Below average — CMS composite of the measures below.
The next survey window likely opens around April 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 Santa Anita Convalescent Hospital during CMS and state inspections, most recent first.
Inaccurate Medication Record Entry: An LVN entered an Ativan order under the wrong resident’s eMAR while training another nurse, even though there was no physician order for that resident and no documentation of anxiety or verbal aggression. The DON confirmed the order belonged to another resident, and staff stated the resident did not exhibit the behaviors tied to the order. The facility’s documentation policy required nursing documentation to be accurate.
A resident with dementia, contractures, and high fall risk developed a swollen, bruised, and painful L arm with no known cause. Staff observed the arm was purple, swollen, and bumped, and the RN, QA nurse, and ADM stated it was an injury of unknown origin that should have been reported within 2 hours, but it was not reported as required by facility policy.
Failure to Develop Individualized Care Plan for Bone Density and ADL Needs: The facility did not develop an individualized, resident-centered care plan with measurable goals, timeframes, and interventions for a resident with osteopenia, dementia, and significant ADL dependence. Record review showed the resident required substantial to maximal assistance with several ADLs and was at high fall risk, while staff interviews confirmed there was no ADL care plan related to bone density despite the resident’s assessed needs.
Incomplete Nursing Documentation After PRN Ativan Administration: A resident with anxiety, psychosis, dementia, and impaired decision-making received PRN Ativan for restlessness, but the RN/LVN progress note only stated the medication was effective and did not document the resident’s observed behavior at reassessment. The LVN reported the resident remained agitated and kept trying to get out of bed after the dose, while the QAN confirmed the note lacked the required description of the resident’s condition and response.
A resident with epilepsy had only one siderail padded even though seizure precautions required both siderails to be padded, and a pad was found under the bed. Another resident receiving oxygen had an oxygen machine at the bedside, but no Oxygen in Use sign was posted. A resident with a recent LBKA was transferred alone by a CNA despite needing substantial to maximal assistance, causing the stump to hit the floor. A separate resident at high fall risk was observed with the bed brakes not locked, contrary to the facility’s fall management policy.
Failure to obtain informed consent for psychotropic medications. Two residents received psychotropic drugs without completed consent documentation. One resident with dementia, bipolar disorder, and other psychiatric diagnoses received Valproic Acid for verbal aggression, but the RP said he was not informed of the medication, its risks and benefits, or alternatives, and the chart had no consent on file. Another resident with vascular dementia, schizophrenia, and a mood disorder received Seroquel and Rexulti, but the consent forms lacked signatures from the resident or RP, despite facility policy requiring signed informed consent from the resident/representative and physician.
Call lights were not kept within reach or usable for four residents with significant cognitive and physical impairments. One resident could not physically pull the call light due to poor hand function, two residents had call lights placed out of reach and could not use them, and another resident had a broken call light clip that left the device unsecured and out of reach while in bed. Staff interviews confirmed the call lights were not appropriate or accessible for the residents' needs, and the DON stated residents should have had call lights within reach or an adaptive device when needed.
MDS assessments for six residents contained incorrect names in Section A on two assessments each. The MDSN stated the system auto-populates names from the EHR and that she was not aware of the name changes, so modification MDSs were not submitted to CMS. The DON stated inaccurate MDS documentation could affect continuity of care and resident outcome tracking, and the facility’s RAI policy requires accurate resident assessment.
Medication administration and controlled drug documentation were inaccurate for two residents. One resident did not receive Lactulose as scheduled when staff forgot the dose and the facility had run out, and another resident received Rivaroxaban and Venlafaxine HCL without food despite orders to give them with food. In addition, hydrocodone-acetaminophen CDRs for a resident were not accurately documented, with mismatched counts and signatures that did not reflect what was actually administered or refused.
Expired wound care and nutritional supplies were found in a med storage room, a controlled med was stored with other meds in the refrigerator instead of a separate locked box, loose pills were discovered in a med cart, unopened latanoprost was kept in the cart rather than refrigerated, and an expired first aid kit was found with emergency supplies. The DON and LVNs confirmed the storage and expiration issues during observation and interview.
Infection Prevention and Control Lapses: A resident with a PICC line had a dressing observed without a date or initials despite an order to change it every 7 days, and an LPN administered an IM ceftriaxone injection to another resident without wearing gloves. In addition, multiple disinfectant wipe containers on several nursing units were observed with lids left open, contrary to staff teaching, the IPN’s explanation, manufacturer instructions, and facility policy.
Failure to Maintain Resident Privacy During ADLs: A resident with Parkinson’s disease, DM 2, anxiety disorder, and bipolar disorder was left exposed from the waist down during ADLs when a CNA left the room without closing the curtain. The resident had intact cognitive skills and needed substantial to maximal assistance with toileting hygiene. The CNA, an LVN, the resident, and the DON all confirmed the curtain should have been closed to protect privacy and dignity.
The facility failed to complete a resident’s MDS within the required 14-day admission timeframe. The resident had malnutrition, DM2, and dementia, and the MDS sections for mood, behavior, and participation in assessment and goal setting were not completed. The MDS Nurse confirmed the assessment was completed 23 days after admission and stated it was not completed on time.
A resident’s discharge-return not anticipated MDS was not completed within the required timeframe after the resident was discharged home. The MDS Nurse stated she was responsible for timely completion and transmission of MDS assessments to CMS and acknowledged the discharge MDS was completed late, beyond the 14-day post-discharge window described in the CMS RAI manual and facility policy.
Measurable Activity Care Plan Not Developed: A resident with malnutrition, DM2, and dementia had an activity care plan that identified dependence on staff for activities, cognitive stimulation, and social interaction, but the goal to remain involved in cognitive and social activities lacked measurable objectives. The AD and ACC both stated the plan was not measurable or quantifiable, despite the facility policy requiring measurable objectives and timetables.
Care Plans Not Reviewed by Target Date: A resident with malnutrition, DM2, and dementia had Dietary, Nursing, Social Services, and Therapy care plans that were not reviewed and completed by the target date in the EMR. The MDSN confirmed the care plans were not revised on time and stated this delays the resident's care. The resident was severely cognitively impaired and needed help with ADLs.
A resident with quadriplegia, kidney failure, urine retention, and a Foley catheter was observed with catheter tubing hanging in a dependent loop below the collection bag, with urine pooled in the tubing. A later observation showed the same issue. An LVN stated Foley tubing should drain continuously without dependent loops or kinks, and the DON stated staff were not following the facility policy requiring tubing to be secured to prevent dependent loops.
Respiratory care was not provided as ordered for two residents. One resident with COPD and dementia was observed without continuous O2 in place despite an order for 2 L/min via NC, and the oxygen equipment was found off or stored beside the bed. Another resident with aphasia, respiratory failure, and COPD had an order for Ipratropium-Albuterol nebulizer treatments, but was observed sleeping without the nebulizer mask on while the treatment was running; the ADON confirmed the mask was not in place and the DON stated the resident did not receive the full dose of medication.
Dialysis Resident Left Water Pitcher at Bedside Despite Fluid Restriction. A resident with ESRD, dialysis dependence, and severe cognitive impairment had an order for no water pitcher at bedside due to fluid restriction. During observation, the resident was seen with a water pitcher on the table despite a posted sign stating no water pitcher at bedside. An LVN and the DON stated the pitcher should not have been there because the resident was on fluid restriction and intake needed to be monitored.
Failure to provide medically related social services for a resident with loose upper teeth and a request for new dentures. The resident had dementia and lacked decision-making capacity, with RP involved as the decision maker. Social services documented the denture request but did not follow up with the dental clinic or update the RP for months. The resident remained worried about swallowing the loose teeth, and the DON stated the SSW should have followed up with the dentist and kept the family informed.
Medication administration errors caused the facility’s error rate to exceed 5 percent. During med pass, an LVN gave a resident’s Rivaroxaban and Venlafaxine HCL with water and without food, even though both the order and bubble pack indicated they should be taken with food. The LVN said she assumed breakfast earlier in the morning made it acceptable, and the DON stated the meds should have been given with food or a snack.
Late Lunch Tray Delivery: A resident with Parkinson's disease, DM2, anxiety disorder, and bipolar disorder, who had intact cognition and could make medical decisions, did not receive lunch at the scheduled delivery time. The resident reported that lunch had been arriving late for months, sometimes around 1:30 PM, and said the food did not taste good anymore. The DON and KS stated meal trays should be delivered around the scheduled time, and the facility policy listed regular meal times of 7 AM, 12 PM, and 5 PM.
A resident with severely impaired cognition and no decision-making capacity was given a Twinkie that had been brought in for another resident. CNA 5 took the food from one resident's room to the other, and an LVN opened the wrapper and fed it to the resident. Staff, including the IPN and DON, stated the food should not have been shared because of cross contamination and infection control concerns, and the facility's visitor-food policy required outside food to be stored and identified for the intended resident.
Incomplete medication documentation was found for two residents. One resident’s IV meropenem dose was administered by an RN but not documented in the IV administration record, and another resident’s Endocet dose was documented at different times in the MAR and controlled drug record. Staff interviews confirmed the records were not completed right after administration, and the DON and ADON stated medication documentation should be accurate and completed immediately after giving the drug.
A resident with HF and DM and documented decision-making capacity signed an arbitration agreement without being properly informed of its terms or the right to refuse. The resident said he did not know about the agreement and wanted to sue in court if he had a dispute, while admission staff incorrectly told him he could still go to court after arbitration and could rescind at any time. The ADM later stated that signing the agreement meant giving up the right to resolve disputes in court before a jury, with only a 30-day rescission period.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
A resident with Alzheimer’s disease, Parkinson’s disease, and GERD, who lacked decision-making capacity and had a POA identified as responsible party, had an arbitration agreement in the medical record showing electronic signatures for both the resident and the POA even though neither actually signed the document. The admission coordinator and assistant administrator reported that a third‑party electronic admission system automatically marked documents as signed once the admission packet was opened, without requiring true signatures. The POA confirmed receiving but not signing the arbitration agreement, while facility policies required accurate, complete records and resident/representative signatures on admission and arbitration agreements only when they agree to the terms.
A resident with Alzheimer's disease, dementia, type 2 DM, and impaired decision-making capacity was prescribed Zyprexa 2.5 mg at bedtime for bipolar disorder manifested by screaming without cause. A Schizophrenia Diagnosis Checklist showed the resident did not meet criteria for schizophrenia, yet the consent form documented that the responsible party consented to Zyprexa for schizophrenia rather than bipolar disorder. The DON confirmed the discrepancy between the physician’s order and the consent form, despite a facility policy requiring that informed consent for psychotherapeutic drugs include disclosure of the correct reason for treatment and the nature of the illness.
A resident with Alzheimer’s disease, dementia, and type 2 DM was admitted with a POA identified and a long-standing primary care MD documented on a hospital face sheet, but the facility assigned a different attending MD without consulting the resident or POA. The Admissions Coordinator and Director of Marketing each acknowledged they did not speak with the POA or resident about physician choice and did not inform them of the assigned MD, assuming others would handle it. Facility policies on designation of attending physician and resident rights required that residents be asked to choose a personal MD prior to or upon admission and be informed when the facility designates one, but this process was not followed, resulting in the resident being placed under the care of a different MD without the POA’s knowledge or consent.
A resident with cataracts, muscle weakness, right arm pain, moderate cognitive impairment, and a documented high fall risk required supervision/touching assistance for ambulation per the MDS and care plan, which also directed staff to assist with transfers/locomotion and remind the resident to request help before walking. Despite this, the resident was allowed to walk independently outside a patio area while using a wheelchair like a walker, without staff present to supervise or assist. The resident lost balance, fell backward, and hit his head on the floor while attempting to grab the wheelchair, as confirmed by the resident, a respiratory therapist, and nursing staff, who acknowledged that required supervision and assistance were not provided at the time of the fall.
A resident with severe cognitive impairment, mobility limitations, and high fall risk did not have a person-centered care plan developed or implemented to address their need for supervision and assistance with ADLs. Despite assessments and staff confirming the need for substantial support, the facility failed to document or provide a care plan as required by policy.
A resident’s MDS was inaccurate in two areas: the admission assessment listed both a walker and wheelchair even though the resident used a wheelchair only, and the Quarterly MDS failed to include a recent unwitnessed fall. The resident had moderate cognitive impairment and required assistance with several ADLs. The MDS nurse stated the walker entry was checked in error and the fall was omitted from the later assessment.
A resident with cognitive impairment and significant physical disabilities was able to leave the facility unsupervised after a pedestrian assisted in opening a parking lot gate, which was remotely unlocked by a receptionist who did not verify the individual's identity. The resident was not accounted for during routine checks and was later found hospitalized after being missing for several hours. The facility did not follow its own procedures for monitoring and controlling access, resulting in the resident's elopement.
Surveyors identified that the facility did not maintain the building structure to prevent pest and rodent entry, including a tree branch touching the laundry roof, an open section of eaves, and gaps around drainpipes in the laundry area. Maintenance and environmental services staff acknowledged the issues, and pest control had previously recommended corrective actions that were not completed.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, resulting in increased risk for resident accidents.
A deficiency was cited for not ensuring a resident's right to dignity, self-determination, communication, and the exercise of their rights. The report does not specify the exact actions or events that led to this failure.
A resident with dementia and significant care needs was not monitored or assessed for 72 hours after an alleged physical abuse incident, as required by facility policy. Nursing staff did not document the resident's condition for multiple shifts following the event, despite the resident's inability to verbalize changes and the facility's established procedures for post-incident monitoring.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
A resident with multiple medical conditions was served food items, including pasta and carrots, at temperatures below the facility's required standards. Observations and temperature checks confirmed that several food items on resident and test trays did not meet the policy's temperature requirements, and staff acknowledged the deficiency.
A dumpster in the back parking lot was observed overflowing with kitchen trash, including open food waste, and its lid was not closed. Staff confirmed the dumpster was smelly and surrounded by flies, and stated it should have been closed and not emitting odors. Facility policies require garbage to be properly contained and dumpsters to be kept closed and clean, which was not followed in this instance.
Two residents were found living in unsanitary conditions, including a dirty toilet seat with dried substances, cluttered and stained floors, a soiled towel left on a linen barrel, and an uncollected food tray. Staff acknowledged the room was dirty, and one resident expressed concern about the bathroom's cleanliness. Facility policy requires a clean and homelike environment, which was not maintained.
A resident with dementia, a history of falls, and muscle wasting was found with their call light on the floor and out of reach while needing assistance for a brief change. Staff confirmed the call light should have been accessible, as required by the care plan and facility policy, but it was not, preventing the resident from requesting help.
A deficiency was cited for not ensuring a resident's right to dignity, self-determination, communication, and the exercise of their rights. The report does not specify the exact circumstances or individuals involved.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors.
A resident with a history of sexually inappropriate behavior and a physician's order for 1:1 supervision was not provided with a sitter, allowing the resident to sexually abuse another cognitively impaired resident. Prior incidents of inappropriate behavior were not properly reported or addressed, and required supervision was not implemented, leading to the abuse.
A resident with a history of wandering and violent behavior, who had a physician's order for 1:1 supervision, was not provided with a sitter as required. This lapse allowed the resident to enter the room of another cognitively impaired resident and commit a sexual assault, which was discovered by an LPN responding to a scream. The facility lacked a process to ensure sitter assignments were tracked and implemented, leading to the incident.
The facility did not ensure that most direct and indirect care staff received required in-service training on resident rights and facility responsibilities, as only a small portion of staff attended the scheduled session and there was no evidence of training for other shifts. Both the DSD and DSDC confirmed the training was incomplete, and facility policy requiring annual education and monitoring of attendance was not followed.
The facility did not provide required behavioral health training to 452 out of 552 direct and indirect care staff, as shown by incomplete attendance records and missing lesson plans. This deficiency affected staff knowledge and preparedness in caring for residents with behavioral health issues, particularly those housed in a secure dementia/behavioral unit.
A resident with moderate cognitive impairment and a history of psychiatric and behavioral issues engaged in sexually inappropriate behavior, which was observed by a 1:1 sitter. The incident was not promptly reported, and nursing staff did not develop or implement a care plan to address the behavior, contrary to facility policy. This failure placed other residents at risk.
A resident with intact cognitive abilities and multiple medical conditions repeatedly requested that certain individuals not visit and that her responsible party be changed. Despite these clear requests, staff did not update records or enforce her preferences, resulting in unwanted visits and emotional distress for the resident.
Inaccurate Medication Record Entry
Penalty
Summary
The facility failed to maintain accurate clinical records when LVN 2 entered lorazepam (Ativan) under one resident’s name without a physician order for that resident. The resident was admitted with diagnoses including cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting the right non-dominant side, and unspecified cirrhosis of the liver. The resident’s MDS dated 5/29/2026 indicated intact memory and cognitive skills for daily decision making, and the resident required varying levels of assistance with eating, hygiene, dressing, transfers, toileting, bathing, and walking. During record review, the resident’s physician orders showed a one-time order for lorazepam injection for anxiety manifested by verbal aggression, but the Assistant Administrator stated there were no progress notes on or before 5/29/2026 documenting anxiety or verbal aggression. CNA 1 stated the resident did not display behaviors or verbal aggression during the stay, and LVN 1 stated the resident was not anxious or verbally aggressive and that there was no report from the previous shift indicating such behavior. LVN 1 also stated she did not know who ordered the Ativan or why it was ordered for the resident. LVN 2 stated she entered the Ativan order under the resident’s name while teaching a new LVN how to enter medication orders and forgot to delete it afterward. LVN 2 stated the resident was never ordered Ativan by the physician and acknowledged she should not have entered the order even for teaching purposes. The DON stated the Ativan order belonged to another resident and was entered under the wrong resident because the eMAR was open during training. The facility policy on nursing documentation stated documentation must be concise, clear, pertinent, and accurate.
Failure to Report Injury of Unknown Origin Within Required Timeframe
Penalty
Summary
The facility failed to report an unusual occurrence involving a resident with contractures, bone density and structure disorders, dementia, and moderate cognitive impairment. The resident was assessed as high risk for falls and, on 6/7/2026, was noted to have an abnormality of the left upper arm, with pain, moaning, fright, and tension, and was transferred to a general acute care hospital. Skin observation documented swelling and abnormality of the left upper arm, and progress notes described the arm as red and appearing fractured. Staff interviews indicated that the resident’s left inner elbow and upper arm were observed to be purple, swollen, and bumped, with facial grimacing and significant pain. The RNA, LVN, CNA, RN, QA nurse, and administrator all stated the condition was considered an injury of unknown origin and should have been reported within 2 hours, but it was not reported. The facility policy titled Abuse Prevention and Prohibition Program required allegations of injuries of unknown source to be reported immediately by phone, but no later than 2 hours after forming the suspicion.
Failure to Develop Individualized Care Plan for Bone Density and ADL Needs
Penalty
Summary
The facility failed to develop an individualized, resident-centered care plan with measurable objectives, timeframes, and interventions to meet Resident 1’s oxygen needs. Resident 1 was originally admitted to the facility and later readmitted with diagnoses including contracture of both knees, left elbow, and right hand, disorders of bone density and structure, and dementia. The Minimum Data Set dated 4/18/2026 indicated the resident was moderately impaired in cognitive skills for daily decision making and required substantial to maximal assistance with eating, oral hygiene, and upper body dressing, and was dependent for toileting hygiene, showering/bathing, lower body dressing, putting on/taking off footwear, and personal hygiene. Record review also showed a General Acute Care Hospital document dated 2/1/2026 indicating diffuse osteopenia, and a Fall Risk Assessment dated 2/4/2026 indicating the resident was at high risk for potential falls. During interview, RN 1 stated there was supposed to be a care plan for the resident’s osteopenia but there was not, and that it was important to have an ADL care plan related to bone density so staff could properly care for the resident. The MDS Coordinator stated the resident did not have an ADL care plan related to bone density and should have had one upon admission in 2/2026 to ensure proper care and safety. The QA Nurse stated the ADL care plan for bone density should have been done in 2/2026 to ensure proper care during ADLs such as changing and repositioning. Review of the facility’s Care Planning policy stated a comprehensive person-centered care plan is to be developed for each resident based on individual assessed needs.
Incomplete Nursing Documentation After PRN Ativan Administration
Penalty
Summary
The facility failed to ensure that nursing documentation in the resident’s medical record was accurate and complete for one sampled resident. The deficiency involved the progress notes dated 6/4/2026, which did not include the licensed nurse’s post-monitoring documentation of the resident’s specific behavior after Ativan (lorazepam) was administered as needed for anxiety and restlessness. Resident 1 was admitted and later re-admitted to the facility with diagnoses including mood affective disorder, anxiety disorder, major depressive disorder, psychosis, and dementia. The resident’s MDS dated 5/18/2026 indicated severely impaired cognitive skills for daily decision making and need for partial/moderate assistance with multiple activities of daily living, including toileting hygiene, bathing, dressing, transfers, and ambulation. A physician order dated 6/4/2026 directed Ativan 1 mg by mouth every 6 hours as needed for anxiety for 14 days and included behavior monitoring for restlessness with documentation every shift. The care plan for anxiety directed staff to administer antianxiety medication as ordered, monitor for side effects and effectiveness every shift, monitor the resident for safety, and document target behaviors and responses per facility protocol. During interview, the LVN stated that after Ativan was given at 2:30 AM, the resident remained agitated and continued trying to get out of bed about an hour later. However, the nurses’ progress note for that date documented the medication as effective without describing the resident’s observed behavior at reassessment. The QAN stated that the note did not accurately describe what the LVN saw and heard, and the facility’s documentation policy required nursing notes to describe the resident’s condition, actions taken, and the resident’s response.
Unsafe Environment and Inadequate Supervision
Penalty
Summary
The facility failed to maintain a safe environment for four residents in the accidents care area. For a resident with epilepsy and severe cognitive impairment, both siderails were supposed to be padded for seizure precautions, but only the left siderail was padded while the right siderail was not. A siderail pad was found under the bed. An LVN stated both siderails should have been padded and that the pad should not have been left under the bed after care was provided. The DON stated the resident could have sustained injuries if a seizure occurred while the pads were not in place. For a resident with COPD who was receiving oxygen by nasal cannula, the room had an oxygen machine at the bedside, but no "Oxygen in Use" sign was posted on the door frame. An LVN stated staff forgot to place the sign, and the DON stated the sign was supposed to notify staff and visitors that oxygen was being used in the room. The facility policy required an "Oxygen in Use" sign to be placed on the door frame for residents using oxygen. The facility also failed to ensure adequate assistance and care planning for a resident with diabetes, left eye blindness, peripheral vascular disease, and a recent left below-knee amputation. The resident's records showed dependence for transfers and substantial to maximal assistance needs, but a CNA attempted to transfer the resident alone from the toilet to the wheelchair. The resident slid down and the left stump hit the floor. The CNA stated she had not received report about the resident's level of assistance and tried to lift him by herself. The MDS nurse and DON stated the care plan should have specified the level and number of staff needed for transfers. For another resident with parkinsonism, osteoporosis, adult failure to thrive, high fall risk, and severe cognitive impairment, the bed brake indicator showed the bed was not locked during observation. A CNA, an LVN, and the DON all stated the bed should have been locked. The facility's fall management policy required beds to be in the lowest position with the brakes locked, but the resident's bed was observed unlocked.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to fully inform the resident or the resident’s responsible party in advance of the risks and benefits of proposed psychotropic treatment for two residents. For one resident, the record showed diagnoses including metabolic encephalopathy, dementia, major depressive disorder, unspecified psychosis, anxiety disorder, and bipolar disorder. That resident was admitted and later readmitted to the facility, had an MDS indicating severely impaired cognitive skills for daily decision making, and had a physician order for Valproic Acid 250 mg by mouth twice daily for bipolar disorder manifested by verbal aggression. The care plan for Valproic Acid, dated 2/15/2026, included educating the resident and family about risks, benefits, side effects, and/or toxic symptoms, but during record review the ADON stated the resident had been receiving Valproic Acid since 2/15/2026 and there was no consent on file for its use. The resident’s RP stated he was not aware the resident was receiving Valproic Acid for verbal aggression and said the facility did not inform him about the medication, its risks and benefits, or whether alternative interventions were attempted before it was started. The DON stated that prior to initiating Valproic Acid, consent should have been obtained from the RP to review the purpose of the medication, potential side effects and reactions, and how it would help the resident’s condition. For the second resident, the record showed a readmission with diagnoses including vascular dementia, schizophrenia, and unspecified mood disorder, and the H&P indicated the resident had good decision-making capacity. The resident had orders for Seroquel 25 mg via g-tube twice daily for schizophrenia manifested by yelling out without cause and later Rexulti 1 mg via g-tube daily for dementia manifested by yelling without cause. Reviews of the informed consent forms for both medications showed no signature from the resident or the resident’s representative, and the DON stated informed consent is explained by the physician and then signed by the resident or family, with the signed copy kept in the chart or uploaded electronically. The facility policy stated informed consent must be signed by the resident or representative and the physician, and copies given to the resident or representative.
Call lights not within reach or usable for residents with impaired mobility and cognition
Penalty
Summary
The facility failed to ensure call lights were within reach and usable for four residents who had significant physical and cognitive impairments. Resident 38 had diagnoses including adult failure to thrive, lack of coordination, and muscle weakness, and the MDS indicated severe cognitive impairment and dependence on staff for all functional abilities. OT documented bilateral upper extremity contractures, impaired ROM and strength, and dependence for all ADLs. During observation, the resident held the call light in the right hand but could not physically pull it to request help, and an LVN stated the resident's right hand did not work well enough to use the call light. Resident 77 had diagnoses including hemiplegia/hemiparesis affecting the left non-dominant side, left hand contracture, and muscle wasting and atrophy. The MDS indicated severe cognitive impairment, and OT documented dependence for all ADLs and total assistance needs due to limited strength. During observation, the call light was behind the resident's right shoulder and the resident could not reach or pull it. A CNA stated the call light was not within reach and the resident was unable to pull it, and an LVN stated the resident was not able to physically pull the call light and should have had an adaptive call light appropriate for the resident's needs. Resident 301 had diagnoses including mild neurocognitive disorder, cerebral ischemia, and dementia, and the H&P stated the resident did not have capacity to understand and make decisions. The MDS indicated severe cognitive impairment and dependence or substantial/maximal assistance in all functional abilities. OT documented dependence for all ADLs, a mobility function score of zero, and impaired bilateral upper extremity ROM. During observation, the call light was clipped to the top right-hand side of the bed and the resident could not reach or physically pull it. A CNA and an LVN both stated the resident did not have the call light within reach and could not use it. Resident 386 had diagnoses including muscle weakness, hemiplegia and hemiparesis affecting the right dominant side, and heart failure. The MDS indicated severe cognitive impairment and dependence or substantial/maximal assistance for transfers, lower body dressing, toileting hygiene, and walking 10 feet. OT documented that the resident required assistance or was dependent for all ADLs and had impaired upper extremity strength, fine motor coordination, mobility, and strength. During observation, the call light was hanging from the wall with a broken clip and could not be secured, and the resident could not reach it while in bed. An LVN stated the clip was broken and the call light should have been placed within the resident's reach. The DON stated call lights should be within residents' reach, and if a resident could not physically use the call light, rehab would need to evaluate for a more appropriate device such as an adaptive call light.
MDS Assessments Contained Incorrect Resident Names
Penalty
Summary
The facility failed to ensure the MDS was accurate for six of seven sampled residents. For Residents 55, 126, 134, 233, 263, and 346, the MDS Section A contained incorrect first and last names on two separate MDS assessments for each resident. The report states that these residents had admission records showing they were admitted or readmitted to the facility with various diagnoses, including metabolic encephalopathy, COPD, osteoarthritis of the hip, chronic kidney disease, cerebral ischemia, end stage renal disease, kidney failure, type 2 diabetes mellitus, hypertension, angina pectoris, anemia, and cardiomyopathy. During interview and concurrent record review, the MDS Nurse stated she was responsible for ensuring all MDS assessments were completed and transmitted to CMS timely and accurately. She explained that the facility’s MDS system auto-populates resident names from the electronic health record, and that if names are entered incorrectly at admission and later corrected by the business office, she should be notified so she can complete and submit a modification MDS to CMS. She stated she was unaware of the name changes made to Residents 55, 126, 134, 233, 263, and 346, which is why she did not submit modification MDSs. The DON stated that if there are changes in a resident’s status, names, or if the MDS is not documented accurately, it could affect continuation of care and result in incorrect tracking of resident outcomes. The facility’s RAI Process policy, revised 10/01/2019, states the facility will utilize the RAI process as the basis for the accurate assessment of each resident’s functional capacity and health status, as outlined in the CMS RAI manual.
Medication Administration and Controlled Drug Record Errors
Penalty
Summary
Pharmaceutical services were not provided accurately for two residents during medication administration observations and record review. One resident had orders for Lactulose oral solution 30 mL by mouth twice daily for bowel management, but during the morning medication pass the nurse initially brought eight other medications without Lactulose, then returned to the cart after the resident asked where it was. The nurse stated she had forgotten the medication, and staff later stated the facility had run out of Lactulose and would contact the pharmacy for delivery. The DON stated medications should be administered as scheduled and reordered before they run out so residents do not miss scheduled doses. A second resident, who had diagnoses including paraplegia and hypotension and intact cognitive skills for daily decision making, had orders for Rivaroxaban 20 mg daily and Venlafaxine HCL 75 mg daily, both to be given with food. During the medication pass, the nurse administered both medications with water and without food. The nurse stated she knew the medications required food but assumed it was acceptable because the resident had eaten breakfast earlier. The DON stated the bubble pack labels indicated the medications were to be administered with food and that the nurse should have provided a cracker or cookie if it was not mealtime. Controlled drug records for hydrocodone-acetaminophen for the first resident were also inaccurate. The resident had orders for one tablet every four hours as needed for moderate pain and two tablets every four hours as needed for severe pain. Review of the CDRs and bubble packs showed mismatches between documented counts and the actual remaining tablets, including entries that did not match the medication administered and a signature entered for a dose that was not given because the resident refused. Nurses interviewed stated they signed or documented incorrectly, and one nurse stated she should not have signed the CDR before administration. The DON stated nurses should verify discrepancies between the CDR and bubble pack and document correctly during controlled drug counts.
Expired supplies, improper controlled substance storage, loose medications, and unrefrigerated eye drops
Penalty
Summary
Expired Bottle and Dressing Pack supplies and expired Arginaid Oral Powder were found in Unit 900’s medication storage room during observation and interview with LVN 11. A sealed Bottle and Dressing Pack with an expiration date of 8/14/2025 was observed on the shelf, and LVN 11 stated it was used for draining fluid from a resident but was expired. In the same room, four boxes of Arginaid Oral Powder with an expiration date of 11/26/2025 and four boxes with an expiration date of 1/29/2026 were observed, and LVN 11 stated the packets were expired and should not have been stored there. Resident 147 had diagnoses including type II diabetes mellitus and chronic kidney disease, and the MDS dated 2/28/2026 indicated moderately impaired memory and cognition. The physician ordered lorazepam oral concentrate 2 mg/mL, 0.5 mL every two hours as needed for anxiety. During observation, one bottle of Resident 147’s lorazepam was stored with other medications inside the medication refrigerator in Unit 900’s medication storage room. LVN 11 stated lorazepam was a controlled medication but was stored in the locked refrigerator with all other medications. The DON stated the medication should have been stored in a permanently affixed locked box within the refrigerator, separate from other medications. Medication cart number one in Station Two contained loose medications in two drawers during observation. Six loose pills were found in the second right-hand drawer and four loose pills were found in the third right-hand drawer underneath resident medication blister packs. LVN 17 stated she did not know what the medications were or which resident they belonged to and stated loose medications should not have been in the cart. Resident 27 had diabetes and hypertension, and the physician ordered one drop of latanoprost in each eye at bedtime. An unopened bottle of latanoprost was observed in medication cart 1 instead of being refrigerated as directed by pharmacy. In Unit 400’s medication storage room, an expired first aid kit was observed with emergency supplies, and LVN 10 stated it expired on 4/30/2019.
Infection Prevention and Control Lapses
Penalty
Summary
Resident 380 had diagnoses including ESBL resistance and a right artificial knee joint, and the MDS indicated intact cognitive skills but dependence or partial assistance with several activities of daily living. The physician ordered the PICC line transparent dressing, injection cap, and extension to be changed every 7 days starting 5/24/2026. During observation on 5/26/2026, the resident’s PICC line dressing on the right upper arm was noted to have no date and initials, and LVN 7 stated there was no date and initial on the dressing. RN 3 stated she did not know whether the PICC line dressing had been changed or when it was changed because there was no date and initial on the dressing, and stated the dressing should be changed every 7 days per facility policy. Resident 2 had diagnoses including COPD and atrial fibrillation, and the MDS indicated intact cognitive skills with assistance needed for some activities of daily living. The physician ordered ceftriaxone sodium 1 gram intramuscularly daily for UTI for 10 days with lidocaine. During medication pass observation on 5/27/2026, LVN 12 administered the IM injection in the right upper arm without wearing gloves. When interviewed immediately afterward, LVN 12 stated she should always wear gloves when administering injection medications and said she got distracted while talking to the resident and forgot to put on gloves before giving the ceftriaxone IM medication. The facility also failed to maintain disinfectant wipe containers in a closed condition. On 5/29/2026, multiple wipe containers on Nursing Units 2, 8, and 9 were observed with lids open and cloths hanging out of the containers. The CN stated staff were taught to close the lids after each use, and the IPN stated the lids must be closed to prevent the wipes from drying out and losing disinfecting qualities. The manufacturer’s instructions indicated the lid should be closed after each use to retain moisture, and the facility’s policy required disinfectants to be used per manufacturer instructions.
Failure to Maintain Resident Privacy During ADLs
Penalty
Summary
The facility did not provide privacy for Resident 217 when the resident was exposed from the waist down during ADLs on 5/27/2026. Resident 217’s record showed diagnoses including Parkinson’s disease, type 2 DM, anxiety disorder, and bipolar disorder. The MDS dated 5/13/2026 indicated the resident had intact cognitive skills for daily decision making and required substantial to maximal assistance with toileting hygiene. During an observation at 12:50 PM, Resident 217 was naked from the waist down while no curtain was drawn. CNA 2 stated she had been helping the resident change but left the room to attend to another resident in the next room without closing the curtain, and said she should have closed it before leaving. LVN 2 stated CNA 2 should have drawn the curtain to provide privacy before leaving the room. Resident 217 stated she was very angry because strangers saw her naked from the waist down and said CNA 2 told her she would come back and did not close the curtain. The DON stated Resident 217 should have privacy at all times and CNA 2 should have closed the curtain before leaving the room.
Late Completion of Admission MDS
Penalty
Summary
The facility failed to complete the Minimum Data Set (MDS) within 14 calendar days of admission for one sampled resident, Resident 336. Resident 336 was admitted with diagnoses including malnutrition, type 2 diabetes, and dementia. Review of the MDS showed that the assessment was not completed within 14 days of admission, and the sections for Mood, Behavior, and Participation in Assessment and Goal Settings were not completed. During a concurrent interview and record review, the MDS Nurse stated the assessment was completed 23 days after admission and acknowledged that it was not completed on time, which could affect how Resident 336 is cared for and when care begins. The facility policy titled Resident Assessment Instrument Process stated that the MDS completion date for admission is to be on the 14th calendar day of the resident's admission.
Late Completion of Discharge MDS Assessment
Penalty
Summary
The facility failed to complete a Minimum Data Set (MDS) discharge tracking assessment for one of seven sampled residents reviewed for resident assessment. Resident 319 was admitted with diagnoses including osteoarthritis of the knee and hypertension and was later discharged to home on 1/30/2026. The resident’s MDS summary showed a discharge-return not anticipated assessment dated [DATE], but it was completed on 2/15/2026, which was 2 days after the discharge date. During interview and concurrent record review, the MDS Nurse stated she was responsible for ensuring all residents’ MDS assessments were completed and transmitted to CMS timely. She stated the facility has 14 days to complete a discharge MDS from the resident’s discharge date and another 14 days after completion to transmit it to CMS. The MDS Nurse acknowledged that Resident 319’s discharge MDS was completed late, past the 14-day period after discharge. The facility policy stated MDS assessments are to be transmitted in accordance with the RAI required assessment summary and Medicare assessment reporting schedule, and the CMS MDS 3.0 RAI User’s Manual stated the discharge MDS must be completed within 14 calendar days after discharge and then submitted within 14 calendar days of completion.
Measurable Activity Care Plan Not Developed
Penalty
Summary
The facility failed to create a measurable activities care plan for Resident 336. Resident 336 was admitted with diagnoses including malnutrition, type 2 diabetes, and dementia. The Minimum Data Set dated [DATE] indicated the resident was severely impaired in cognitive skills for daily decision making and needed some help with activities of daily living such as bathing, dressing, using the toilet, or eating. During a concurrent interview and record review on 5/29/2026, the Activities Director reviewed Resident 336's Activity Care Plan dated 5/5/2026 and found that the resident was dependent on staff for activities, cognitive stimulation, and social interaction due to cognitive deficits, immobility, and physical limitations. The goal was for the resident to remain involved in cognitive stimulation and social activities as desired, but no measurable objectives were included. The Activities Director stated the care plan did not include measurable objectives, and the Activities Care Consultant stated that the facility's activity care plan goals were not measurable or quantifiable. The facility's Care Planning policy stated that care plans will include measurable objectives and timetables to meet a resident's medical, nursing, mental, and psychosocial needs.
Care Plans Not Reviewed and Revised by Target Date
Penalty
Summary
The facility failed to review and revise all care plans by the target date for one sampled resident, Resident 336. Resident 336 was admitted with diagnoses including malnutrition, type 2 diabetes, and dementia. The admission record and MDS dated [DATE] indicated the resident was severely impaired with cognitive skills for daily decision making and needed some help with activities of daily living such as bathing, dressing, using the toilet, or eating. During a concurrent interview and record review on 5/29/2026 at 12:44 PM, the MDS Nurse reviewed Resident 336's care plans in the EMR and found that the Dietary, Nursing, Social Services, and Therapy care plans did not indicate they were reviewed and completed by the target date of 5/25/2026. The MDS Nurse stated that Resident 336's care plans were not reviewed and revised by the target completion date and that when care plans are not reviewed and completed by the target date, there is a delay in the resident's care. The facility's Care Planning policy dated 10/24/2022 stated that the care plan must be periodically reviewed and revised by a team of qualified persons after each assessment.
Dependent Loop in Foley Catheter Tubing
Penalty
Summary
The facility failed to ensure proper maintenance and positioning of an indwelling urinary catheter for one of two sampled residents reviewed for catheter care. The resident was admitted with diagnoses including quadriplegia, kidney failure, and urine retention, and the MDS indicated the resident was cognitively intact, dependent on staff for all cares, and used a Foley catheter for urination. During observations, the resident’s Foley catheter tubing was seen hanging with a dependent loop that dipped below the collection bag, and urine was pooled in the tubing. A later observation showed the same condition, with a dependent loop and urine pooled in the looped portion of the drainage catheter. An LVN stated that Foley catheters should drain continuously without dependent loops or kinks and that dependent loops could cause urine to flow back up into the resident and could cause discomfort, pain, and infection. The DON stated Foley catheters should not have a dependent loop and that staff were not following the facility’s policy. The facility policy stated that unobstructed urine flow should be maintained and catheter tubing should be secured to prevent dependent loops.
Respiratory Care Not Provided as Ordered
Penalty
Summary
The facility failed to provide respiratory care for two residents. One resident with COPD and dementia had a physician order for continuous oxygen at 2 L/min via nasal cannula starting 5/11/2026, but during observation the resident was found in bed without oxygen in place. On one occasion the oxygen nasal cannula was on the floor, and on another occasion the oxygen concentrator was turned off with the tubing and concentrator stored beside the bedside nightstand. An LVN stated the resident should have been receiving oxygen continuously and that staff were expected to check to ensure the oxygen was being provided as ordered. The same resident’s record review showed severely impaired cognitive skills and dependence for several activities of daily living, and the MDS indicated the resident was on oxygen therapy. The MDS Nurse stated no care plan had been developed to address oxygen therapy for the resident. The DON stated nurses should check and follow the physician’s order for oxygen therapy and develop a care plan to address oxygen usage. A second resident with aphasia following cerebral infarction, acute and chronic respiratory failure with hypoxia, and COPD with acute exacerbation had an order for Ipratropium-Albuterol inhalation solution every 4 hours for shortness of breath and wheezing. The care plan directed staff to give aerosol or bronchodilators as ordered. During observation, the resident was sleeping and not wearing the nebulizer mask while the breathing treatment was in progress. The ADON confirmed the mask was not on, turned off the nebulizer machine, and stated the mask should be in place during the treatment. The DON stated that without the mask the resident did not receive the full dose of medication.
Dialysis Resident Left Water Pitcher at Bedside Despite Fluid Restriction
Penalty
Summary
Safe, appropriate dialysis care/services were not provided for Resident 21, who was admitted with end stage renal disease and dependence on renal dialysis and had severe cognitive impairment. The resident’s order summary included a fluid restriction stating there was to be no water pitcher at the bedside. During an observation on 5/26/2026 at 9:16 AM, Resident 21 was seen eating breakfast in her room with a sign above the bed stating, “No water pitcher at bedside,” yet a pitcher of water was observed on the resident’s table. During interview, an LVN stated Resident 21 was on a fluid restriction due to dialysis and should not have had a water pitcher at the bedside, explaining that doing so made it difficult to monitor intake and increased the chances of fluid overload. The DON reviewed the order summary and stated fluid restrictions were implemented to prevent fluid overload, that there should not have been a water pitcher at Resident 21’s bedside, and that excessive water could have led to hospitalization, an extra dialysis treatment, or extra medications to stabilize the resident. The facility’s fluid restriction policy stated residents on fluid restrictions would be monitored for intake and licensed nurses would remove the water pitcher and notify caregivers of the restriction.
Failure to Follow Up on Denture Request and Update Family
Penalty
Summary
Medically related social services were not provided for a resident with loose upper teeth and a request for new dentures. The resident had diagnoses including metabolic encephalopathy, anxiety disorder, dementia, and adult failure to thrive, and the H&P stated he did not have the capacity to understand and make decisions, with RP 1 identified as his decision maker. A Social Services Note dated 3/2/2026 documented that the resident had been seen by the dentist on 2/23/2026 and that the social service worker would follow up regarding the family request for dentures. From 3/2/2026 through 5/27/2026, there was no documented evidence that the social service worker followed up with the dental clinic or informed RP 1 about the status of the denture request. During observation on 5/26/2026, the resident’s upper teeth were loose, and he stated he wanted them removed because he was worried he might accidentally swallow them if they fell out without his awareness. RP 1 stated he had requested that the resident’s teeth be fixed because the upper teeth were loose and the resident was afraid of swallowing them, but he received no updates about the request or when dental care would occur. The DON stated the social service worker should have followed up with the dentist, stayed on top of the resident’s need, and informed the family what the plan was.
Medication Administration Error Rate Exceeded 5 Percent
Penalty
Summary
The facility failed to keep its medication error rate below 5 percent. During medication pass observation, 2 medication errors were identified out of 25 observed medication administration opportunities, resulting in an overall error rate of 8 percent for one sampled resident. The errors involved Resident 202, who was admitted with diagnoses including paraplegia and hypotension and whose MDS indicated intact cognitive skills for daily decision making, supervision with eating, partial/moderate assistance with oral hygiene, upper body dressing, and personal hygiene, and dependence for toileting hygiene, showers, and lower body dressing. Resident 202 had physician orders for Rivaroxaban 20 mg daily for DVT and Venlafaxine HCL 75 mg daily for depression. The medication bubble pack for both medications indicated they were to be taken with food. During observation, an LVN administered both medications with water and without food. In interview, the LVN stated she knew the medications required administration with food but assumed it was acceptable because the resident had eaten breakfast around 7 AM. The DON stated the medications should have been given with food, or a cracker or cookie if it was not mealtime, and that licensed nurses should follow medication orders.
Late Lunch Tray Delivery
Penalty
Summary
The facility failed to serve lunch at the scheduled delivery time for one sampled resident who had Parkinson's disease, type 2 diabetes mellitus, anxiety disorder, and bipolar disorder, and who was assessed as having intact cognition and the capacity to make medical decisions. The resident required set-up or clean-up assistance with eating. During observation and interview, the resident's lunch tray was found at the bedside after the resident had already finished eating, and the resident stated that lunch had been late in the past few months, sometimes arriving as late as 12:30 PM and more recently around 1:30 PM. The resident stated that because lunch was delivered late, the food did not taste good anymore. During another observation, a CNA brought the resident's lunch tray into the room and left it on the bedside table, and the resident again stated that lunch kept getting delivered around 1:30 PM every day. The DON stated that meal trays should not be one hour later than the scheduled meal delivery time, and the KS stated that if a tray is scheduled for 12:40 PM, the resident should receive it around that time. The facility's meal delivery time document showed lunch was scheduled to be delivered to the resident's room at 12:40 PM, and the facility policy stated meals are served at regularly scheduled hours, typically 7 AM, 12 PM, and 5 PM.
Sharing Visitor-Brought Food Between Residents
Penalty
Summary
The facility failed to ensure food brought to residents by family or visitors was not shared between residents, as required by its policy. Resident 149 was admitted with diagnoses including endocarditis, peripheral vascular disease, and hypertension, and the H&P stated the resident did not have the capacity to understand and make decisions. The MDS indicated the resident had severely impaired cognitive skills for daily decision making and required staff assistance with eating, transfers, and oral/toileting hygiene. During an observation on 5/26/2026, CNA 5 was seen taking a Twinkie from Resident 234's room, walking it to Resident 149's room, and handing it to LVN 18. LVN 18, while wearing gloves, opened the wrapper and gave the Twinkie to Resident 149 to eat. In interviews, CNA 5, LVN 18, the IPN, and the DON stated that staff should not have taken personal food items from one resident's room to another resident's room because of cross contamination and infection control concerns. The facility's policy on food brought in by visitors stated that outside food may be brought to a resident if compatible with the physician's diet order and should be stored in a sealable container with the resident's name and the date brought to the facility.
Incomplete Medication Documentation in MAR and Controlled Drug Records
Penalty
Summary
The facility failed to maintain complete and accurate nursing documentation for two sampled residents in accordance with its Documentation-Nursing and Medication-Administration policies. For one resident, admitted and later readmitted with ESBL resistance and a right artificial knee joint, the physician ordered meropenem IV every 8 hours starting 5/23/2026. During record review and interview, RN 2 stated she administered the scheduled meropenem at 10 PM on 5/24/2026, but the IV Administration Record did not show that dose as given. RN 2 stated she did not verify that her documentation was complete, and the DON stated the nurse should document the medication as given after administration to ensure accurate and complete documentation. For another resident, admitted with PVD, bilateral above-knee amputations, and anxiety disorder, the MAR showed Endocet was given at 1:11 AM on 5/27/2026. However, the Controlled Drug Record reflected the last dose as 5:07 AM instead of 1:11 AM. LVN 6 stated the previous nurse should have signed both the MAR and the Controlled Drug Record right after giving the Endocet so the correct time would be documented, and the ADON stated the nurse should document in both records right after giving a controlled medication. The facility’s policy stated nursing documentation must be concise, clear, pertinent, and accurate, and that the time and dose of administered medication must be recorded by the person who administers it.
Failure to Properly Explain Arbitration Agreement
Penalty
Summary
The facility failed to ensure that Resident 45 was informed of and understood the proposed arbitration agreement and the right to refuse before signing a binding arbitration agreement. Resident 45 was admitted on 3/20/2026 and readmitted on 3/31/2026 with diagnoses including heart failure and diabetes mellitus. A history and physical dated 3/21/2026 indicated he had the capacity to understand and make decisions. During an interview, Resident 45 stated that if he had a dispute with the facility, he wanted to hire his own attorney and sue the facility in court, and he stated he did not know about the arbitration agreement with the facility. During interviews with the admission assistant and director of admissions, Resident 45's signed arbitration agreement dated 4/28/2026 was reviewed. The admission assistant stated she explained that he could still talk to his own legal counsel and proceed through the court process if dissatisfied with arbitration, and the director of admissions stated the resident would resolve a dispute through arbitration first but could go through court if not happy with the result, and that residents could rescind the agreement at any time. The administrator later stated this explanation was incorrect, explaining that after signing the arbitration agreement, residents gave up their right to resolve a dispute in court before a jury and only had 30 days to rescind the agreement. The facility policy stated the person obtaining signatures must know how to explain the agreement and that the terms and conditions must be clearly explained to the resident or responsible party.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
Inaccurate Electronic Arbitration Agreement Signatures in Medical Record
Penalty
Summary
The facility failed to maintain accurate medical records for a resident when an arbitration agreement in the resident’s admission record showed electronic signatures that were not actually provided by the resident or the responsible party. The resident had been admitted with Alzheimer’s disease, Parkinson’s disease, and GERD, and the History & Physical documented that the resident did not have capacity to understand and make decisions. The admission record identified a responsible party holding power of attorney. Despite this, the arbitration agreement in the electronic admission packet reflected an electronic signature for the resident on 2/10/2026 and for the responsible party on 3/7/2026. During interviews and record review, the Admission Coordinator acknowledged that the arbitration agreement’s electronic signatures for the resident and responsible party were not accurate. The Admission Coordinator explained that the third‑party electronic admission system automatically records an electronic signature for the resident once the admission packet is opened, and marks documents as signed without requiring an actual signature from the resident or responsible party. The Assistant Administrator confirmed that the facility used this third‑party system and that signatures may not be accurately reflected. The responsible party stated that she received the electronic arbitration agreement but did not sign it and did not intend to sign any arbitration agreement for the resident, noting that the resident does not sign legal documents. Facility policies required that medical records be accurate, timely, and complete, and that residents or their representatives sign and date the admission agreement, including arbitration agreements, only if they agree to the terms.
Failure to Obtain Accurate Informed Consent for Antipsychotic Medication
Penalty
Summary
The facility failed to obtain accurate informed consent for the use of the antipsychotic medication Zyprexa for a resident. The resident was admitted and later readmitted with diagnoses including Alzheimer's disease, dementia, and type 2 DM, and an MDS assessment showed moderately impaired cognitive skills and a need for assistance with activities of daily living. A Schizophrenia Diagnosis Checklist dated 2/12/2026 indicated the resident did not meet criteria for schizophrenia. However, the History & Physical dated 2/25/2026 documented a present illness of bipolar disorder and stated the resident did not have the capacity to understand and make decisions. On 2/25/2026, the physician's order directed Zyprexa 2.5 mg by mouth at bedtime for bipolar disorder manifested by screaming without cause. The facility’s consent form, also dated 2/25/2026, documented that the resident’s responsible party was made aware of and consented to Zyprexa 2.5 mg for a diagnosis of schizophrenia with the behavior of screaming without cause, rather than for bipolar disorder as written in the physician’s order. In an interview, the DON confirmed that the consent obtained was for schizophrenia and not for bipolar disorder, and stated it was important to obtain the correct consent so the resident and responsible party would know and be able to choose the appropriate treatment plan. The facility’s informed consent policy required that the attending physician disclose the reason for treatment and the nature and seriousness of the resident’s illness when obtaining informed consent for therapies including psychotherapeutic drugs.
Failure to Honor Resident’s Right to Choose Attending Physician
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to choose an attending physician prior to or upon admission, as required by facility policy. The resident was admitted with diagnoses including Alzheimer’s disease, dementia, and type 2 DM, and had moderately impaired cognitive skills for daily decision making, requiring varying levels of assistance with ADLs. The admission record listed a specific physician (MD 3) as the primary physician, while a face sheet faxed from a general acute care hospital identified a different physician (MD 1) as the resident’s primary care physician. The resident’s POA (RP 1) was identified in the admission record, but neither the resident nor RP 1 was asked to choose an attending physician at or before admission. RP 1 reported not being informed that MD 1 was not the attending physician until a change of condition occurred, and stated she was never told the resident would be assigned a new physician or asked about her choice, despite MD 1 having been the resident’s primary physician for over 10 years. The Admissions Coordinator acknowledged assigning the resident to MD 3 without asking RP 1 about physician choice and did not notify RP 1 of the change, stating it was not her responsibility. The Director of Marketing stated that when the referral was received, she assigned the resident to one of the facility doctors without speaking to the resident or RP 1 about their choice of attending physician and did not follow up, assuming another staff member would do so. Review of the facility’s policies on Designation of Attending Physician and Resident’s Rights confirmed that residents must be asked to choose a personal attending physician prior to or upon admission and be informed when the facility designates one, which did not occur in this case, as acknowledged by the Administrator.
Failure to Supervise High Fall-Risk Resident During Ambulation
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and assistance to prevent a fall for a resident assessed as high risk for falls. The resident had diagnoses including cataract, muscle weakness, and right arm pain, and an MDS dated 10/24/2025 documented moderately impaired cognitive skills for daily decision-making. The MDS also indicated the resident required supervision/touching assistance for ambulation (walking 10 feet, 50 feet with two turns, and 150 feet) and setup/cleanup assistance for toileting hygiene, lower body dressing, footwear, and personal hygiene. The resident’s fall risk assessment dated 12/3/2025 identified the resident as high risk for falls. The care plan for fall risk, revised 10/30/2025, directed staff to provide assistance with transferring and locomotion as needed and to educate/remind the resident to request assistance prior to transfer/ambulation. A separate care plan for elopement risk, also revised 10/30/2025, instructed staff to address wandering behavior by walking with the resident and to evaluate the need for additional supervision. On 12/16/2025, the resident experienced a witnessed fall outside the patio area while entering another unit, during which the resident fell backward and hit his head on the floor. Progress notes from that date at 9:00 AM documented that the resident fell outside the patio area while entering another unit and fell backward while trying to grab his wheelchair. In an interview, the resident stated he had been walking by himself while pushing the wheelchair when he fell outside the unit. A respiratory therapist reported observing the resident using his wheelchair like a walker, losing balance, and falling backward while she was only present to open the door and was not supervising the resident; she confirmed the resident was by himself at the time of the fall. The RN supervisor and QA nurse both confirmed that, based on the MDS and care plan, the resident required supervision/touching assistance when walking, meaning a person should be with the resident to guide and help as needed, and acknowledged that no one was with the resident and he did not have the required assistance at the time he was ambulating and fell. Facility policies on fall management, care planning, and safety of residents required development and implementation of care plans and provision of a safe environment, but the resident was allowed to ambulate without the indicated supervision and assistance when the fall occurred.
Failure to Develop and Implement Person-Centered Care Plan for Resident Requiring ADL Assistance
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for one resident who required supervision and assistance with Activities of Daily Living (ADLs). The resident had multiple diagnoses, including lack of coordination, difficulty walking, dementia, and Parkinson's Disease, and was assessed as having severely impaired cognitive skills and high dependency for various ADLs such as toileting, bathing, dressing, and transfers. Multiple assessments, including the Minimum Data Set and Fall Risk Assessments, indicated the resident was at high risk for falls and required substantial to maximal assistance or supervision for mobility and transfers. Interviews with staff, including a CNA and the Director of Rehab, confirmed the resident needed supervision or touching assistance during walking and transfers. Despite these documented needs and facility policy requiring comprehensive, person-centered care plans, a review of the resident's medical chart revealed no care plan addressing the need for supervision or assistance with ADLs. Staff interviews, including with an LVN and the DON, confirmed that no specific care plan had been developed or implemented for this resident's supervision or assistance needs. The facility's policy emphasized the importance of individualized care planning involving the interdisciplinary team, but this process was not followed for the resident in question.
Inaccurate MDS Documentation for Mobility Device and Fall History
Penalty
Summary
The facility failed to ensure accurate MDS documentation for one resident. On the admission MDS, the resident was documented as using both a walker and a wheelchair as mobility devices, even though the admission assessment indicated the resident had a wheelchair only. The resident’s record also showed diagnoses that included malignant neoplasm of the liver, alcohol use unspecified uncomplicated, and altered mental status. The MDS further described the resident as having moderate cognitive impairment and needing varying levels of assistance with activities such as toileting hygiene, bathing, dressing, footwear, and personal hygiene. The facility also failed to accurately document the resident’s fall history on the Quarterly MDS. The resident had an unwitnessed fall at bedside on 10/7/2025, as documented in the IDT Post Event Review, but the Quarterly MDS stated the resident had no falls since admission, entry, reentry, or the prior assessment. During interview, the MDS nurse stated the walker entry was checked in error on the admission MDS and that the fall episode was forgotten on the Quarterly MDS. The MDS supervisor stated accurate MDS documentation is important for patient care planning, reimbursement, regulatory compliance, and measuring quality of care.
Failure to Supervise and Prevent Resident Elopement
Penalty
Summary
A deficiency occurred when the facility failed to supervise and ensure the safety of a resident in accordance with its Wandering and Elopement Policy and Procedure. The resident, who had chronic obstructive pulmonary disease, chronic pulmonary edema, and bilateral below-the-knee amputations, was moderately cognitively impaired and required significant assistance with activities of daily living. Despite these needs, the resident was able to leave the facility unsupervised through a parking lot gate after an unknown pedestrian pressed the gate button, which was then opened by the receptionist without verifying the identity or purpose of the individual at the gate. The resident was last seen in the facility's patio area in the afternoon and was not accounted for during routine checks by staff. Multiple staff interviews revealed that the resident was not observed returning to his room at the usual time, and there was uncertainty among staff regarding supervision responsibilities in the patio area. The facility's security camera footage later confirmed that the resident exited the facility through the parking lot gate with the assistance of a pedestrian, and staff did not realize the resident was missing until several hours later during shift change and meal distribution. The receptionist, who was responsible for monitoring the parking lot gate, did not follow the facility's protocol to verify the identity of individuals requesting access. This lapse allowed the resident to leave the premises undetected. The resident was eventually found by a neighbor and admitted to a general acute care hospital with decompensated congestive heart failure and pleural effusion after being exposed to the outside environment for an extended period. The facility's failure to provide adequate supervision and to follow established procedures directly led to the resident's elopement and subsequent hospitalization.
Failure to Maintain Building Structure and Prevent Pest Entry
Penalty
Summary
The facility failed to maintain the building structure in a manner that prevented possible entry points for pests and rodents. Observations revealed a tree branch with foliage was in direct contact with the roof structure of the laundry department, creating a pathway for pests and rodents to access the facility. Additionally, a section of the eaves outside the laundry department, measuring 30 inches by 4 inches, was left open without a wood cover or frame, further increasing the risk of pest and rodent entry. Inside the laundry room, a metal frame on the floor surrounding two drainpipes had large gaps and holes, providing additional access points for pests and rodents. Interviews with the Maintenance Supervisor and Environmental Services Director confirmed awareness of the issues, with both acknowledging the importance of maintaining the facility structure and following pest control recommendations. The pest control service report had previously identified the vegetation contact as a risk and recommended trimming, but this action was not completed. The facility's policy and procedure indicated that the maintenance department is responsible for ensuring the safety and operability of the building, grounds, and equipment at all times to protect the health and safety of residents, visitors, and staff.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Honor Resident Rights
Penalty
Summary
A deficiency was identified regarding the failure to honor a resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it mention any particular events, observations, or resident conditions related to the incident.
Failure to Monitor and Document Resident After Alleged Abuse Incident
Penalty
Summary
The facility failed to ensure that a resident was assessed and monitored for 72 hours following an alleged incident of physical abuse, as required by the facility's policy and procedure. The resident, who had diagnoses including adult failure to thrive, dementia, and weakness, was dependent on staff for most activities of daily living and had moderately impaired cognitive skills. After an alleged episode of physical abuse by a certified nurse assistant, the care plan was updated to include regular assessment of the resident's emotional status. However, a review of the medical records revealed that there was no documentation of monitoring for the resident's condition during all shifts on the day following the incident. Interviews with nursing staff and facility leadership confirmed that 72-hour monitoring and documentation should have been completed for each shift, especially given the resident's inability to verbalize changes in condition. The facility's policy required licensed nurses to document the resident's status every shift for at least 72 hours after a change in condition, but this was not done. The absence of monitoring and documentation was acknowledged by multiple staff members, including the Director of Nursing, who confirmed that the required assessments were not performed as per policy.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved in the deficiency.
Failure to Serve Food at Proper Temperatures
Penalty
Summary
The facility failed to serve food at the proper temperatures as required by its policy and procedure titled Food Temperatures. During an interview, a resident reported that her food was usually served cold. Observation and temperature checks confirmed that the food items served to the resident, including pasta and carrots, were below the required serving temperature of more than 140 degrees Fahrenheit, with the pasta at 123°F and carrots at 108°F. Additional test trays also showed food items, such as chicken and rice casserole and carrots, being served below the required temperature, and milk being served above the acceptable cold temperature of less than 41°F. The resident involved had a medical history including diabetes mellitus, hypertension, and depression, and required varying levels of assistance with activities of daily living, including setup or clean up assistance with eating. Both the Quality Assurance Nurse and the Administrator confirmed that the food temperatures did not meet the facility's policy requirements at the time the food was served to the resident. The facility's policy specified that food not meeting the required temperatures should be reheated or chilled to the proper temperature before serving, which was not done in this instance.
Improper Disposal and Overflowing Dumpster
Penalty
Summary
During an observation, one of two dumpsters located in the facility's back parking lot was found to be overflowing, with its lid not closed. The dumpster contained kitchen trash, including crushed eggshells in an open box, and emitted a strong odor of spoiled or rotten food. Flies were visibly present around the dumpster. Staff interviews confirmed that the dumpster was overflowing, smelly, and surrounded by flies, and that it should have been closed and not emitting odors. The Dietary Director and Dietary Aid both stated that dumpsters are supposed to be closed at all times and that kitchen trash should be double-tied in plastic bags before being placed in the dumpster to prevent attracting insects and rodents. A review of the facility's policies and procedures revealed that garbage and trash cans are to be used according to manufacturer guidelines, cleaned routinely, and that food waste should be placed in covered garbage and trash cans. The pest control policy also indicated that garbage and trash are not permitted to accumulate in any part of the facility. The observed practice of leaving the dumpster overflowing and uncovered, with improperly disposed food waste, was not in accordance with these policies.
Failure to Maintain Clean and Sanitary Resident Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, sanitary, and home-like environment for two of three sampled residents by not ensuring the cleanliness and orderliness of their living space. Observations and interviews revealed that the toilet seat in the residents' room had brownish to reddish dry substances, and the floor was cluttered with empty cups, cup covers, food wrappers, and food stains. Additionally, a dirty white towel with a brownish substance was found placed on top of a covered linen barrel instead of inside it, and an old food tray from dinner had not been picked up. Both the housekeeping staff and the assistant administrator acknowledged the room was dirty, with the assistant administrator specifically noting the presence of dry feces on the toilet seat and the potential for the environment to harbor bacteria and attract pests. Resident records indicated that one resident had intact cognitive skills while the other had severely impaired cognitive skills, both with medical histories including diabetes and a history of falls. The infection preventionist nurse confirmed that food should have been removed after meals, towels should be properly stored for infection control, and the floor and toilet should be kept clean. One resident expressed concern about the unclean bathroom and the possibility of becoming ill as a result. The facility's policy and procedures require staff to maintain a safe, clean, and homelike environment, which was not followed in this instance.
Call Light Not Kept Within Reach for High-Risk Resident
Penalty
Summary
A deficiency occurred when staff failed to ensure that a resident's call light was within reach, as required by the facility's policy and the resident's care plan. The resident, who had diagnoses including dementia, a history of falls, and muscle wasting, was assessed as being at high risk for falls and required varying levels of assistance with daily activities. The care plan specifically indicated that the call light should be attached and within reach, and the facility's policy also required the call light to be accessible to residents. During an observation, the resident's call light was found on the floor, out of reach, while the resident was attempting to indicate a need for a brief change. Staff interviews confirmed that the call light should not have been on the floor and that the resident knew how to use it to request assistance. The failure to keep the call light within reach meant the resident was unable to call for help when needed, contrary to both the care plan and facility policy.
Failure to Honor Resident Rights
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it mention any particular events or residents involved.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation or review, indicating that the required protocols for protecting confidential resident information or proper record-keeping were not followed as expected. No additional details about specific residents, staff actions, or the circumstances leading to the deficiency are provided in the report.
Failure to Provide Required Supervision Resulting in Sexual Abuse
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident from sexual abuse by another resident. The resident who committed the abuse had a physician's order for one-to-one (1:1) supervision due to wandering and sexually inappropriate behaviors, but was not provided with a sitter during the night shift. This lack of supervision allowed the resident to enter another resident's room and commit sexual abuse, which was discovered by a nurse responding to a scream. The nurse found the perpetrator on top of the victim, whose pants and diaper were pulled down above the knees. The incident was confirmed by multiple staff interviews and documentation. Prior to the incident, there were documented episodes of the perpetrating resident engaging in sexually inappropriate behavior, such as playing with his private area. These behaviors were observed by certified nursing assistants but were either not reported promptly to licensed staff or not documented and addressed according to facility policy. The facility's change of condition policy required that such behaviors be reported to the physician, monitored, and documented, but this was not done. The lack of timely reporting and intervention meant that no new or updated interventions were developed to prevent further incidents. The victim was a resident with severe cognitive impairment, requiring significant assistance with daily activities and supervision for safety. The perpetrator had a history of paranoid schizophrenia, violent behavior, and was HIV positive. The failure to provide required supervision and to act on prior sexually inappropriate behaviors directly led to the incident of sexual abuse. Staff interviews confirmed that the required 1:1 supervision was not in place at the time of the incident, and that there was no process to ensure compliance with sitter assignments.
Failure to Provide 1:1 Supervision Results in Resident-to-Resident Sexual Assault
Penalty
Summary
The facility failed to ensure adequate supervision and accident hazard prevention for a resident with a known history of wandering and behavioral issues. One resident, diagnosed with paranoid schizophrenia, violent behavior, and HIV, was assessed as having a significant risk for wandering and had a physician's order for a 1:1 sitter to provide constant supervision. Despite this order, the resident was not assigned a 1:1 sitter during the overnight shift, and there was no process in place, such as a sitter log, to ensure compliance with the order. As a result of this lack of supervision, the resident with wandering behavior entered the room of another resident who had severe cognitive impairment due to dementia, depression, and schizophrenia. The cognitively impaired resident required substantial assistance with daily activities and was unable to protect herself. During the incident, the resident with wandering behavior was found on top of the other resident, whose pants and diaper were pulled down, and he admitted to having sex with her. Staff interviews and record reviews confirmed that the 1:1 sitter was not provided as ordered, and the facility's policies required that physician orders be carried out completely and that residents be protected from abuse. The absence of a sitter and lack of monitoring directly led to the incident, which was discovered when a nurse responded to a scream and found the resident in the act. The event was reported to supervisory staff, law enforcement, and other relevant authorities.
Failure to Provide Resident Rights Training to Majority of Staff
Penalty
Summary
The facility failed to ensure that the majority of its staff, specifically 524 out of 552 direct and indirect care staff, received in-service training on resident rights and facility responsibilities as required by facility policy. Record review showed that the Resident Rights in-service was scheduled for April 2025, but attendance records indicated that only 28 staff members attended, primarily from the night shift. There were no sign-in sheets or evidence of training for the other shifts, and both the Director of Staff Development (DSD) and the Staff Development Consultant (DSDC) confirmed that the in-service was not provided to all staff. The DSD stated it was not possible to keep track of all staff attendance, and the DSDC acknowledged the significant impact this lack of training could have on residents. Interviews with the DSD and DSDC further revealed that the facility's policy requires annual and as-needed training on resident rights for all staff, and that department heads are responsible for ensuring staff attendance at mandatory in-services. The DSD admitted that incomplete in-service attendance meant staff might be unaware of critical information regarding resident rights, including the right not to be abused and the right to receive or decline care. The facility's policy also states that lack of staff attendance should be reported to the administrator and department heads, but this process was not followed, resulting in a deficiency in staff education on resident rights.
Failure to Provide Behavioral Health Training to Majority of Staff
Penalty
Summary
The facility failed to provide behavioral health training to 452 out of 552 direct and indirect care staff, as required by the facility assessment and policy. Record reviews showed that the annual in-service calendar scheduled behavioral health training for November, but attendance records from the December in-service indicated that only 100 staff, primarily from the morning shift, participated. There was minimal representation from the evening shift and only one night shift staff attended, leaving the majority of staff without the required training. The Director of Staff Development confirmed that no follow-up was conducted to ensure all shifts received the training, and the Director of Nursing acknowledged the absence of a lesson plan in the in-service binder, further indicating the training was incomplete. Interviews with staff, including a CNA and an LVN, revealed that the lack of behavioral health in-service could impact their ability to provide appropriate care and identify resident behaviors. The facility's policies require the Director of Staff Development to assess educational needs, plan and implement training, and maintain attendance records with lesson plans, but these requirements were not met. The facility assessment identified a secure unit for residents with dementia or behavioral issues, highlighting the importance of this training for the 49 residents with behavioral health concerns.
Failure to Develop and Implement Care Plan for Sexually Inappropriate Behavior
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan to address a resident's sexually inappropriate behavior, specifically the act of touching his private area and making inappropriate requests to a staff member. The resident, who had diagnoses including paranoid schizophrenia and violent behavior, was assessed as having moderate cognitive impairment and required supervision for several activities of daily living. Despite an incident being observed and reported by a 1:1 sitter, there was a delay in reporting the behavior to nursing staff, and no care plan interventions were initiated to address the inappropriate sexual behavior. Interviews with nursing staff confirmed that the incident should have been reported immediately and that a resident-centered care plan should have been developed and implemented to ensure the safety of the resident and others. A review of facility policy indicated that care plans must be updated to address changes in behavior, but this was not done following the incident. The lack of timely reporting and failure to initiate appropriate care planning placed other residents at risk.
Failure to Honor Resident's Rights to Visitor Choice and Responsible Party
Penalty
Summary
The facility failed to honor a resident's right to receive visitors of her choice and to designate her own responsible party. The resident, who had diagnoses including type 2 diabetes mellitus, end stage renal disease, and required dialysis, was cognitively intact and capable of making her own decisions. Despite multiple documented requests from the resident to restrict visits from certain individuals and to change her responsible party to another person, these requests were not acted upon by facility staff. Documentation in the resident's records, including social services notes and interdisciplinary team notes, showed that the resident repeatedly expressed her desire not to have visits from specific visitors and to have a different responsible party involved in her care. The resident also communicated her wishes directly to staff members, including certified nursing assistants and social services staff, and requested that her medical records be updated to reflect these changes. However, the facility did not update the records or enforce the resident's preferences, resulting in unwanted visits and continued involvement of the previously designated responsible party. During interviews and observations, the resident stated she felt unsafe and uncomfortable due to the facility's failure to respect her choices regarding visitors and responsible party. Staff confirmed that the resident had the capacity to make these decisions and that her requests should have been honored. The facility's own policy required staff to respect residents' rights to self-determination and to document personal preferences, but these procedures were not followed in this case.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 6,871 citations issued within 25 miles in the last 12 months — including the 24 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Temple City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Baldwin Gardens Nursing Center | 0.2 mi | ★★★★★ | 19 | 0 |
| Temple City Healthcare | 1.2 mi | ★★★★★ | 34 | 0 |
| Rosemead Healthcare Center | 1.4 mi | ★★★★★ | 24 | 0 |
| Arcadia Care Center | 1.5 mi | ★★★★★ | 9 | 0 |
| San Marino Healthcare Center | 1.8 mi | ★★★★★ | 24 | 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.