time during the survey. Her care plan indicated the need for alternative communication tools due to language barriers and visual impairment. However, the communication board was only recently placed in her room, and staff were not consistently using it to facilitate communication. Resident 63, who is moderately impaired cognitively and does not speak English, reported that staff did not use a communication board to communicate with him. He relied on his sister for assistance in communicating with staff. The communication board was only delivered to his bedside shortly before the surveyor's visit. The facility's policies on translation and communication needs were not effectively implemented, as adaptive devices like communication boards were not consistently provided to residents with limited English proficiency.
Failure to Provide Resident-Centered Activities
Penalty
Summary
The facility failed to provide activities based on comprehensive assessments and resident preferences for two residents, leading to a deficiency in meeting their physical, mental, and psychosocial needs. Resident 78, who was admitted with multiple health conditions including cancer and sepsis, expressed that he had not been offered any activities since his admission. Despite having intact cognitive skills and a desire to engage in his favorite activities, such as listening to the radio, he remained in bed without any engagement. The Activities Director acknowledged the oversight and confirmed that Resident 78 had not been offered his preferred activity. Resident 22, who was admitted with chronic obstructive pulmonary disease and hepatic failure, also experienced a lack of personalized activities. Although capable of making decisions, Resident 22 expressed dissatisfaction with the limited activities offered, such as Bingo and exercise videos, and desired more diverse options like mahjong and outings. The Activities Director noted that the facility's van, previously used for outings, was broken and had not been repaired, limiting the ability to provide off-site activities. The facility's policy on activity programs, which was not adhered to, requires activities to be designed to meet individual resident needs and interests, with a variety of options available daily. The policy also mandates that activities should include cardiovascular stimulation, intellectual engagement, and outings, which were not provided to the residents in question. This failure to follow the policy contributed to the deficiency in meeting the residents' needs.
Failure to Monitor and Adjust Psychotropic Medications
Penalty
Summary
The facility failed to ensure that the drug regimens for four residents were free from unnecessary medication use, as required by their policy. Resident 47 was prescribed two anxiety medications, Clonazepam and Lorazepam, without specific indications for their use being monitored. Additionally, the resident's behaviors related to the use of Cymbalta and Zyprexa were not adequately monitored, as hashmarks were not used to tally episodes of crying and paranoid delusions. Interviews with staff revealed that Resident 47 exhibited daily behaviors of crying and yelling, which were not properly documented, indicating a need for medication adjustment. Resident 62 was prescribed Quetiapine Fumarate for psychosis, but the specific behavior for its use was not monitored. The facility's policy required that antipsychotic medications be used only when behavioral symptoms present a danger to the resident or others, and the symptoms are due to mania or psychosis. The consultant pharmacist noted that the current behavior of restlessness/agitation did not justify the need for an antipsychotic medication, and the behavior needed to be more specifically described. Resident 33 was prescribed Escitalopram for depression without a specific indication or behavior being monitored. The resident reported feeling sad and anxious, which affected her ability to eat and participate in physical therapy. Resident 45 was prescribed Seroquel for psychosis, but a gradual dose reduction was not attempted, nor was a clinical rationale documented for why it would be contraindicated. The facility failed to notify the physician of the pharmacist's recommendation for a dose reduction, resulting in the resident continuing to receive the medication without displaying any behaviors of psychosis.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a 16% error rate during a medication pass observation. This deficiency involved two residents, with four medication errors identified out of 25 opportunities. One of the errors involved a Licensed Vocational Nurse (LVN) who did not wait the required five seconds before removing the needle after administering Humulin R insulin to a resident with diabetes mellitus. This action was contrary to both the facility's policy and the manufacturer's instructions, potentially affecting the resident's blood sugar management. Another error involved the Infection Preventionist Nurse (IPN) failing to administer Letrozole as ordered for a resident with a history of breast cancer. The medication was not available during the scheduled administration time, and the dose was missed. Additionally, the IPN administered Clopidogrel Bisulfate and Metoprolol Succinate outside the prescribed one-hour window, which was not in accordance with the facility's policy for timely medication administration. The residents involved had significant medical histories, including diabetes mellitus and breast cancer, which required precise medication management. The failure to adhere to prescribed medication administration protocols and timing could have impacted the residents' health conditions. The facility's policies on insulin administration and medication timing were not followed, leading to these medication errors.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications, leading to several deficiencies. Medications were left unattended on top of a medication cart, which could have been accessed by residents, posing a risk of adverse consequences. Additionally, unopened insulin pens for two residents were stored in the medication cart instead of the refrigerator, contrary to manufacturer's guidelines, potentially affecting the efficacy of the insulin. Another deficiency involved the failure to label an opened box of Ipratropium-Albuterol solution with the date it was opened, which is crucial as the medication expires seven days after opening. This oversight could lead to the administration of expired medication, reducing its effectiveness for the resident with COPD. Furthermore, an expired Mometasone nasal spray was found in the medication cart, which should have been removed according to the facility's policy, risking the use of ineffective medication. The facility also failed to maintain proper storage and labeling of medications in the medication storage room. Several opened medications were found without labels indicating the date they were opened, and some were improperly stored in the medication storage room instead of the medication cart. This practice could lead to medication errors and contamination, as medications were being transferred between containers by the nursing staff, which is against the facility's policy.
Deficiencies in Food Handling and Hygiene Practices
Penalty
Summary
The facility failed to adhere to proper food handling practices, as observed during a survey. Expired food was not discarded, and food items in the dry storage room, refrigerators, and freezers were not labeled with the item name, date opened, and expiration date. This oversight was noted with various food items, including bread, cheesecake powder, cookie dough, and ground meat. Additionally, the facility did not ensure that kitchen equipment and food carts were clean and free of food debris, with observations of dirty microwave knobs, food processors, and can openers. The facility also failed to maintain cleanliness in the kitchen environment. Dusty electric fans were stored in the dry storage room, and food storage areas were cluttered with items like open Styrofoam cups and plastic cup lids. The garbage container was improperly placed next to a freezer, and leaking soy sauce was found inside a refrigerator. These conditions were acknowledged by the dietary staff, who admitted to lapses in maintaining cleanliness and proper storage practices. Furthermore, dietary staff did not consistently perform hand hygiene or change gloves during food preparation and tray line assembly. Instances were observed where staff members used the same gloves for multiple tasks, such as handling food trays, opening refrigerators, and using kitchen tools, without changing gloves in between. This practice was contrary to the facility's policy and procedure, which emphasized the importance of hand hygiene and changing gloves to prevent food contamination.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility staff failed to adhere to infection control measures in several instances, leading to potential risks of infection spread among residents. In one case, a Certified Nursing Assistant (CNA) was observed handling soiled linens from a resident with chronic obstructive pulmonary disease, diabetes, and hypertension without wearing gloves and holding the linens close to her body, contrary to the facility's policy. This practice was confirmed by the Director of Staff Development and a Registered Nurse Supervisor, who emphasized that such actions could lead to contamination of staff clothing and subsequent transmission of infections to residents. Another deficiency involved the improper cleaning and disinfection of a glucometer used for a resident with radiculopathy and diabetes. A Licensed Vocational Nurse (LVN) failed to disinfect the glucometer after use, placing it back in the medication cart drawer without cleaning it. This oversight was acknowledged by the LVN and a Registered Nurse Supervisor, who noted the importance of disinfecting equipment to prevent the spread of bloodborne pathogens and contamination of other items in the drawer. Additional lapses in infection control were observed with the lack of proper signage for enhanced barrier precautions for a resident on isolation due to tuberculosis and other conditions. The absence of appropriate signage was noted by an MDS Nurse and a Registered Nurse Supervisor, who stated that such signage is crucial for reminding staff and visitors of necessary precautions. Furthermore, both a Licensed Vocational Nurse and an Infection Preventionist Nurse failed to perform hand hygiene before and after administering medications to residents, which they acknowledged as a breach of infection control protocols.
Facility Fails to Maintain Safe and Unobstructed Hallways
Penalty
Summary
The facility failed to provide a safe environment for Resident 43 by not ensuring that the designated exit door was clear of obstructions. During an observation, a wheelchair was found blocking the emergency exit doors, which could impede a rapid evacuation in case of an emergency. Interviews with the Activity Director and the Interim Director of Nursing confirmed that wheelchairs should not be left in the middle of the hallway leading to emergency exits, as this could prevent residents from evacuating quickly and safely. The facility's policy and procedure on exits clearly stated that all personnel should keep exits clear at all times. Additionally, the facility did not maintain a clutter-free hallway for Resident 43, who has hemiplegia and hemiparesis following a cerebral infarction. Observations revealed multiple wheelchairs, a Hoyer lift, a walker, and a clean linen cart cluttering the hallway, posing a risk of accidents, tripping, or falls for Resident 43. Interviews with Resident 43 and staff members, including a Certified Nursing Assistant and a Licensed Vocational Nurse, highlighted the potential hazards caused by the cluttered hallways, especially during busy times when residents move between activities and meals. The facility's policy on Safety and Supervision of Residents emphasized the importance of identifying and mitigating environmental hazards and individual resident risks. However, the presence of wheelchairs, equipment, and bins in the hallway for extended periods was acknowledged by staff, including a Registered Nurse Supervisor, as a potential issue for patient injury and tripping hazards. The facility's Quality Assurance and Performance Improvement committee was responsible for evaluating and addressing such hazards, but the report does not mention any corrective actions taken to resolve these deficiencies.
Failure to Obtain Informed Consent for Treatment and Medication
Penalty
Summary
The facility failed to fully inform two residents of the risks and benefits of their proposed care, which is a violation of the facility's policy. Resident 185 was admitted with several diagnoses, including dementia and adult failure to thrive, and was totally dependent on staff for daily activities. However, the Admission Consent Forms, which include consent for treatment, disclosure of medical records, and photography, were not completed or signed upon admission. The Registered Nurse Supervisor acknowledged that the forms should have been completed during admission or the following day, and the family should have been contacted. The absence of a signed Admission Consent Form meant that the resident did not give consent for treatment or the disclosure of medical records. Resident 62, who was admitted with diagnoses of psychosis and dementia, was prescribed Seroquel, an antipsychotic medication, without obtaining informed consent. The resident's cognitive skills for daily decision-making were severely impaired, and the facility's policy requires that informed consent be obtained from the resident or their representative before administering such medication. The Registered Nurse Supervisor confirmed that informed consent was not obtained, which is necessary due to the potential side effects of the medication. The facility's policy on antipsychotic medication use mandates that residents and their representatives be informed of the risks, benefits, and potential adverse consequences of the medication.
Failure to Follow Self-Administration of Medications Policy
Penalty
Summary
The facility failed to adhere to its policy on self-administration of medications for one resident, identified as Resident 20, by not obtaining a physician's order and not conducting an assessment to determine the resident's capability to self-administer medications. Resident 20 was admitted with diagnoses including calculus of gallbladder with acute cholecystitis, lack of coordination, and unspecified glaucoma. The Minimum Data Set (MDS) assessment indicated that Resident 20 had moderately impaired cognitive skills for daily decision-making and required assistance with various activities of daily living. During observations and interviews, it was found that Resident 20 had bottles of Cod Liver Oil and Halibut Liver Oil on her bedside table, which she stated were brought by her family and not prescribed by her physician. The Registered Nurse Supervisor confirmed that these medications were not prescribed and should have been reported to the physician. The facility's policy requires that the interdisciplinary team assess a resident's ability to self-administer medications and that any unauthorized medications found at the bedside be turned over to the nurse in charge. However, this process was not followed, as there was no interdisciplinary team assessment form for Resident 20 to self-administer medication.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light was within reach for one of the sampled residents, which was not in accordance with the facility's policy and procedure for the Residents' Call System. The deficiency was identified during an observation and interview with the resident, who was unable to locate the call light and expressed a need for assistance to request hot tea or water. The call light was found placed under the draw sheet, out of the resident's reach, which prevented the resident from calling for help when needed. The resident involved in this deficiency was admitted with multiple diagnoses, including adult failure to thrive, benign prostatic hyperplasia, syncope, and a history of falls. The resident was noted to be totally dependent on staff for bed mobility, transfer, locomotion, and toileting, and had cognitive and communication deficits due to dementia. The care plan for the resident specifically indicated the need to keep the call light within reach, highlighting the importance of this intervention given the resident's condition. Despite this, the call light was not accessible, as confirmed by a Licensed Vocational Nurse during an observation.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 7,080 citations issued within 25 miles in the last 12 months — including the 35 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near San Gabriel
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Live Oak Rehab Center | 0.3 mi | ★★★★★ | 38 | 1 |
| Ivy Creek Healthcare & Wellness Centre | 0.5 mi | ★★★★★ | 13 | 0 |
| San Gabriel Valley Medical Ctr D/p Snf | 0.5 mi | ★★★★★ | 17 | 0 |
| Broadway Healthcare Center | 0.6 mi | ★★★★★ | 18 | 0 |
| Alhambra Healthcare & Wellness Centre, Lp | 0.6 mi | ★★★★★ | 1 | 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.