Average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at San Gabriel Conv Center during CMS and state inspections, most recent first.
The facility failed to keep one resident’s medication regimen free from unnecessary drugs when Journavx was given for an extended period, including while pain was documented as 0, and was administered via G-tube despite being labeled do not crush and intended for short-term acute pain use. The facility also failed to monitor another resident’s response to PRN lorazepam ordered for anxiety/agitation, and the record showed no monitoring of efficacy or side effects as required by policy.
Expired food was found in the kitchen, including a bottle of Kitchen Bouquet past its best-buy date, and staff acknowledged it should not have been stored for use. In a separate kitchen observation, a DA handled clean dishes, touched dirty dishes and carts, and washed hands improperly while keeping gloves on before returning to the clean dish task. The DS, RDC, and DA stated this created cross-contamination and infection control concerns and did not follow facility policy on sanitation, handwashing, and dating/labeling.
Infection control failures were observed when an RNA moved between three residents needing feeding assistance without washing or sanitizing hands between residents, including leaving one resident mid-meal and returning without hand hygiene. The facility also did not flush water heaters, and the MS did not know he was responsible for monitoring sinks and shower areas for biofilm. In addition, open food was observed at a nursing station, and staff stated food should not be there for infection control.
A resident with DM, adult failure to thrive, anorexia, and cognitive impairment needed feeding assistance and was on a mechanically altered/therapeutic diet. While an RNA was encouraging the resident to eat in the dining room, the resident pushed the tray aside and said she was full; the RNA placed a finger over her own mouth and said shush. Staff later stated residents should not be shushed, and the DON confirmed the action was not respectful and did not follow the facility's Dignity policy.
Bed-Hold Notice Not Properly Documented for Hospital Transfers: A resident with severe cognitive impairment and total dependence on staff was transferred to the hospital twice for acute changes in condition, and the facility’s Bed-Hold notices were not signed or fully completed to show the resident’s representative was notified and acknowledged the bed-hold information. The RNS and DON confirmed the forms were incomplete and did not reflect the facility’s written bed-hold and transfer notification policies.
A comprehensive care plan was not developed for two residents with distinct needs. One resident with chronic respiratory failure, hypoxia, HIE, and PVS was transferred to the hospital for tachycardia and hypotension, but the care plan did not address the change in condition or transfer. Another resident with dementia and major depressive disorder was prescribed PRN lorazepam for anxiety/agitation, but no care plan addressed the medication use, associated warning, or monitoring of response.
Care Plan Not Updated for Resident-Specific Activities: A resident with chronic respiratory failure, PVS, and type 2 DM had activities documented as sensory stimulation, conversation, and music, but the care plan did not reflect these resident-specific interventions. The AD confirmed the care plan was not updated to match the resident’s current assessment and activities, and the DON stated care plans should be patient centered and specific.
A resident with a G-tube, DM, and dementia had soiled drainage gauze and redness around the stoma site, but staff did not consistently assess, document, or report the change in condition. An LVN said he should have checked the dressing and notified the TN, while a TN said she saw pinkish skin around the site on prior days but assumed it was normal and did not inform the MD or document it. The DON stated staff should have reported the change in condition and monitored the site for worsening or improvement.
A resident at risk for pressure injury had a LAL mattress that was not set according to the resident’s weight. The resident had severe cognitive impairment, MASD, and skin treatments in place, and the mattress was observed set at 400 pounds despite the resident weighing 169 pounds. The TN, RNS, and DON stated the mattress should have matched the resident’s weight to support skin maintenance and pressure relief, and the facility policy required staff to follow the manufacturer’s instructions.
Failure to Provide Adequate Supervision and Reassess Fall Prevention Interventions: A resident with dementia, gait impairment, and a history of falls was identified as high fall risk and placed on the Falling Star Program with alarms and frequent visual monitoring. The resident had an unwitnessed bathroom fall with a forehead hematoma, later fell again when a CNA left the resident unbuckled in a shower chair and turned away, and staff observed the resident repeatedly turning off the bed alarm without prompt response. The RN and DON stated the care plan was not revised and there was no documented evaluation of the fall prevention interventions’ effectiveness.
A resident receiving hospice care with severely impaired cognition and multiple chronic conditions, including Alzheimer's disease and a foot ulcer, was prescribed routine Tramadol for moderate pain. The care plan directed staff to assess non-verbal pain indicators and monitor medication effectiveness, but the MAR showed repeated Tramadol administration for pain levels of 0-4/10 without documented pain assessment and reassessment in the clinical record.
A resident with acute and chronic respiratory failure with hypoxia, Type 2 DM with hyperglycemia, generalized muscle weakness, and impaired cognition was placed in four locked bed rails for fall risk. The record showed only one alternative intervention, one-to-one activities and supervision, with no documented evidence explaining why it was ineffective, and the DON stated there was no documented active order for a low bed or other alternative. The resident was observed asleep with all four bed rails up and locked, and the care plan and active orders did not show monitoring for safe bed rail use.
Pharmacist consultant failed to identify and report medication regimen irregularities for a resident receiving Journavx via G-tube for pain management. The MAR showed the medication was continued even after acetaminophen was documented as effective, and the pharmacist did not notify the prescriber, DON, or medical director. The pharmacist also stated he did not know Journavx was non-crushable.
A resident with CKD, hydronephrosis, kidney cyst, and dementia had a positive urine culture and sensitivity reported to the facility, but the result was not promptly communicated to the attending MD. Staff interviews and record review showed the LPN/RN did not notify the MD until the next morning, and IV abx for the UTI were not started until later, after the abnormal lab was finally addressed.
A resident with dementia and severe cognitive impairment was prescribed lorazepam PRN for anxiety/agitation, but the informed consent form had no prescriber signature. During record review, the RNS and DON both stated the prescriber should have signed the consent after explaining the medication’s benefits and risks to the resident’s representative, as required by facility policy.
Failure to Provide Written Transfer and Bed-Hold Notices: A resident with dementia, ASHD, and HTN was transferred to the hospital for chest pain, and the order included a 7-day bed hold. Record review showed the RP was not documented as being informed in writing of the transfer or bed hold, and the MRD confirmed there was no RP signature on either form. The DON stated the facility did not follow its transfer/discharge notice policy.
Failure to Develop Incontinence and Scheduled Toileting Care Plan: A resident with spinal stenosis, CKD, and dementia had documented bladder incontinence and required moderate assistance with toileting hygiene, but the baseline and comprehensive care plans did not identify incontinence or scheduled toileting. The Bowel and Bladder Program Screener showed the resident was not continent of bowel and bladder and was a candidate for scheduled toileting, yet the care plan and task flowsheets did not reflect that intervention.
Failure to Reapply Skin Barrier Cream for a Resident with MASD. A resident with chronic respiratory failure, ventilator dependence, and gastrostomy dependence had peri-rectal MASD with reddened, macerated, fragile skin and an order for daily and PRN skin barrier cream. During peri-care, CNAs observed pink skin breakdown but did not apply cream or notify the TN when the cream was no longer present. The TN later confirmed the resident had no barrier cream on the buttocks and stated it should have been reapplied after the brief change.
Failure to implement scheduled toileting for a resident with urinary incontinence. A resident with spinal stenosis, CKD, and dementia was assessed as a candidate for scheduled toileting on the bowel and bladder screener, but the care plan and task flowsheets did not show the intervention was in place. The MDS Coordinator and DON stated the resident should have been placed on a scheduled toileting program when indicated by assessment, and the facility policy required scheduled toileting to improve continence status.
Infection control was deficient when a CNA removed a resident’s soiled brief, cleaned the resident’s buttocks, and then continued care with the same gloves without hand hygiene. The CNA placed a new brief, repositioned pillows, and touched the resident’s body while still wearing the same gloves. The resident had chronic respiratory failure, ventilator dependence, gastrostomy dependence, and no decision-making capacity, and the facility’s IPN, DON, and policy all stated staff should change gloves and perform hand hygiene after brief care.
A resident with a history of respiratory failure and COPD, identified as full code, was found unresponsive and not breathing. Facility staff did not promptly activate the emergency response system, delayed calling 911, and failed to perform effective CPR according to policy and professional standards. Instead of chest compressions and rescue breaths, staff performed a chest rub, and there was confusion about emergency procedures. When EMS arrived, the resident was found deceased, with no evidence of effective life-sustaining measures having been provided.
The facility did not ensure that documentation regarding advance directives and POLST forms was accurate and consistent for two residents. In both cases, the information on the POLST forms did not match the Advance Directive Acknowledgment forms, and the Social Services Director confirmed these discrepancies. This failure resulted in unclear records about the residents' wishes for life-sustaining treatment.
The facility did not adequately protect resident privacy when baby monitors used for safety were left on and visible in public or semi-public areas, such as on medication carts and unattended nursing station desks. This allowed unauthorized individuals to view live video feeds of residents, including those with dementia and impaired cognition, contrary to facility policy and privacy expectations.
Surveyors found that three residents receiving oxygen therapy did not receive care in accordance with facility policy and physician orders. Oxygen tubing was observed on the floor and not dated, and staff failed to monitor, assess, and document abnormal vital signs for a resident with acute respiratory failure. There was also a delay in activating the emergency response system and calling 911 when a resident was found unresponsive, and another resident's oxygen equipment was not properly stored or labeled. These deficiencies resulted in one resident being found dead upon EMS arrival.
The facility did not ensure that outdoor refuse containers were closed with tight-fitting lids and kept covered, as required by policy. Multiple containers were overfilled and could not be closed, with staff unaware of container ownership and sharing containers with a neighboring facility, leading to persistent overflow and noncompliance with refuse management procedures.
A resident with multiple chronic conditions developed new swelling, redness, and warmth in the left elbow, but nursing staff did not notify the physician as required by facility policy. Despite observations and assessments by the treatment nurse and LVN, there was no documentation of physician notification or new treatment orders for the condition.
A resident with dementia and psychosis was prescribed quetiapine, but the facility failed to consistently document the specific behaviors justifying its use and did not perform a required gradual dose reduction (GDR) despite a pharmacist's recommendation. Documentation was inconsistent across the care plan, physician orders, and medication records, and there was no evidence of physician follow-up or clinical rationale for not attempting a GDR.
A resident with anxiety and hypothyroidism, who lacked decision-making capacity, did not have their required quarterly MDS assessment completed and submitted to CMS within the mandated timeframe. The MDS was completed and transmitted nearly two months late, as confirmed by facility staff and records, resulting in a failure to provide timely and accurate resident information.
Two residents did not have comprehensive, person-centered care plans addressing their specific communication and sensory needs. One resident's care plan failed to include their primary language, while another's did not address severe hearing impairment or the use of hearing aids. Staff interviews and documentation confirmed these omissions, despite facility policy requiring individualized care planning.
A resident with left-sided hemiplegia and contractures did not receive physician-ordered restorative nursing treatments, including PROM exercises and application of a left AFO and hand splint, for several days. Staff were unable to explain the omission, and observations confirmed the devices were not in use as required by the care plan.
A resident with dementia, Parkinson's Disease, and a recent fall was not provided with a call light within reach or a floor mat as required by their care plan and physician's orders. Staff left the resident alone in a wheelchair without ensuring these fall prevention measures were in place, and interviews confirmed the omissions.
A resident with an indwelling catheter and complex urinary conditions did not receive consistent monitoring or documentation of intake/output and bladder distention as required by facility policy and physician orders. After the initial monitoring period, staff failed to evaluate the need for continued I&O tracking, and nursing notes lacked details on bladder assessments and specific UTI symptoms, even when abnormal findings were present. This led to missed documentation and assessment of significant changes in the resident's urinary status.
A resident with severe hearing and vision impairments did not receive appropriate social services when dissatisfaction with new hearing aids was not addressed. Despite repeated requests from the resident, responsible party, and nursing staff, the Social Service Director failed to arrange an audiology appointment with the resident's preferred provider, leaving the resident without effective hearing assistance and impacting quality of life.
A resident with dementia and psychosis was prescribed quetiapine, and the facility did not respond to a consultant pharmacist's recommendation for a gradual dosage reduction. There was no documentation of physician follow-up, psychiatric care, or a clear rationale for continued use of the medication, and the specific behaviors justifying the prescription were inconsistently documented across records.
A resident with multiple medical conditions and moderately impaired cognition was served a meal containing beef, despite a documented dislike for beef on her care plan, dietary notes, and meal ticket. Staff interviews and observations confirmed that the cook overlooked the resident's food preference, resulting in the resident being served an unwanted meal.
A resident with multiple complex medical conditions experienced a lack of complete and accurate documentation regarding abnormal vital signs and changes in condition. Nursing staff admitted to not consistently recording low or fluctuating blood pressure and oxygen saturation levels, sometimes omitting 'bad' numbers due to fear of being questioned by leadership. This resulted in an incomplete medical record that did not reflect the resident's deteriorating status prior to a fatal event, contrary to facility policy requiring thorough and objective documentation.
A resident with severe cognitive impairment and a gastrostomy was found with an enteral feeding formula bag that was not labeled with the date and time it was opened, contrary to facility policy. The LPN on duty could not confirm when the bag was started or if it was expired, and the DON confirmed that labeling is required to ensure timely formula changes.
A review of room measurements and occupancy revealed that multiple rooms housing three residents each did not meet the required 80 sq ft per resident, with each resident receiving only about 72–74 sq ft. Staff and residents reported sufficient space for care and mobility, but the facility did not comply with the minimum space standard.
A CNA was assigned double shifts despite known incompetency issues, including sleeping during shifts and failing to provide necessary care, leading to a decline in resident well-being. The facility faced staffing shortages and did not use agency staff, resulting in the CNA covering extra shifts.
Two residents with cognitive impairments and mobility issues experienced falls due to inadequate supervision and monitoring. One resident was found on the floor by a CNA who failed to follow protocol, while another fell after attempting to use a commode with a non-functioning bed alarm. Staff interviews revealed communication issues and insufficient training, contributing to the facility's failure to implement effective fall prevention measures.
The facility failed to accommodate the communication and safety needs of three residents, leading to unmet needs and potential neglect. One resident was not provided with a communication board, another had an incorrect communication board, and a third had a call light out of reach, all resulting in significant care deficiencies.
The facility failed to ensure that residents' medical records were updated with documentation that advance directives (AD) were discussed and provided to residents and/or responsible parties. This deficiency was observed in four of the five sampled residents, with missing or improperly stored AD and POLST forms, compromising the residents' rights to make informed decisions about their care and treatment.
The facility failed to complete and submit MDS assessments within the required time frame for four residents, including those with dementia, hyperlipidemia, anemia, and seizures. The delays were attributed to staff being too busy with other tasks, potentially compromising the quality of care.
The facility failed to ensure the quarterly MDS were completed and submitted to the CMS database within the required time frame for four residents. The MDS Nurse and the Director of Nursing attributed the delays to staffing issues, which led to late assessments and submissions, potentially compromising residents' quality of care and safety.
The facility failed to assist four residents with ADLs, including grooming and oral hygiene. Two residents were found with untrimmed, dirty fingernails, and another resident had poor oral hygiene with no assistance provided. Staff interviews and observations confirmed the lack of adherence to care plans and facility policies.
The facility failed to follow proper sanitation and food handling practices, including using a rusted can opener with peeling chrome plating and not properly testing the chlorine level in the dishwasher. These actions could potentially contaminate food and dinnerware used by residents.
A facility failed to meet professional standards by not applying gentle pressure to the lacrimal duct after administering eye drops to a resident with Alzheimer's and hyperlipidemia. The LVN was unaware of this requirement, which was confirmed by the DON.
The facility failed to ensure nurses were competent in maintaining correct settings on low air loss mattresses (LALM) based on residents' weights. Observations and interviews revealed inconsistent knowledge and training among staff, leading to incorrect LALM settings for multiple residents, including one with a physician order for LALM for skin maintenance.
A facility failed to ensure safe pharmaceutical services when an LVN left a medication cart unlocked before entering a resident's room. The DON confirmed that the cart should always be locked unless in use, as per facility policy, to prevent unauthorized access and potential harm.
The facility failed to follow its infection control policy for a resident with a gastrostomy tube (GT) feeding, leading to the use of a contaminated tube. CNAs found the GT feeding port on the floor and reconnected it without proper sanitation, and the RN restarted the feeding without changing the tube. The Infection Prevention Nurse and Director of Nurses confirmed that the protocol was not followed, posing an infection risk.
Unnecessary medication use and lack of monitoring for psychoactive medication
Penalty
Summary
The facility failed to ensure Resident 6’s drug regimen was free from unnecessary drugs when Journavx was administered for an extended period from 3/29/2026 through 6/16/2026, despite the medication’s pharmaceutical recommendation to be used for the shortest duration consistent with individual treatment goals. Resident 6’s record showed diagnoses including chronic respiratory failure and dementia, and the MDS indicated moderately impaired cognition and that the resident received a scheduled pain medication regimen. The physician order dated 3/29/2026 directed Journavx 50 mg via G-tube every 12 hours for pain management. Record review showed Journavx was given from 4/1/2026 through 6/15/2026 for pain documented as zero on multiple administrations, and the medication was administered 148 times. The MAR also showed acetaminophen liquid entries with pain scores of 3 or 4 and documentation that the medication was effective on several dates in June. During interview, RN 1 stated Resident 6 had oral gratification only for a short period at the beginning of the year and medications were never given by mouth, and that it was not appropriate to crush Journavx and administer it via G-tube because the medication was marked do not crush. The facility also failed to monitor Resident 76’s response to lorazepam prescribed as needed for anxiety manifested by agitation and aggressive behavior toward others. Resident 76 had diagnoses including dementia and major depressive disorder, and the H&P stated the resident did not have the capacity to understand and make decisions; the MDS indicated severe cognitive impairment and no behavioral symptoms toward others. The physician order dated 5/28/2026 prescribed lorazepam 0.5 mg by mouth as needed for anxiety for 14 days, but the record showed no monitoring of the resident’s response or side effects. The DON and RNS stated monitoring should have been done, including every shift, and the facility policy required monitoring for efficacy and adverse consequences when medications are prescribed for behavioral symptoms.
Expired Food Item and Improper Hand Hygiene in Kitchen
Penalty
Summary
Food was stored and handled in a manner that did not follow professional standards of practice or the facility’s policies on sanitation, infection control, dating, and labeling. During an observation in the kitchen, a bottle of Kitchen Bouquet was found expired on 3/28/2026. The Dietary Supervisor acknowledged the item was expired and stated it should not have been stored for use. The Registered Dietician later stated expired items should not have been in the kitchen because the quality of the food would not be guaranteed and could raise issues with safety and nutritional value, including taste, and could cause residents to get an upset stomach. The facility also failed to maintain sanitary food handling practices during dish handling. A Dietary Aid was observed removing clean dishes from the dishwasher, handling dirty dishes and placing them into the dishwasher without removing gloves, washing hands over the gloves with soap suds from a container filled with dirty dishes, and then returning to put away clean dishes. The Dietary Aid also arranged food carts for easier access to dirty plates and rinsed her hands without removing gloves or using soap before resuming the task. The Registered Dietician Consultant, Dietary Supervisor, and Dietary Aid all stated that staff should not touch dirty surfaces while handling clean dishes and should remove gloves and wash hands with soap and water when changing tasks, and the facility policy stated gloves are single-use and handwashing is required after handling carts, soiled dishes, and when beginning a different task.
Infection control failures during resident feeding, water system monitoring, and food storage at the nursing station
Penalty
Summary
The facility failed to follow its Infection Control policy and procedures in multiple areas. During dining room observation, RNA 1 assisted Resident 57 with feeding, then left that resident before the meal was finished and went to Resident 91 to assist with feeding without washing or sanitizing hands in between. RNA 1 later returned to Resident 57 without hand hygiene and then proceeded to assist Resident 97 at the same table without washing or sanitizing hands. Resident 57 had diagnoses including GERD, DM, and iron deficiency anemia, needed assistance with feeding, and had moderate cognitive impairment. Resident 91 had diagnoses including protein-calorie malnutrition, cachexia, and encephalopathy, lacked capacity to make decisions, needed feeding assistance, and had severe cognitive impairment. Resident 97 had diagnoses including DM, adult failure to thrive, and anorexia, lacked capacity to make decisions, needed feeding assistance, and had moderate cognitive impairment. The facility also failed to ensure its water heaters were flushed and that the Maintenance Supervisor knew how to monitor for biofilm. During observation with the MS, Water Heaters A, B, C, and D were seen, and the MS stated he did not drain the water heaters to remove impurities or possible water-borne pathogens growing in the tanks. The Infection Prevention Nurse stated the facility’s water management measures included flushing the water heater tanks to remove mineral buildup and possible water-borne bacteria such as Legionella. In a separate interview, the MS stated he was not aware he was responsible for monitoring sinks, shower rooms, tubs, and drinking areas for biofilm and stated he did not know what biofilm was. The Infection Prevention Nurse stated the MS, housekeepers, and herself were responsible for checking those areas monthly for biofilm as a control measure for possible growth of waterborne pathogens. The facility further failed to keep open food items out of Nursing Station A. During observation, there were 4 to 5 unopened snack bars and one open bag of chips on the desk at Nursing Station A. RN 1 stated there should not be any snacks, especially open snacks, at the nursing station for infection control. The Medical Records Director stated she was eating a bag of chips at Nursing Station A and had just opened a new bag. The Infection Prevention Nurse stated there should be no food or drinks at the nursing station because of infection control. The facility’s Infection Control policy stated it maintained an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection.
Resident Shushed During Meal Assistance
Penalty
Summary
The facility failed to ensure staff assisted a resident with dining in a manner that promoted dignity and respected the resident's right to refuse food. Resident 97 was admitted with diagnoses including DM, adult failure to thrive, and anorexia, and the record showed the resident did not have decision-making capacity, needed assistance with feeding, had moderate cognitive impairment, and was on a mechanically altered and therapeutic diet. The resident's care plan included interventions to honor food preferences and respect the resident's right to refuse. During an observation in the dining room, RNA 1 was seen sitting with Resident 97 and encouraging the resident to eat while the resident pushed the meal tray to the side. When the resident began speaking in a slightly louder tone, RNA 1 placed her right index finger over her own mouth and said shush. The resident then refused to eat more because she was already full. RNA 1 later stated staff should not shush a resident and should instead take the resident to a more comfortable area, report the refusal to the charge nurse, or offer a food alternative. Interviews with other staff and the resident confirmed that shushing a resident was not appropriate. Resident 97 stated she was full and did not want to eat anymore. RNA 2 and TN 1 both stated staff should never shush a resident and described the action as rude and, in their view, abusive. The DON stated staff should ask the resident first in a language the resident understood and should never shush a resident because it was not respectful. The facility's Dignity policy stated residents were to be treated with dignity and respect at all times, allowed to choose when to eat, and protected from demeaning practices.
Bed-Hold Notice Not Properly Documented for Hospital Transfers
Penalty
Summary
The facility failed to ensure the Bed-Hold notice for Resident 82 was signed by the resident’s representative to indicate acknowledgement of receipt when the resident was transferred to the hospital on two occasions. Resident 82’s record showed the resident was admitted and later readmitted to the facility with diagnoses including chronic respiratory failure with hypoxia, tracheostomy, and gastrostomy. The H&P stated the resident did not have the capacity to understand and make decisions, and the MDS identified severe cognitive impairment and total dependence on staff for self-care. On 4/21/2026, Resident 82 developed fever, elevated RR, elevated HR, and elevated BP, and the responsible party and physician were notified before the resident was transferred to the GACH. The physician ordered transfer via 911 and indicated a seven-day bed hold if the resident was admitted. The Notification of Bed Hold for this transfer did not indicate that the resident’s representative was notified, and no signature was obtained from the responsible party acknowledging the bed hold notice. On 5/1/2026, Resident 82 again had tachycardia and hypotension, was transferred to the GACH, and the physician ordered a seven-day bed hold per facility protocol. The Notification of Bed Hold for this transfer was also not signed by the resident’s representative and did not show that the responsible party was notified and the bed hold explained. Interviews with the RNS and DON confirmed the forms were not completed entirely and that the facility staff were not following the facility’s Bed-Holds and Returns policy and Transfer or Discharge Notices policy, which required residents and/or representatives to be informed in writing of bed-hold and transfer information.
Failure to Develop Resident-Specific Care Plans for Hospital Transfer and Lorazepam Use
Penalty
Summary
A comprehensive, resident-specific care plan was not developed and implemented for two residents with identified needs. One resident was readmitted with chronic respiratory failure with hypoxia, hypoxic ischemic encephalopathy, and persistent vegetative state, and the H&P indicated the resident did not have the capacity to understand and make decisions. The MDS also indicated the resident was in a persistent vegetative state with no discernable consciousness. For this resident, the physician ordered transfer to a general acute care hospital via 911 on 5/1/2026 due to tachycardia and a hypotensive episode with a 7-day bed hold per facility protocol. Review of the care plans showed no care plan for the transfer to the hospital related to tachycardia and hypotension. During interview and record review, the MDS Nurse confirmed that no care plan had been developed for the transfer, and the DON stated that when a resident has a change of condition and transfers to the hospital, a care plan should be developed or updated. A second resident was admitted with dementia and major depressive disorder, and the H&P indicated the resident did not have the capacity to understand and make decisions. The resident’s physician orders included lorazepam 0.5 mg by mouth as needed for anxiety manifested by agitation and aggressive behavior toward others for 14 days. Review of the care plan showed no care plan for lorazepam use. During interview, the RNS stated there should be a care plan for the black box warning associated with lorazepam, changes in condition, and the resident’s behaviors in response to lorazepam, and the DON stated there should be a care plan when a resident is receiving psychotropic medications.
Care Plan Not Updated for Resident-Specific Activities
Penalty
Summary
The facility failed to revise or update the care plan for one sampled resident to address resident-specific activities such as sensory stimulation, conversation, and music, as required by the facility’s policy and procedure titled Care Plans, Comprehensive Person-Centered. The resident was admitted with diagnoses including chronic respiratory failure with hypoxia, persistent vegetative state, and type 2 diabetes mellitus with hyperglycemia. The history and physical did not indicate whether the resident had the capacity to understand and make decisions, and the MDS dated 5/26/2026 indicated the resident was in a persistent vegetative state with no discernable consciousness. A review of the resident’s Documentation Summary Report for 5/2026 and 6/2026 showed activities provided included sensory stimulation, supply, conversation, and music. However, the care plan did not identify these resident-specific activities. During interview and record review, the Activities Director confirmed the resident did not have a care plan specific to the current activities being provided and stated activities staff did not update or revise care plans to reflect the resident’s most current assessment and activities. The DON stated care plans should be patient centered and specific, as they give staff more details to guide resident care. The facility policy stated the interdisciplinary team develops and implements a comprehensive, person-centered care plan and revises it as resident information and conditions change.
G-tube Site Irritation and Drainage Not Properly Monitored or Reported
Penalty
Summary
The facility failed to ensure appropriate care and services were provided for one sampled resident with a G-tube to prevent skin irritation, breakdown, and infection as directed by the resident’s care plan and the facility’s Gastrostomy/Jejunostomy Site Care and Enteral Feeding-Safety Precautions policies. Resident 6 was admitted and readmitted with diagnoses including chronic respiratory failure, DM, and dementia, and had orders for G-tube site care with normal saline, pat dry, and dry dressing, along with enteral feeding via pump. The resident’s care plan identified a high risk for infection related to the feeding tube and directed staff to monitor for signs and symptoms of infection and notify the MD if any were present. During observation, Resident 6 was found with light-brown soiled drainage gauze over the G-tube stoma site and redness around the site. An LVN stated the site looked irritated and that he should have checked the dressing during the morning assessment and notified the treatment nurse. The TN observed drainage and redness measuring about 4 to 5 cm around the site and stated she was not sure how long the resident had had the rash or irritation, which could further lead to infection and skin breakdown if not treated. Another TN stated she had seen pinkish skin around the stoma on prior days, assumed it was normal, and did not document it or inform the physician or other licensed staff. The DON stated the nurse should have informed the doctor of any change in condition, documented it, checked residue, measured leak, calculated gauze change frequency, and monitored for improvement or worsening.
Low Air Loss Mattress Set Incorrectly for Resident at Risk for Pressure Injury
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not ensured for one sampled resident who was at risk for pressure injury. Resident 82 was admitted and readmitted with diagnoses including chronic respiratory failure with hypoxia, tracheostomy, and gastrostomy. The resident’s H&P stated the resident did not have the capacity to understand and make decisions, and the MDS dated 6/1/2026 indicated severe cognitive impairment, moisture associated skin damage, and risk for pressure ulcers/injuries. The resident also had skin and ulcer/injury treatments that included a pressure reducing device for the bed, nonsurgical dressings, and ointments/medications. The resident’s weight was documented as 169 pounds, and a physician’s order dated 6/5/2026 directed use of a low air loss mattress for skin care management every shift. During observation on 6/15/2026, the resident’s LAL mattress had a yellow circle sticker under the weight setting of 160, but the mattress was set at 400 pounds. The Treatment Nurse stated the mattress should have been set according to the resident’s weight and not at 400, and that an incorrect setting could make the mattress too hard and cause a pressure injury. The Registered Nurse Supervisor and the DON both stated the LAL mattress should have matched the resident’s weight to optimize skin maintenance and relieve pressure, and the facility policy required staff to follow the manufacturer’s instructions and adjust the mattress based on the resident’s weight. The manufacturer’s manual also stated the air mattress could be adjusted to a desired firmness according to the patient’s weight or a health care professional’s suggestion.
Failure to Provide Adequate Supervision and Reassess Fall Prevention Interventions
Penalty
Summary
The facility failed to provide adequate supervision for a resident who was identified as high risk for falls. The resident was admitted with diagnoses including heart failure, dementia, history of falling, and abnormalities of gait and mobility. The resident’s initial fall risk assessment identified the resident as high risk for falls, and the care plan called for frequent visual observation, a safe clutter-free environment, and placement on the Falling Star Program with close observation near the nursing station. After an unwitnessed fall in the bathroom, the resident was found sitting on the floor in front of the bathroom door with a large bump on the forehead and was transferred to an acute care hospital. The hospital discharge summary documented a superficial hematoma on the forehead and instructed the facility to ensure fall precautions were taken. The interdisciplinary team narrative documented that the resident would remain on the Falling Star Program and have the bed placed in the lowest position with bed and chair alarms to alert staff that the resident was high risk for falls. Later, during a shower, a CNA unbuckled the resident from the shower chair and turned to reach for soap while the resident leaned forward to grab the shower head, causing the chair to tip over and the resident to fall off the chair. The record showed continuous monitoring was documented, but there was no documented evidence of revised or updated interventions after this fall. During observations, the resident was able to stand up and turn off the bed alarm, and the alarm continued sounding for several minutes before staff responded. Staff interviews confirmed the resident frequently got out of bed to turn off the alarm, that staff were expected to check the resident right away when the alarm sounded, and that the resident’s care plan had not been revised after the falls. The DON also stated there was no documented evidence that the fall prevention interventions were evaluated for effectiveness.
Failure to Assess and Reassess Pain After Tramadol Administration
Penalty
Summary
The facility failed to ensure safe, appropriate pain management for a resident receiving hospice services who was prescribed Tramadol for moderate pain. Resident 8 was admitted with diagnoses including Alzheimer's disease, cerebral infarction, Type 2 DM with hyperglycemia and a foot ulcer, and contractures of both knees. The resident's care plan identified that the resident received Tramadol and was at risk for adverse effects, with interventions to review pain medication efficacy, assess whether pain intensity was acceptable, and notify the physician if pain control was not adequate. The resident's cognitive skills were severely impaired, and the resident did not have the capacity to understand and make decisions. The record showed that Resident 8 received Tramadol as a routine medication via g-tube for moderate pain, and later the order summary indicated Tramadol HCL 50 mg every 8 hours for moderate pain. The resident's care plan for hospice care directed staff to assess for non-verbal indicators of pain, administer pain medication as ordered, and monitor effectiveness of the pain medicine and notify the physician as needed. However, during review of the MAR for May and June 2026, Resident 8 continued to receive Tramadol multiple times for pain levels documented as 0-4/10 without pain assessment and reassessment documented in the clinical record, including assessment of intensity, characteristics, patterns, frequency, timing, duration, and location of pain.
Failure to Document Alternatives and Monitor Bed Rail Use
Penalty
Summary
The facility failed to evaluate why alternative interventions were ineffective before installing four bed rails for Resident 10 and failed to monitor the resident’s use of side rails as required by the facility’s Bed Safety and Bed Rails policy. Resident 10 was admitted with acute and chronic respiratory failure with hypoxia, Type 2 DM with hyperglycemia, and generalized muscle weakness. The record showed that the only alternative intervention documented before bed rail use was one-to-one activities and supervision, but there was no documented evidence explaining why that alternative did not work. An order dated 3/30/2026 indicated bilateral full bed rails due to fall risk, and the care plan later documented all bed rails up and locked when in bed with an intervention to attempt less restrictive devices on an ongoing basis. Resident 10’s history and physical stated the resident did not have capacity to understand and make decisions, and the MDS described moderately impaired cognition, dependence for ADLs and functional mobility, no prior falls in the 2 to 6 months before admission, and daily use of bed rails. During observation, Resident 10 was found asleep in bed with all four bed rails up and locked. The DON stated there was no documented evidence of an active order for a low bed and no other alternative attempted with a documented reason for its inability to meet Resident 10’s needs before placing four bed rails. The DON also stated the care plan did not indicate monitoring for bed rails while in use and the Active Orders list did not show an active order to monitor the safe use of the bed rails.
Pharmacist Failed to Report Journavx Medication Irregularities
Penalty
Summary
The facility failed to ensure the consultant pharmacist identified and reported medication irregularities during the monthly medication regimen review for one resident who had been admitted and readmitted with chronic respiratory failure, a stage 4 sacral pressure ulcer, and dementia. The resident had a physician order dated 3/29/2026 for Journavx oral tablet 50 mg via G-tube every 12 hours for pain management, and the medication administration record showed the medication was administered via G-tube from 3/29/2026 through 6/15/2026. The consultant pharmacist’s medication regimen reviews for 4/2026, 5/2026, and 6/2026 contained no documentation that the pharmacist identified the irregularity or notified the physician, DON, or medical director that Journavx was being given via G-tube despite a pharmaceutical recommendation that it should not be crushed. The record also showed that from 6/1/2026 through 6/15/2026, acetaminophen liquid was administered and documented as effective on multiple dates, yet Journavx continued to be given every 12 hours. During interview and record review, the consultant pharmacist stated he had not notified the prescriber and did not know the medication was non-crushable. The DON stated that nurses were expected to identify the DO NOT CRUSH label and that the concern should have been addressed with the attending physician; the DON also stated medication use should be consistent with the resident’s condition and that administering a non-crushable medication in crushed form could have been ineffective and increase the risk of adverse effects.
Delayed notification of abnormal urine culture and sensitivity results
Penalty
Summary
The facility failed to notify Physician 1 of Resident 90’s final urine culture and sensitivity result when it was reported to the facility at 10:27 PM on 6/13/2026. Resident 90 was admitted with chronic kidney disease, an acquired kidney cyst, hydronephrosis with renal and ureteral calculous obstruction, and dementia, and her history and physical indicated she did not have the capacity to understand and make decisions. Her care plan identified her as at risk for fluid retention and recurrent UTI, with interventions to monitor for signs and symptoms of UTI and to follow up with laboratory results such as urinalysis and urine culture and sensitivity as ordered. Resident 90’s lab record showed that the urine culture grew Proteus mirabilis and that the final urine culture and sensitivity was reported to the facility on 6/13/2026 at 10:27 PM. During interviews, LVN 3 stated she did not know about the positive UA or urine culture until the morning of 6/15/2026 when RN 1 notified her. RN 1 stated she found the abnormal laboratory results first thing in the morning on 6/15/2026 and then notified Physician 1, and stated it was the responsibility of the licensed nurse to review lab results and notify the physician of abnormal or critical results promptly. The Infection Preventionist Nurse stated there was no documented evidence in the nursing progress notes that the final urine culture and sensitivity results were reported to Physician 1 on 6/13/2026 or 6/14/2026, and stated the licensed nurse who received the results did not notify Physician 1. The IPN also stated that if the licensed nurse was unable to notify Physician 1 promptly, the Medical Director should have been notified. Resident 90 did not start IV antibiotic treatment until the morning of 6/15/2026. The DON stated that when the facility receives abnormal or critical abnormal lab results, it is the responsibility of the licensed nurse to notify the physician promptly to prevent a delay in treatment.
Missing Prescriber Signature on Psychotropic Medication Consent
Penalty
Summary
The facility failed to ensure that informed consent for the use of lorazepam was signed by the prescriber for one sampled resident. Resident 76 was admitted with diagnoses including dementia and major depressive disorder, and the H&P stated the resident did not have the capacity to understand and make decisions. The MDS indicated severe cognitive impairment. A physician order dated 5/28/2026 prescribed lorazepam 0.5 mg by mouth as needed for anxiety manifested by agitation and aggressive behavior toward others for 14 days. During interview and record review, Resident 76’s informed consent for lorazepam was reviewed and found to have no prescriber signature. The RNS stated the prescriber would call the family to explain the benefits and risks of the medication to the resident’s representative and sign the informed consent, and stated the prescriber should have signed it. The DON also stated informed consent should be obtained prior to administering psychotropic medication and that the prescriber should have signed the form. The facility policy stated the prescriber must sign an informed consent form after explaining all necessary information to the resident or representative.
Failure to Provide Written Transfer and Bed-Hold Notices
Penalty
Summary
The facility failed to follow its transfer/discharge procedure for one resident when the resident’s responsible party was not notified in writing of the resident’s transfer to the hospital. The resident was admitted with diagnoses including dementia, atherosclerotic heart disease, and hypertension, and the MDS dated 5/9/2026 indicated mildly impaired cognition and memory. On 5/9/2026, the physician ordered the resident transferred to the hospital via 911 for chest pain and noted that a 7-day bed hold per facility protocol would be in place. During record review, the Notification of Bed Hold dated 5/9/2026 did not indicate that the responsible party was informed, and the Medical Records Director stated there was no signature from the responsible party showing understanding of the bed hold form. The Notice of Proposed Transfer/Discharge dated 5/9/2026 also did not indicate that the responsible party was informed, and the Medical Records Director stated there was no signature from the resident or responsible party on the form. The DON reviewed the facility’s policy titled Transfer or Discharge Notices and stated the facility did not follow the policy in this case regarding providing written documents for transfer and bed hold.
Failure to Develop Incontinence and Scheduled Toileting Care Plan
Penalty
Summary
The facility failed to develop a scheduled toileting care plan and an incontinence care plan for Resident 1. Resident 1 was admitted with diagnoses including spinal stenosis, chronic kidney disease, and dementia. The MDS dated 6/1/2026 indicated Resident 1's mental and cognitive functions were intact, that Resident 1 was occasionally incontinent of the bladder, and that Resident 1 required moderate assistance with toileting hygiene. The urinary continence task flowsheet from 5/5/2026 through 5/8/2026 showed episodes of urinary incontinence on 5/6/2026, 5/7/2026, and 5/8/2026. During interview and record review, the MDS Coordinator reviewed Resident 1's Bowel and Bladder Program Screener form dated 5/6/2026, which indicated Resident 1 was not continent of both bowel and bladder and was a candidate for scheduled toileting. The baseline care plan did not identify bladder incontinence, and the comprehensive care plan did not identify incontinence or scheduled toileting as focus areas. The MDS Coordinator stated Resident 1 should have been placed on a scheduled toileting program and that the intervention should have been reflected in the care plan and task flowsheets. The DON stated that if a resident is incontinent, this should be identified as early as the baseline care plan.
Failure to Reapply Skin Barrier Cream for Resident with MASD
Penalty
Summary
The facility failed to provide skin barrier cream per physician’s order for a resident with peri-rectal MASD. The resident had diagnoses including chronic respiratory failure, ventilator dependence, and gastrostomy dependence, and was documented as lacking capacity to understand and make decisions. The MDS indicated the resident was in a persistent vegetative state with impairment to both upper and lower extremities. The care plan and skin reassessment identified peri-rectal MASD with reddened, macerated, fragile skin and directed staff to provide treatment as ordered. The physician’s order required cleansing the peri-rectal area, patting it dry, and applying skin barrier cream daily and as needed. During observation, CNA 1 and CNA 2 provided peri-rectal hygiene care, but the resident’s buttocks had small pink areas of skin breakdown and no white barrier cream was present. CNA 1 cleansed the area and applied a new brief without applying cream, stating the treatment nurse had applied it earlier and that she would not notify the nurse because the redness was not new. The treatment nurse stated licensed nurses must apply the cream at least daily and as needed when it is wiped away, and that CNAs must notify him when brief changes occur so he can reapply it. The treatment nurse later observed that the resident did not have skin barrier cream on the buttocks and stated the CNAs should have notified him so more cream could be applied. The DON stated CNAs must notify the treatment nurse every time a brief change is performed because the cream may be wiped away during peri-rectal hygiene care.
Failure to Implement Scheduled Toileting for a Resident with Urinary Incontinence
Penalty
Summary
The facility failed to ensure a scheduled toileting program was implemented for one resident who was identified as a candidate for scheduled toileting. The resident was admitted with diagnoses including spinal stenosis, chronic kidney disease, and dementia. The Minimum Data Set indicated the resident’s mental and cognitive functions were intact, the resident was occasionally incontinent of the bladder, and required moderate assistance with toileting hygiene. The urinary continence task flowsheet showed episodes of urinary incontinence on multiple days. A bowel and bladder program screener form indicated the resident was not continent of both bowel and bladder and was a candidate for scheduled toileting. During interview and record review, the MDS Coordinator stated the resident should have been placed on a scheduled toileting program based on the screener results, and that such an intervention would appear on the care plan and task flowsheets if implemented. Review of the care plan and task flowsheets showed no scheduled toileting program was in place. The DON stated that if the screener form identifies a resident as a candidate for scheduled toileting, a care plan should be created to initiate the program, and the facility policy titled Urinary Incontinence stated staff will provide scheduled toileting to improve continence status if indicated by assessment.
Infection Control Lapse During Brief Change and Personal Care
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when CNA 1 did not perform hand hygiene after handling Resident 2’s soiled brief during ADL care. During observation, CNA 1 removed the soiled brief, cleaned Resident 2’s buttocks with a wet washcloth, and continued wearing the same gloves while placing a new brief on the resident, repositioning pillows, and touching the resident’s arm, head, and legs. CNA 2 was present during the care and returned the resident to a back-lying position in bed. Resident 2’s record showed a history of chronic respiratory failure, ventilator dependence, and gastrostomy dependence, and the resident did not have the capacity to understand and make decisions. The MDS indicated Resident 2 was in a persistent vegetative state with impairment to both upper and lower extremities. In interviews, CNA 1 stated she did not change gloves or perform hand hygiene after cleaning the resident’s buttocks and before placing the new brief, and acknowledged she should have done so for infection control. CNA 2, the IPN, and the DON each stated staff should change gloves and perform hand hygiene after changing a resident’s brief and before continuing care. The facility’s Infection Control policy stated staff must clean their hands after each direct resident contact and perform hand hygiene before and after assisting a resident with personal care and after handling linens.
Failure to Provide Immediate and Effective CPR to Full Code Resident
Penalty
Summary
The facility failed to provide immediate, effective, and uninterrupted basic life support (BLS) and cardiopulmonary resuscitation (CPR) to a resident who was identified as full code and found unresponsive and not breathing. Despite the resident's Physician Orders for Life Sustaining Treatment (POLST) indicating full code status, staff did not promptly activate the emergency response system (code blue), initiate the BLS sequence, or call 911 emergency services in a timely manner. There was a delay of 26 to 31 minutes from the time the resident was reported unresponsive to the time 911 was called. During this period, staff did not follow the facility's policy and procedure for CPR, which required immediate action. The staff involved, including an RN and two LVNs, did not perform effective and continuous CPR as required by professional standards and the facility's policy. Instead of performing chest compressions and rescue breaths at the recommended ratio and rate, the RN described performing a chest rub or gentle circular motion on the resident's chest, which does not meet the criteria for effective CPR. There was also no evidence that rescue breaths were provided, and the use of the crash cart and other emergency equipment was inconsistent. Interviews revealed confusion among staff regarding the resident's code status, the sequence of emergency actions, and the proper technique for CPR. The resident had a complex medical history, including pneumonia, acute respiratory failure with hypoxia, and chronic obstructive pulmonary disease (COPD) with exacerbation. The care plans and physician orders indicated the need for close monitoring and immediate intervention in the event of respiratory or cardiac arrest. Despite these directives, staff failed to document abnormal vital signs, did not communicate changes in the resident's condition effectively, and did not adhere to the established emergency protocols. When emergency medical services arrived, the resident was found deceased, with signs of lividity and no signs of life, indicating a significant lapse in the provision of life-sustaining treatment.
Inconsistent Documentation of Advance Directives and POLST Forms
Penalty
Summary
The facility failed to ensure that documentation regarding advance directives and Physician Orders for Life Sustaining Treatment (POLST) was accurate and consistent for two of five sampled residents. For one resident with chronic systolic heart failure and type 2 diabetes, the POLST indicated the presence of an advance directive, while the Advance Directive Acknowledgment form stated otherwise, and no advance directive was found in the medical chart. The Social Services Director confirmed the inconsistency and acknowledged that the information should have been clarified and updated to reflect the resident's wishes. For another resident with chronic respiratory failure and hypertensive heart disease, the POLST indicated no advance directive, but the Advance Directive Acknowledgment form stated that one existed. The Social Services Director was unable to determine which staff member completed the form and confirmed the mismatch between the documents. The facility's policy requires honoring residents' rights to formulate and have advance directives, but the inconsistent documentation failed to ensure that staff would have accurate information about residents' wishes in the event of a medical emergency.
Failure to Protect Resident Privacy with Improper Use of Monitoring Devices
Penalty
Summary
The facility failed to protect the privacy and confidentiality of three residents' personal and medical information by not restricting access to baby monitors used for resident monitoring. Observations revealed that cameras were installed in residents' rooms and the live video feeds were displayed on monitors placed in areas accessible to unauthorized personnel and passersby. For example, one resident's baby monitor was left on top of a medication cart in a public area, allowing anyone passing by to view the resident's bed, even when the resident was not present in the room. Additionally, monitors were left on at nursing stations or desks, sometimes unattended, with the display screens visible to anyone entering or passing by the area, including non-staff individuals. Staff interviews confirmed a lack of consistent understanding and adherence to privacy protocols regarding the use of monitoring devices. Some staff members were unaware of the intended use or placement of the cameras, while others admitted to leaving monitors on and in visible locations for convenience during medication passes or while away from the nursing station. The Director of Nursing acknowledged that the current practice could potentially violate residents' privacy, especially when the monitors captured and displayed images of residents who were not the intended subjects of monitoring. The facility's own policy required that monitoring devices be used solely as safety interventions, with access restricted to authorized staff and in a manner that respects residents' dignity and privacy. However, the observed practices did not align with these requirements, as monitors were left on and visible in public or semi-public areas, and sometimes displayed images of multiple residents without proper consent or notification to responsible parties.
Failure to Provide Safe and Appropriate Respiratory Care and Emergency Response
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's provision of respiratory care for three residents receiving oxygen therapy. For one resident, oxygen tubing was observed on the floor and not labeled with the date opened, contrary to facility policy, which requires tubing to be dated and kept off the floor to prevent contamination. A certified nursing assistant confirmed the tubing should not touch the floor due to infection control concerns, and the Director of Nursing stated that tubing should be changed if it comes into contact with the floor. Another resident, with a history of acute respiratory failure, pneumonia, and COPD, was not monitored or assessed according to physician orders and the care plan. The nursing staff failed to titrate oxygen as ordered for low oxygen saturation, did not consistently assess or document abnormal vital signs, and did not promptly notify the physician when the resident exhibited low and fluctuating blood pressure and oxygen saturation. Interviews revealed that abnormal blood pressure readings were sometimes omitted from documentation, and there was confusion among staff regarding the resident's code status and the appropriate emergency response. The facility's emergency response system was not activated in a timely manner, and there was a delay in calling 911 after the resident was found unresponsive with critically low oxygen saturation. Additionally, another resident's nasal cannula was not dated or stored in a clean bag when not in use, as required by facility policy. These practices placed residents at risk for infection and, in the case of the resident with acute respiratory failure, resulted in the resident being found dead upon EMS arrival. The facility's policies on oxygen administration, monitoring, and emergency response were not followed, and staff interviews confirmed lapses in documentation, assessment, and adherence to established procedures.
Outdoor Refuse Containers Not Properly Closed or Maintained
Penalty
Summary
The facility failed to ensure that five of five outdoor refuse containers were closed with tight-fitting lids and kept covered, as required by policy. Observations revealed that six outdoor refuse containers were overfilled with trash bags, preventing the lids from closing fully. One container was completely open, while the others could not be closed due to being overfilled. Housekeeping staff were unaware of which containers belonged to the facility, and it was noted that the containers were shared with a neighboring facility, contributing to the overflow. Staff from the neighboring facility also disposed of trash in these containers without clear designation of ownership. The Director of Maintenance confirmed that the containers were overfilled and could not be closed until the waste management company arrived later in the day. There were no labels or signs indicating which containers belonged to the facility, and the issue of shared containers had not been addressed. The facility's policy required all garbage and refuse containers to have tight-fitting lids and to be kept covered when not in continuous use, but this was not followed, as observed during the survey.
Failure to Notify Physician of Change in Condition
Penalty
Summary
The facility failed to notify the physician of a significant change in condition for one resident who developed edema, redness, and warmth in the left elbow. The resident had a history of chronic respiratory failure with hypoxia, contractures, and heart failure, and was dependent on staff for all activities. Initial assessments and skin evaluations upon admission and readmission did not document any edema or redness in the left elbow. On a subsequent assessment, the resident was observed to have a red, swollen, and warm left elbow. The treatment nurse and LVN both noted the change but were unsure if the physician had been notified, and there were no active treatment orders for the condition. Review of the resident's records, including physician orders and nursing progress notes, revealed no documentation that the physician had been informed about the new onset of edema or that any interventions had been initiated. Interviews with nursing staff and the Director of Nursing confirmed that the expectation was for licensed nurses to thoroughly assess residents and promptly report changes in condition to the physician. The facility's policy and procedure required immediate notification of the physician for changes such as swelling or discoloration. However, there was no evidence that this protocol was followed in the case of the resident's left elbow edema.
Failure to Define Behaviors and Perform Gradual Dose Reduction for Psychotropic Medication
Penalty
Summary
The facility failed to properly identify and define specific problematic behaviors related to the use of quetiapine, an antipsychotic medication, for a resident diagnosed with dementia and psychosis. Documentation across the resident's physician orders, care plan, informed consent, and medication administration record was inconsistent, with different descriptions of the behaviors justifying the use of quetiapine. This inconsistency made it unclear why the medication was being used and whether its continued use was necessary for the resident. Additionally, the facility did not perform a required gradual dose reduction (GDR) for the resident's quetiapine therapy. Although the consultant pharmacist recommended a GDR, there was no evidence that the physician considered or responded to this recommendation, nor was there documentation of any clinical rationale for not attempting a GDR. The resident's dose of quetiapine remained unchanged since its initial prescription, and there was no record of psychiatric care or evaluation regarding the ongoing need for the medication. The facility's own policy requires that psychotropic medications be used only for specific, documented behaviors and that GDRs be attempted regularly unless clinically contraindicated. Despite this, the facility did not ensure that the use of quetiapine for this resident was clearly justified or that efforts were made to reduce the dosage as required. The Director of Nursing acknowledged these failures, noting the lack of clear documentation and follow-up regarding the use and monitoring of psychotropic medication for the resident.
Failure to Complete and Submit Timely Quarterly MDS Assessment
Penalty
Summary
The facility failed to ensure that a resident's assessment was updated and submitted to CMS at least once every three months as required. Specifically, a resident who had been readmitted with diagnoses including anxiety and hypothyroidism did not have their quarterly Minimum Data Set (MDS) assessment completed and transmitted within the mandated timeframe. The MDS coordinator confirmed that the quarterly MDS was due but was not completed and transmitted until nearly two months after the target date. The delay was identified during a review of the resident's electronic health records and confirmed by the facility's CMS submission report. The resident in question had a history and physical indicating a lack of capacity to make decisions. Despite this, the required quarterly MDS assessment was not completed and submitted on time, as confirmed by both the MDS coordinator and the DON. The facility's own policy requires comprehensive assessments at intervals designated by OBRA and PPS requirements, but this was not followed in this instance, resulting in a failure to provide CMS with timely and accurate resident information for quality care measure and tracking purposes.
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, resulting in deficiencies related to communication and sensory needs. For one resident with dementia and diabetes, whose primary language was Korean, the care plan did not address the resident's language barrier. Multiple assessments and interviews confirmed that the resident required or preferred communication in Korean and needed an interpreter for interactions with healthcare staff. Observations showed the resident did not respond to English but did respond to Korean, and both nursing staff and family confirmed the importance of addressing the language barrier in the care plan. Despite this, the care plan lacked any mention of the resident's language needs. For another resident with end-stage renal disease, legal blindness, and bilateral lower limb amputations, the care plan did not address the resident's severe hearing impairment or the use of hearing aids (HA). Documentation and staff interviews confirmed the resident was hard of hearing and required HAs, but the care plan did not include interventions or monitoring related to hearing loss or HA use. The resident reported issues with the provided HA, including discomfort from background noise, and had requested follow-up appointments and updates, which had not been addressed. Staff interviews further revealed that the absence of a care plan for hearing impairment was an oversight, and that such a plan should have been developed. Facility policy required that comprehensive, person-centered care plans be developed within a specified timeframe after assessment, including measurable objectives and timetables to meet each resident's needs. The policy also emphasized the importance of culturally competent care and interdisciplinary team involvement. In both cases, the facility did not follow its own policies and procedures, resulting in the failure to address significant communication and sensory needs in the care plans for these residents.
Failure to Provide Ordered Restorative Nursing Treatments
Penalty
Summary
The facility failed to provide restorative nursing treatment as ordered for one resident with a history of left-sided hemiplegia, left hand contracture, and left ankle contracture. Physician orders and the resident's care plan required daily passive range of motion (PROM) exercises and the application of a left ankle-foot orthosis (AFO) and a left resting hand splint for four hours each day. Documentation and interviews revealed that from 5/16/2025 to 5/22/2025, the resident did not receive the ordered application of the left AFO, and from 5/20/2025 to 5/22/2025, the left resting hand splint was also not applied as required. Observations confirmed that the resident was not wearing the prescribed splint or AFO during multiple visits, and both the restorative nursing assistant and certified nursing assistant were unable to explain why the devices were not applied. The resident reported not having the devices on for several days, despite usually wearing them. The Director of Physical Therapy emphasized the importance of following physician orders to prevent further decline in range of motion and foot drop. Facility policy required restorative nursing care to be provided as outlined in the resident's plan of care, which was not followed in this instance.
Failure to Implement Fall Prevention Interventions for High-Risk Resident
Penalty
Summary
A deficiency occurred when staff failed to provide a safe environment for a resident with dementia, Parkinson's Disease, diabetes mellitus, and a recent history of falls. The resident was identified as high risk for falls and was enrolled in the facility's Falling Star/Super Star Program, which required specific interventions such as keeping the call light within reach and placing a floor mat next to the bed as per physician's orders. Despite these documented interventions, staff did not ensure the call light was accessible when the resident was left alone in the room in a wheelchair, and a floor mat was not placed after the room was deep cleaned, contrary to the physician's order and care plan. Observations and interviews confirmed that the call light was not within the resident's reach and that the required floor mat was missing. Staff members acknowledged these omissions, and the Director of Nursing confirmed that staff were responsible for implementing fall precaution interventions, including those not followed in this instance. Facility policy also required these interventions for residents at high risk for falls, but they were not consistently implemented for this resident.
Failure to Monitor and Document Catheter Care and Urinary Output
Penalty
Summary
The facility failed to provide necessary care and services to a resident with an indwelling catheter by not following its own policies and physician orders regarding monitoring and documentation. Specifically, after the initial 30-day period of intake and output (I&O) monitoring, there was no evaluation or documentation to determine if continued I&O monitoring was needed, as required by facility policy. Additionally, the nursing staff did not consistently monitor or document findings related to bladder distention, despite this being indicated in the resident's care plan and physician orders. The resident in question had a complex medical history, including urinary tract infection (UTI), obstructive and reflux uropathy, benign prostatic hyperplasia with lower urinary tract symptoms, urinary retention, and chronic respiratory failure. The care plan identified the resident as being at risk for alteration in urinary elimination and UTI due to the use of an indwelling catheter. Interventions included monitoring urine characteristics and output, observing for bladder distention, and notifying the physician of any changes. However, after the initial 30 days, there was no record of continued I&O monitoring, and staff interviews revealed that urine output was not measured or reported unless specifically done by CNAs and communicated to nurses. Documentation was also lacking regarding the assessment of bladder distention and specific signs and symptoms of UTI, even when such symptoms were present. For example, on two occasions, the presence of UTI symptoms was noted in the treatment administration record, but no specific symptoms or bladder assessments were documented in the nursing notes. The resident later experienced gross hematuria and required catheter replacement and hospitalization. Staff interviews confirmed that required assessments and documentation were not consistently performed as ordered.
Failure to Provide Medically-Related Social Services for Hearing-Impaired Resident
Penalty
Summary
The facility failed to provide medically-related social services for a resident who was hard of hearing and dissatisfied with the provided hearing aids. The resident, who also had end stage renal disease, legal blindness, and bilateral lower limb amputations, was documented as having significant hearing and vision impairments but was cognitively intact. Despite a physician order for an audiology consult as needed for hearing problems, and repeated requests from the resident, responsible party, and nursing staff, the Social Service Director (SSD) did not arrange an appointment with the resident's preferred audiologist (Provider 1) after the resident expressed dissatisfaction with the new hearing aids due to disturbing background noise. Documentation showed that the resident received new hearing aids and initially reported satisfaction, but soon after reported issues with background noise and requested to return the aids and see his previous audiologist. Multiple progress notes and interviews confirmed that the resident, his responsible party, and nursing staff repeatedly asked the SSD for updates and assistance in scheduling an audiology appointment. The SSD acknowledged receiving these requests but did not follow through, citing difficulty contacting the provider and ultimately not making the appointment or providing updates. Observations confirmed that the resident was not using the hearing aids and required staff to raise their voices to communicate. The facility's policies and job descriptions required the SSD to assist with medically-related social services, including arranging for needed services and facilitating communication needs. However, there was no documented evidence that the SSD clarified provider contact information or made the necessary referral, resulting in the resident remaining hearing impaired and negatively impacting his quality of life.
Failure to Respond to Pharmacist's GDR Recommendation for Psychotropic Medication
Penalty
Summary
The facility failed to respond to a consultant pharmacist's recommendation for a gradual dosage reduction (GDR) of quetiapine for a resident diagnosed with dementia and psychosis. The pharmacist made the recommendation on 2/5/25, and although the facility left a message with the psychiatrist on 2/9/25, there was no documented response from the physician or evidence of further follow-up. The resident's clinical record did not contain documentation of psychiatric care or any indication that a physician considered the GDR request, approved a lower dose, or provided a resident-specific clinical rationale for not attempting a GDR. Additionally, the facility did not clearly identify or document the specific behavioral issues related to the resident's use of quetiapine. The problematic behaviors listed in the physician's order and informed consent documentation differed from those in the care plan and medication administration record, making the rationale for continued use of quetiapine unclear. The Director of Nursing confirmed that a GDR was not performed and that there was no documentation to indicate that a GDR attempt was clinically contraindicated, as required by facility policy.
Failure to Honor Resident Food Preference
Penalty
Summary
A deficiency occurred when the facility failed to honor a resident's documented food preference. The resident, who had diagnoses including hypertension, anemia, osteoarthritis, dementia, and muscle weakness, was admitted and assessed as having moderately impaired cognition and requiring assistance with eating. The resident's care plan and dietary notes specifically indicated a dislike for beef, and the meal ticket on the lunch tray also reflected this preference. Despite these clear indications, the resident was served beef chop suey for lunch, as observed by staff and confirmed by the resident, who stated she did not like beef. Interviews with the restorative nursing assistant, dietary supervisor, and cook revealed that the cook overlooked the meal ticket and served beef to the resident. Both the dietary supervisor and the restorative nursing assistant acknowledged that the resident's food preference should have been honored and that alternative protein options were available. Facility policy and procedure documents reviewed also confirmed the requirement to honor resident food preferences and ensure meal tickets accurately reflect these preferences.
Failure to Accurately Document Resident's Change of Condition and Vital Signs
Penalty
Summary
The facility failed to maintain complete and accurate documentation of all services provided to a resident, as well as progress toward care plan goals and changes in the resident's medical, physical, functional, or psychological condition. The resident in question had a complex medical history, including pneumonia, acute respiratory failure with hypoxia, COPD with exacerbation, chronic kidney disease, dementia, and other comorbidities. The care plan required close monitoring of oxygen saturation, prompt notification of the physician for significant changes, and documentation of all relevant assessments and interventions. Despite these requirements, there was a lack of documented evidence regarding abnormal vital signs, specifically low and fluctuating blood pressure readings and oxygen saturation levels below 90%. Multiple nurses admitted during interviews that they did not consistently document abnormal findings, with some stating they only recorded 'good' numbers or did not document unless a significant event occurred. One nurse reported that she would be questioned by facility leadership if she documented 'bad' numbers. There was also a lack of documentation regarding the resident's change of condition prior to the emergency event, and the physician was not clearly notified of the resident's unstable status. The deficiency resulted in an inaccurate depiction of the resident's care and health status, as critical information about the resident's deteriorating condition was omitted from the medical record. The facility's own policies required objective, complete, and accurate documentation of all changes in condition and interventions, but these were not followed. The lack of documentation was confirmed by both record review and staff interviews, and the resident ultimately experienced a severe event leading to death, with emergency responders noting the resident was dead on arrival and had signs of having been deceased for some time.
Failure to Label Enteral Feeding Formula Bag
Penalty
Summary
The facility failed to ensure that the enteral tube feeding formula bag for one resident was labeled with the date and time it was opened and hung, as required by the facility's policy and procedure for enteral feeding monitoring. During observation, an opened bag of Fibersource formula was found hanging from an IV pole next to the resident's bed, with the feeding tubing placed inside the feeding pump and ready for infusion. There was no open date indicated on the formula bag, and the licensed vocational nurse present was unable to state when the bag was opened or if it was expired. The nurse confirmed that the bag should have been labeled with the date and time, and acknowledged not knowing when the current bag was started. The resident involved had a history of dementia and gastrostomy, with severe cognitive impairment and dependence on staff for all activities of daily living. The physician's orders specified the administration of tube feeding at a set rate and schedule. The facility's policy required licensed nurses to write the time, date, and rate on the formula bottle, and to discard closed system formula after 48 hours. The lack of labeling on the formula bag meant staff could not determine if the formula was still safe for use, which was confirmed by both the nurse and the Director of Nursing during interviews.
Resident Rooms Below Minimum Size Requirement
Penalty
Summary
The facility failed to ensure that resident rooms met the required minimum size of 80 square feet per resident for multiple occupancy rooms, as determined through observation, interviews, and record review. Specifically, 27 out of 50 sampled rooms were found to be occupied by three residents each, with total room sizes ranging from 217 to 223.24 square feet, resulting in each resident having less than the required 80 square feet of personal space. The Client Accommodations Analysis form confirmed these measurements, and the rooms in question provided between 72.33 and 74.41 square feet per resident. Despite the deficiency in room size, interviews with staff and residents indicated that they felt there was enough space to perform necessary care tasks, use mobility aids, and maintain privacy. Observations during the survey period also noted that the rooms allowed for adequate movement, nursing care, and use of equipment. However, the facility did not meet the regulatory requirement for minimum room size per resident in the identified rooms.
Incompetent CNA Assigned Double Shifts Despite Warnings
Penalty
Summary
The facility failed to ensure that a Certified Nurse Assistant (CNA 1) demonstrated the necessary competency skills to care for residents as indicated in their care plans. CNA 1 was assigned to work double shifts despite the facility being aware of her incompetency, which included sleeping during work hours, taking longer breaks than scheduled, leaving work without notifying anyone, and failing to change or reposition residents who were found soiled. These actions resulted in residents not receiving the quality of care necessary to achieve their highest potential, leading to a decline in their well-being. The report details that CNA 1 had received written warnings for her performance issues, which were reported by both a Registered Nurse Supervisor and a charge nurse. Despite these warnings, CNA 1 continued to work multiple shifts to cover staffing shortages, as confirmed by the Director of Staff Development (DSD). The DSD acknowledged the staffing shortages and the facility's decision not to use agency staff, which led to CNA 1 working extra shifts. The facility's policy requires sufficient and competent nursing staff, but the DSD did not respond when asked if staff with poor performance warnings were allowed to continue working with residents.
Inadequate Supervision and Monitoring Leads to Resident Falls
Penalty
Summary
The facility failed to ensure that two residents, identified as Resident 1 and Resident 3, were free from accident hazards and provided with adequate supervision to prevent falls. Resident 1, who was admitted with dementia, difficulty walking, and osteoarthritis, was found on the floor by a CNA who did not follow protocol by calling a nurse before assisting the resident back to bed. The resident's care plan indicated a high risk for falls due to cognitive impairment and unsteady gait, yet the CNA was not informed of the resident's fall risk or the necessary interventions to prevent falls. Resident 3, who had severe cognitive impairment and was dependent on assistance for mobility, was found on the floor with injuries after attempting to use a commode that had been moved away from the bed. The bed alarm, which was supposed to alert staff when the resident attempted to get up, was not functioning. The CNA responsible for Resident 3 admitted to leaving the room and later finding the resident on the floor, indicating a lack of proper supervision and monitoring. Interviews with staff revealed communication breakdowns and inadequate training, as CNAs were not fully aware of residents' fall risks or the interventions required to prevent accidents. The facility's policies on fall risk assessment and accident prevention were not effectively implemented, leading to repeated falls and injuries for the residents involved.
Failure to Accommodate Resident Communication and Safety Needs
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of three residents, leading to significant communication barriers and unmet needs. Resident 88, who has severe cognitive impairment and does not speak the dominant language, was not provided with a communication board. This resulted in the resident being unable to effectively communicate her needs, such as requesting food, which was not understood by the staff. The CNA was unaware of the resident's needs due to the absence of the communication board, leading to unmet needs and potential neglect of care. Resident 98, who also has cognitive impairments and prefers to communicate in his native language, was not provided with a communication board in his preferred language. This led to misunderstandings and refusals of oral care, as the resident did not understand the staff's requests. The CNA used an incorrect communication board, which further confused the resident and resulted in the resident not receiving necessary oral hygiene care. The DON acknowledged that the correct communication board should have been used to ensure the resident's needs were met. Resident 7, who has severe cognitive impairment and is at risk for falls, was found with the call light out of reach. This deficiency could prevent the resident from calling for assistance, especially in emergencies. The CNA and ADM both confirmed that the call light should always be within the resident's reach to ensure safety and timely assistance. The facility's policy also mandates that call lights be accessible to residents at all times, highlighting a failure to adhere to established protocols.
Failure to Maintain Accurate Advance Directive Documentation
Penalty
Summary
The facility failed to ensure that residents' medical records were updated to indicate documentation that advance directives (AD) were discussed and written information was provided to the residents and/or responsible parties. This deficiency was observed in four of the five sampled residents. For instance, Resident 7's clinical chart lacked a signed Advance Directive Acknowledgement (ADA) form, which was instead stored in an overflow chart, making it inaccessible during emergencies. Similarly, Resident 113's clinical chart did not contain an ADA form, and there was no evidence that the resident or their responsible party was informed about their right to formulate an AD. Resident 107's chart also lacked an ADA form, and it was unclear if the resident or their responsible party was informed about their rights regarding ADs. Additionally, the facility failed to ensure that AD and Physician Orders for Life-Sustaining Treatment (POLST) were current and part of Resident 39's clinical records. Resident 39 had an AD and POLST, but these documents were not present in the resident's chart at the time of review. The Social Service Director acknowledged that the AD and POLST should have been in the resident's chart and that the resident's History and Physical (H&P) needed to be updated to reflect the presence of these documents. The absence of these critical documents in the clinical chart could lead to inaccurate care and treatment, especially during emergencies. The facility's policy and procedure titled
Failure to Complete MDS Assessments Timely
Penalty
Summary
The facility failed to ensure the comprehensive Minimum Data Sets (MDS) were completed within the required time frame for four sampled residents. Resident 70, who was admitted with dementia and hyperlipidemia, had an MDS target date of 4/2/24, but the assessment was completed on 5/8/24 and submitted on 5/16/24. The MDS Nurse (MDSN) admitted that the assessment was late due to being occupied with other tasks. Similarly, Resident 54, admitted with hyperlipidemia and anemia, had an MDS target date of 4/2/24, but the assessment was completed on 5/10/24 and submitted on 5/16/24. The MDSN acknowledged the delay and cited the same reason for the late submission. Resident 4, who was admitted with dementia and anemia, had an MDS target date of 4/2/24, but the assessment was completed on 5/14/24 and submitted on 5/16/24. The MDSN again admitted that the assessment was late due to other tasks. Resident 100, admitted with seizure and anemia, had an MDS target date of 4/1/24, but the assessment was completed on 5/14/24 and submitted on 5/16/24. The MDSN stated that the assessment was completed late due to being too busy with other tasks. During interviews, the MDSN and the Director of Nursing (DON) both acknowledged that the late assessments could result in delayed treatment and compromised quality of care. The DON emphasized the importance of timely assessments to ensure consistent and quality care for residents. The facility's failure to complete and submit the MDS assessments on time was attributed to staff being too busy with other tasks, which could negatively affect the provision of necessary care and services for the residents.
Failure to Timely Complete and Submit Quarterly MDS
Penalty
Summary
The facility failed to ensure the quarterly Minimum Data Sets (MDS) were completed and submitted to the CMS database within the required time frame for four sampled residents. Resident 70, diagnosed with dementia and hyperlipidemia, had an MDS target date of 1/4/24, but the assessment was completed on 3/28/24 and submitted on 4/3/24. Similarly, Resident 54, with hyperlipidemia and anemia, had an MDS target date of 1/4/24, but the assessment was completed on 3/29/24 and submitted on 4/3/24. Resident 4, diagnosed with dementia and anemia, had an MDS target date of 1/11/24, but the assessment was completed on 3/29/24 and submitted on 4/3/24. Lastly, Resident 100, with seizures and anemia, had an MDS target date of 1/2/24, but the assessment was completed on 2/19/24 and submitted on 5/16/24. All these assessments were completed and submitted late, beyond the 14-day requirement from the assessment reference date (ARD). The MDS Nurse (MDSN) acknowledged the delays and attributed them to staffing issues, which led to the MDSN and the MDS Coordinator being pulled to perform other tasks in the facility, resulting in the late completion and submission of the assessments. During interviews, the MDSN and the Director of Nursing (DON) confirmed that the late assessments could result in delayed treatment, potentially compromising residents' quality of care and safety, especially for those with major condition changes. The DON stated that the facility had staffing issues that affected the timely completion of the MDS and that extra staff was utilized to help catch up with MDS completion. The DON emphasized the importance of timely assessments to ensure consistent and quality care for the residents. The CMS Resident Assessment Instrument (RAI) Version 3.0 Manual, dated October 2023, indicates that the quarterly MDS must be completed no later than 14 calendar days from the ARD and transmitted no later than 14 days from the MDS completion date. The facility's failure to adhere to these guidelines resulted in the late completion and submission of the MDS for the four sampled residents, potentially affecting their care and treatment.
Failure to Assist Residents with ADLs
Penalty
Summary
The facility failed to assist four of five sampled residents with activities of daily living (ADL), specifically in maintaining good grooming and personal and oral hygiene. Resident 19 and Resident 87, both with severe cognitive impairments and physical contractures, were observed with untrimmed and dirty fingernails. Despite care plans indicating the need for assistance with grooming, including nail trimming, these tasks were not performed by the assigned CNAs. The Director of Nursing (DON) confirmed that nail care is a CNA duty and should be done on bath days and as necessary, as per the facility's policy on nail care. Resident 98, who has moderate cognitive impairment and requires partial assistance for oral hygiene, was found to have poor oral hygiene with red gums, food stuck to the teeth, and no oral care kit available. The resident reported never having received assistance with teeth cleaning since admission. Observations and interviews with staff confirmed that oral care was not consistently provided, despite care plan interventions requiring dental/oral care twice a day. The DON acknowledged that CNAs are expected to provide oral care as part of their daily tasks and should report any issues to the Charge Nurse. The facility's failure to provide necessary grooming and oral hygiene assistance as outlined in the residents' care plans resulted in poor hygiene and discomfort for the residents. The lack of adherence to the facility's policies on nail care and oral hygiene was evident, as confirmed by staff interviews and observations. This deficiency had the potential to negatively impact the residents' quality of life and self-esteem, as well as pose health risks such as infections and dental issues.
Improper Sanitation and Food Handling Practices
Penalty
Summary
The facility failed to follow proper sanitation, preparation, and food handling practices, which could prevent the outbreak of foodborne illness. During a kitchen observation, a heavily rusted can opener with peeling chrome plating was found on top of a three-compartment sink. The can opener was used by a kitchen cook to open canned food that morning. The Certified Dietary Manager acknowledged the need to replace the can opener due to its deteriorated condition, which could potentially contaminate the food. The facility's policy indicated that equipment should be kept in proper working condition and any unsafe items should be reported immediately, which was not adhered to in this case. Additionally, during an observation of the dishwashing process, a dietary assistant failed to properly test the chlorine level in the dishwasher. The assistant did not compare the color of the test strip to the color chart in the test strip container, relying instead on memory and experience. The facility's policy and the manufacturer's guidelines required the chlorine level to be between 50-100 PPM, and a chlorine log to be maintained. This failure to follow proper procedures could result in inadequate disinfection of dinnerware used by residents.
Failure to Apply Pressure to Lacrimal Duct During Eye Drop Administration
Penalty
Summary
The facility failed to meet professional standards of quality for Resident 27 by not applying gentle pressure to the lacrimal duct after administering Carboxymethylcellulose sodium ophthalmic solution. This practice is necessary to prevent systemic absorption of the medication. During a medication pass observation, an LVN administered the eye drops without applying the required pressure to the lacrimal duct, despite following other standard procedures such as washing hands, donning gloves, and documenting the administration on the MAR. The LVN admitted to being unaware of the need to apply pressure to the lacrimal duct and only realized the correct procedure after searching for information online during the interview with the surveyor. Resident 27, who has diagnoses including Alzheimer's disease and hyperlipidemia, was admitted to the facility with severely impaired cognitive skills and required moderate assistance with daily activities. The resident's physician had ordered the administration of Carboxymethylcellulose sodium ophthalmic solution four times a day for dry eyes. The Director of Nursing confirmed that the LVN should have applied gentle pressure to the lacrimal duct to prevent the medication from draining away from the eye, as per the instructions on the product package.
Inadequate Training on Low Air Loss Mattress Settings
Penalty
Summary
The facility failed to ensure that nurses were competent in maintaining the correct settings on low air loss mattresses (LALM) based on residents' weights. This deficiency was identified through observations, interviews, and record reviews. For instance, Resident 35, who had a physician order for an LALM for skin maintenance, was observed with incorrect LALM settings on multiple occasions. The Minimum Data Set Nurse (MDSN) found that the LALM settings for at least four residents, including Resident 35, were incorrect during his rounds. Despite the MDSN adjusting the settings, subsequent observations showed that Resident 35's LALM was still set incorrectly. Interviews with various staff members, including Licensed Vocational Nurses (LVNs) and the Director of Staff Development (DSD), revealed a lack of consistent knowledge and training regarding the correct settings for LALMs. LVN 3 and LVN 4 admitted to either not knowing how to set the LALM or not recalling any training on the matter. The DSD and the Treatment Nurse (TN) provided conflicting information on whether the LALM should be set to the lower or upper limit based on the resident's weight. This inconsistency in understanding and practice among the staff contributed to the incorrect settings observed. The Quality Assurance Consultant (QAC) and the Director of Nurses (DON) acknowledged that the facility had recently changed the LALM company, and the new devices had different settings from the previous ones. The QAC confirmed that the product's manual did not specify how to adjust the settings, leading to confusion among the staff. The DON admitted that proper guidance and in-service training should have been provided before the new products were rolled out to ensure all staff were aware of the correct guidelines. This lack of training and clear instructions resulted in the improper use of LALMs, potentially compromising the residents' skin integrity and overall well-being.
Medication Cart Left Unlocked
Penalty
Summary
The facility failed to ensure the safe provision of pharmaceutical services when one of seven medication carts was left unlocked before a Licensed Vocational Nurse (LVN) entered a resident's room to administer medications. During a medication pass observation, the LVN did not lock the medication cart, which was left unattended in the hallway with two staff members standing nearby and a resident walking past the unlocked cart. The LVN admitted to forgetting to lock the cart and acknowledged the importance of keeping it locked for resident safety. The Director of Nursing (DON) confirmed that the medication cart should always be locked unless in use to prevent unauthorized access. A review of the facility's policy and procedure indicated that medication carts must be kept closed, locked, and secure during medication administration. The failure to lock the medication cart posed a risk of unauthorized access to medications, which could lead to serious harm if ingested by residents.
Failure to Implement Infection Control Policy for Enteral Feedings
Penalty
Summary
The facility failed to implement its infection control policy and procedure for enteral feedings for Resident 6, who was found with a gastrostomy tube (GT) feeding on the floor. Resident 6, who has a history of hypertensive heart disease with heart failure, muscle weakness, and dementia, was observed with the GT feeding tube on the floor, uncovered, and attached to a feeding pump machine that was off. The resident's care plan indicated a risk for infection and required the tubing to be changed per policy or as ordered, and the equipment to be cleaned and disinfected as indicated. Certified Nurse Assistants (CNAs) 3 and 5 were observed assisting Resident 6 and found the GT feeding port on the floor. CNA 5 picked up the uncovered port and reconnected it to Resident 6's GT port, then covered it with a towel. Registered Nurse (RN) 2 was later informed by CNA 3 about the situation and restarted the GT feeding without changing the contaminated tube. RN 2 admitted to not knowing the tube had been on the floor and continued using the same tube. Interviews with the Infection Prevention Nurse (IPN) and the Director of Nurses (DON) revealed that the proper protocol was not followed. The IPN stated that the entire GT feeding system should have been changed if it touched the floor, as it would be considered contaminated. The DON confirmed that the CNA should have notified the Charge Nurse immediately to have the tube feeding system changed to prevent infection risk. The facility's policy on enteral feedings and infection control emphasized maintaining aseptic technique and changing administration sets if contaminated.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Rosemead
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Green Acres Healthcare Center | 0 mi | ★★★★★ | 12 | 0 |
| Monterey Healthcare & Wellness Centre, Lp | 0.2 mi | ★★★★★ | 24 | 0 |
| Del Mar Convalescent Hospital | 1.5 mi | ★★★★★ | 19 | 0 |
| Rio Hondo Subacute & Nursing Center | 2.1 mi | — | 51 | 0 |
| Monterey Park Conv Hosp | 2.2 mi | ★★★★★ | 19 | 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 August 2026) and official state health department websites.