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 Monica Rehabilitation Center during CMS and state inspections, most recent first.
Failure to In-Service CNA on Merry Walker Safety for High-Fall-Risk Resident: A resident with severely impaired cognition, dementia, multiple prior falls, and a care plan for a helmet, Merry walker, and 1:1 sitter fell while ambulating with the device after abruptly standing and losing balance. CNA 1 stated she had not received in-service training or a report on the resident's risks or the safe use of the walker, and the resident sustained a nasal fracture and forehead laceration requiring transfer to a GACH.
A resident with fluctuating decision-making capacity, severe cognitive impairment, and dependence for most ADLs was given mirtazapine consent documentation that was signed by the resident even though the nurse and interpreter sections were blank. Staff reported the resident spoke Farsi, but the facility used a family member, an unapproved interpreter app, and other residents’ private caregivers for translation. The DON also could not explain how the resident’s language or alertness was determined, and no communication board was posted in the room.
Loss of Resident Personal Belongings: A resident with severe cognitive impairment and dependence on staff for most ADLs had missing personal items, including compression hose and a blanket. Her RP reported the items were not protected from being lost or misplaced, and the SW stated the facility relied on labeling belongings, while the resident’s requested compression socks were not the correct ones.
CNAs lacked the required competency to care for residents, including the ability to speak and understand English and identify/report abuse. Record review showed one CNA had incomplete employment documentation and no prior experience, while the other stated English a little and had no prior CNA experience. During interview, both CNAs could not name at least five types of abuse; one stated, “I don't know” when asked about mandated reporting, and the other said, “I am not a mandated reporter” and “I don't report then.”
Inaccurate Elopement Risk Assessment and Resident Elopements: A resident with cognitive impairment, AFib, HF, DM, and a recent attempted elopement was not accurately assessed as an elopement risk. Staff confirmed the assessment was incorrect, no elopement care plan was in place at the time, and the resident later eloped twice from the facility after removing a wander guard and exiting through the back elevator and smoking patio gate. Observations also found a gate alarm mechanism obstructed and staff reported the alarm had been left disarmed or unarmed at times.
Failure to assess chest pain, recheck after nitroglycerin, and report critical potassium: A resident with DM, AFib, HF, prior MI, cognitive impairment, and a history of wandering/elopement complained of chest pain and received nitroglycerin, but the chart did not show a comprehensive RN assessment or reassessment after the medication. The resident’s readmission paperwork also showed a potassium of 2.7 mmol/L that was not identified or reported to the physician at the time described. The resident later left the facility and went to a GACH, and staff noted the resident had removed the wander guard.
Failure to assess chest pain, report critical lab value, and prevent elopement: A resident with severe cognitive impairment, cardiac disease, and a history of wandering/elopement was not accurately identified as an elopement risk, had no elopement care plan until after leaving the facility, and was able to exit through the back elevator and smoking patio gate. The resident complained of chest pain and received nitroglycerin, but was not comprehensively assessed or re-assessed afterward. The resident’s hospital discharge summary showed hypokalemia with a potassium of 2.7 mmol/L, but the abnormal result was not reviewed or reported to the physician on readmission.
A resident with severe cognitive impairment and wandering behavior was not adequately supervised or protected from elopement. Staff documented an inaccurate elopement risk assessment, did not have an elopement care plan in place before repeated exits, and the resident was able to remove a wander guard and leave the facility without staff knowledge, later arriving at GACH for care. The facility also had an unsecured patio/alley gate with an alarm that was not functioning or was left disarmed, and staff reported the gate was sometimes left open or not rearmed.
The facility failed to develop comprehensive, person-centered care plans for several residents with identified needs. A resident on antibiotics for a UTI had no care plan for the cephalexin treatment, two residents with dementia and PTSD lacked diagnosis-specific care plans, one resident with repeated refusals of restorative nursing services and mobility deficits had no plan to address the refusals or functional decline risk, and a resident with an indwelling urinary catheter had no catheter care plan. Staff including the LVN, ADON, RNS, MDS nurse, and DON confirmed the missing care plans.
A facility failed to follow a resident’s oxygen order by continuing oxygen use even though O2 saturations remained above the ordered threshold, and also failed to properly label and date another resident’s BiPAP storage bag. The residents had COPD and other significant medical conditions, and staff interviews confirmed the oxygen was being used at all times and the BiPAP mask/tubing bag was not labeled as required by policy.
SB6 lunch trays were not consistently prepared to IDDSI Level 6 standards. During tray line observation, an SB6 Braised Pork Shoulder tray contained irregular strands and chunks, and a later sample tray had pork pieces larger than 15 mm x 15 mm. The RD found that the printed recipe in the DS office did not include SB6 preparation instructions, while the menu software recipe specified the correct size. The DS and SLP both observed the tray and agreed the pieces were not aligned with SB6 guidelines for residents with dysphagia.
Unsanitary food handling and kitchen sanitation: A cook used the same gloves across multiple meal-prep tasks, including handling and breaking apart meats, while used cloths and towels were left on prep and food-contact surfaces, including near clean utensils and serving ware. A manual can opener blade had visible debris while in use, and food debris was found on the kitchen floor under and between equipment. The DS stated the glove practice was not followed, rags were supposed to stay in sanitizer, and the can opener and floor conditions were unsanitary.
Failure to ensure a resident wore an ID armband. A resident with dementia, psychotic disturbance, and severe cognitive impairment was observed without an ID armband in the room. An LVN stated the resident can remove the armband and that missing ID can lead to mistaken identity or medication error. An RNS and the DON stated lack of proper identification could result in wrong meds or services, and the facility policy states wristbands are used to help ensure meds and treatments are given to the right resident.
Failure to Preserve Resident Dignity During Feeding: A CNA was observed standing over a resident while feeding her, rather than being seated. The resident had GERD, TBI, anxiety, and cognitive impairment, and required staff assistance with ADLs. The CNA stated she should have been seated for the resident's dignity, and the DON confirmed staff were expected to sit when assisting residents with eating.
Call Lights Not Within Reach: Two residents had call lights out of reach, including one resident with severe cognitive impairment and extensive ADL dependence whose call light was clipped to a roommate’s bed, and another resident with hemiplegia and total physical assistance needs whose call light was hanging under the bed. Staff and the DON acknowledged that inaccessible call lights prevent residents from calling for help and can leave needs unmet; one resident stated it was frustrating and humiliating to sit wet when unable to reach the call light.
Failure to Report Repeated Refusals of Ordered Care and Safety Measures: A resident with significant functional dependence repeatedly refused RNA ROM exercises, and staff documented the refusals and discussed them in RNA meetings without notifying the physician. Another resident with dementia and high fall risk repeatedly refused to wear an ordered helmet while walking with a merry walker, was observed walking without it, and staff confirmed the refusals were not reported to the physician as required by policy.
Unattended laptop screens on medication carts exposed residents’ personal and medical information, including names, room numbers, DOB, code status, phone numbers, and vital signs. An LPN left one screen open while helping another resident, another left a screen open while assisting elsewhere, and a third left a tab open while helping other nurses. The DON and staff acknowledged that HIPAA requires resident information to be kept private and that the screen must be hidden.
A resident with dementia, Alzheimer's disease, anxiety, depression, and failure to thrive was found with the bed pushed against a wall and a bedside table plus a Merri walker placed to block movement and prevent ambulation. An LVN said the setup was used to keep the resident from getting up, and the DON stated it constituted a physical restraint without a physician order.
Inaccurate and late MDS assessments were identified for two residents. One resident with schizophrenia, major depressive disorder, and psychosis had PASRR records showing a positive level I screen and a level II evaluation recommending specialized services, but the MDS incorrectly indicated no serious mental illness. Another resident with COPD, dysphagia, and a CVA had an annual MDS that was submitted late. The MDS Nurse and DON acknowledged the inaccuracies and late submission.
Failure to Submit Required Death in Facility MDS Assessment: A resident with hemiplegia and hemiparesis after cerebral infarction died in the facility after a CNA found the resident not breathing, an LVN found the resident unresponsive, and CPR was initiated before paramedics pronounced death. The MDS Nurse stated no death in facility assessment was started, completed, or transmitted within the required timeframe, and the DON stated the MDS must be accurate and submitted on time.
MDS assessments were inaccurately coded for three residents. One resident’s MDS showed insulin use even though the MAR and orders showed no insulin was given, and the MDS nurse confirmed the error. Another resident with left-sided hemiplegia had documented ROM impairment in the left arm, but GG 0115A was coded as no limitation despite observation and OT findings. A third resident with right-sided hemiplegia had documented ROM limitations in both arms and both legs, yet GG 0115A and GG 0115B were both coded as no limitation; the MDS nurse confirmed both codes were incorrect.
PASRR Level II Not Completed After Positive SMI Screen: A resident with dementia, bipolar disorder, and anxiety had a PASRR Level I screen positive for SMI, which required a Level II mental health evaluation. The evaluation was noted as unable to be completed, and the MDS Nurse confirmed the Level II had not been done. The DON stated PASRR Level II is important to determine appropriate placement and support psychiatry referral and care planning.
Failure to Support Mobility and Communication Needs: A resident with muscle wasting, osteoarthritis, and coordination deficits was repeatedly observed in bed and reported that staff did not assist him out of bed regularly, while nursing staff said he was only taken out for showers and appointments. Another resident with severe cognitive impairment and a Farsi language barrier was unable to communicate needs because staff did not have the resident’s Farsi communication board available, and multiple staff members stated they could not determine what she needed.
Delayed hospital transfer and splinting without OT assessment: One resident had increased generalized weakness and a physician order to transfer to GACH, but the transfer did not occur until the next day and the physician was not documented as being told why the transfer was delayed. Another resident with right-sided hemiplegia and severe cognitive impairment had a right-hand splint applied by a COTA even though the OT evaluation did not include a splint assessment or splinting goals, and the OT confirmed no documented assessment was done before the splint was first applied.
Low Air Loss Mattress Set Incorrectly for Resident at High Risk for Pressure Ulcers. A resident with a Braden score indicating high pressure ulcer risk and an order for a LAL mattress had the mattress set at 320 lbs even though the pump label indicated a range of 150-180 lbs for the resident’s weight. The TN stated she adjusted the setting to 180 lbs, and the DON stated the mattress setting should be based on the resident’s weight or within range because an out-of-range setting may not be effective and could overinflate the mattress.
A facility failed to maintain or improve ROM and mobility for two residents with significant neurologic impairment and severe cognitive impairment. One resident’s PT, OT, and JMA documentation did not objectively measure all impaired joints or include both legs in the JMA, while the other resident’s RNA staff did not follow the physician’s splint order and instead applied a right-hand roll splint without an order. The DOR and DON confirmed the missing measurements and the incorrect splint use.
A resident with dementia, Alzheimer’s disease, muscle weakness, severe cognitive impairment, and a history of multiple falls was observed walking in the hallway in a merry walker without the ordered helmet and without staff supervision. The care plan called for staff monitoring and supervision, and the physician ordered helmet use whenever walking with the merry walker. The DOR, LVN, ADON, and DON all confirmed the resident was walking unsupervised without the helmet, and the ADON stated staff did not enforce the order because the resident refused.
A resident with Parkinson’s disease, MS, malnutrition, depression, and osteoarthritis had lidocaine 5% patches ordered for the right elbow and left ankle on a 12-hours-on/12-hours-off schedule. Staff observed undated patches, and record review plus interview showed the patches were left on beyond the ordered timeframe, with the LPN stating they had been applied the prior day and not removed per schedule. The DON confirmed the patches were supposed to be changed every 12 hours in accordance with the order and facility policy.
A resident with muscle wasting, osteoarthritis, and lack of coordination had ADL deficits and physician orders for PT and OT evaluations, but the evaluations were not completed. The resident stated he could move all extremities but could not sit, walk, or care for himself and needed PT and OT services. The DOR confirmed the ordered rehab evaluations were missed because he was unaware of the orders, despite facility policy requiring therapy services per physician order.
Therapy records were not readily accessible for three residents with significant rehab needs, including hemiplegia, hemiparesis, aphasia, muscle wasting, osteoarthritis, and lack of coordination. The MRD, ADM, DOR, and DON stated prior PT/OT documentation was on a different electronic system, had not fully switched over, and had to be requested from the previous rehab company, making the records difficult to obtain and not immediately available for review.
Failure to Develop and Update Fall Risk Care Plan: A resident admitted with dementia, toxic encephalopathy, and a history of falls was identified as a moderate fall risk, but no fall risk care plan was developed. The resident later had an unwitnessed fall with a spine fracture requiring a brace, and later developed an injury of unknown origin with ecchymosis, pain, limited movement, and a skin tear to the LUE. The DON confirmed the care plan was not developed on admission and was still absent after these events.
The facility did not maintain clean and sanitary ventilation intake screens in resident rooms, as evidenced by thick dust accumulation on intake screens located above the beds of two residents. One resident reported the dust had been present for a long time and was concerned about inhaling it, while another resident, in the facility for several years, stated he had never seen the screens cleaned. The Maintenance Supervisor confirmed the presence of dust on an intake screen in another room and acknowledged the potential for allergen exposure, despite a facility policy requiring a safe, clean, and sanitary homelike environment.
Surveyors found that resident food storage practices did not follow facility P&P in multiple nutrition rooms. On two floors, open dry food items such as cereal and chips were stored in cabinets without labels or dates, and multiple bags and containers of resident food in refrigerators lacked required resident names, received dates, and open dates. Refrigerators were also overcrowded, limiting air circulation, despite posted instructions that all resident food must be labeled with name, date, expiration date, and discarded after 72 hours, and a written P&P requiring proper coverage, dating, labeling, and avoidance of overcrowding.
Staff failed to respect two English-speaking residents’ rights to dignity and communication when staff spoke to each other in a foreign language while providing care. Both residents had documented English as their primary language and required varying levels of assistance with ADLs and bed mobility; one had intact cognition and the other had mild memory problems. Each resident reported hearing staff speak in a language they did not understand during care, with one expressing concern that staff could be talking about her. A CNA acknowledged that staff should not speak a different language than the one the resident speaks, and the facility’s Resident Rights policy requires employees to treat residents with kindness, respect, and dignity and to support them in exercising their rights.
A resident with encephalopathy, Parkinson’s disease, epilepsy, schizophrenia, documented impaired decision-making capacity, and memory problems was assessed as being at risk for elopement and had a care plan calling for a Wanderguard bracelet, frequent visual checks, and staff awareness of elopement risk. A nurse obtained a physician order for a Wanderguard and attempted to obtain consent from the resident’s representative, but follow-up was left to the next shift and not completed. No order for Wanderguard use or monitoring of wandering behaviors was entered, and no related monitoring or documentation occurred. The resident subsequently eloped, demonstrating that the facility did not implement the care-planned interventions for wandering risk.
Staff failed to follow facility linen-handling policies and infection control practices. An in-service on proper linen handling required storing clean linen in designated clean areas or carts, keeping it covered during transport, and only bringing needed amounts into each room, but one CNA was not listed as having attended. A resident with multiple serious conditions and total dependence on staff had a large open plastic bag of mixed clean linen items stored on the nightstand, which a CNA used as a central supply for all assigned residents by transferring linen from that bag into other rooms. Another CNA described handling linen separately for each resident, while an LVN stated CNAs were educated to keep separate linen bags in each room and acknowledged that linen brought into a room is considered dirty. Surveyors also observed two linen carts with covers flipped up, leaving clean linen exposed, contrary to policy requiring clean linen to be protected from environmental contamination.
Staff failed to follow facility policy for assisting with in-room meals for three cognitively impaired residents who required varying levels of help with eating. One resident with metabolic encephalopathy, dementia, and total dependence for eating was found lying flat in bed with food in the mouth and on the linens while the meal tray remained mostly untouched and covered; the assigned CNA had been redirected to the dining room to assist two other residents needing feeding help and did not promptly return. For all three residents, care plans required documentation of PO intake at every meal, but intake records for the cited day showed either no intake data or "resident not available," and the CNA did not report decreased intake to an LVN as expected. Interviews revealed that usual restorative nursing assistant coverage in the dining room was absent that day, CNAs were managing multiple feeder residents, and charge nurse supervision did not ensure that feeding assistance and intake documentation were completed according to policy.
A resident with schizophrenia, bipolar disorder, severe cognitive impairment, and documented medical noncompliance repeatedly refused ordered Depakote and risperidone over multiple days, including several stretches of three or more consecutive refusals. The care plan required notifying the physician of risks related to non-compliance, and facility policy required physician notification and documentation when consecutive doses of vital medications were refused. Review of the MAR and nursing notes, along with interviews with an LVN and the DON, showed that no physician notification or response was documented despite these repeated refusals, resulting in a significant medication error.
A resident with ESRD and dependence on hemodialysis, along with other serious comorbidities, had physician orders for thrice-weekly dialysis with specified chair times and transportation schedules. The resident’s care plan and clinical documentation show that multiple dialysis sessions were missed because transportation either did not arrive or would arrive too late, and on one occasion due to an expired PCS form that had not been timely completed and signed, which was required for insurance-authorized transport. Staff interviews confirmed that social services relied on PCS-based insurance transportation, that some contracted transportation companies failed to show without warning, and that nursing staff coordinated orders and transportation with social services, yet these processes did not prevent the resident from missing several medically necessary dialysis appointments despite facility policies stating that social services would help obtain transportation and assist in arranging appointments.
A resident with a history of cerebral infarction, aphasia, hemiplegia, and hemiparesis, but no documented cognitive impairment, and the resident’s POA were not provided with required written notices of Medicaid/Medicare coverage, share of cost (SOC), or monthly billing statements. Due to ownership changes and high turnover in the business office and social services, the facility did not update records or send periodic SOC notifications, and the business office could not verify that any monthly statements or SOC notices had been mailed. The POA reported never receiving statements or SOC information and only learned of four months of unpaid SOC when contacted by a third‑party company, despite facility policy requiring monthly itemized billing and written notice before changes in non‑covered costs.
Staff failed to follow hand hygiene standards when two CNAs fed a dependent, cognitively impaired resident with multiple diagnoses, including anoxic brain damage, UTI, immune disorder, and heart failure. One CNA placed a bed remote on the floor, then on the bed without cleaning it, and proceeded to feed the resident without hand hygiene; another CNA entered from the hallway and began to feed the resident without hand hygiene. Both CNAs acknowledged not performing hand hygiene, while the ADON and IP confirmed that hand hygiene is a required standard precaution per facility policy and CDC-based infection prevention guidelines.
Surveyors found that the facility did not develop required discharge care plans for three cognitively intact residents with multiple comorbidities, including fractures, OA, morbid obesity, DM, dysphagia, and serious mental health conditions. Each resident required extensive or total assistance with toileting, bathing, and transfers, yet no discharge care plans were present in their records. The DSS reported that discharge planning is supposed to begin at admission and be updated regularly, while the MRA confirmed that no discharge care plans existed for these residents.
The facility did not report an allegation of verbal and physical abuse between two residents to the appropriate authorities within the required two-hour timeframe, despite being aware of the incident and having a policy mandating immediate reporting. Both residents had significant medical conditions and required staff assistance, and the delay in reporting was confirmed through staff interviews and record review.
The facility did not ensure that the Social Services Director assessed or documented the psychosocial well-being of several residents following incidents of alleged physical and verbal abuse. Despite incidents involving law enforcement and staff-witnessed verbal altercations, affected residents did not receive required follow-up or support, and the lack of documentation was confirmed by staff interviews. This failure was inconsistent with facility policy and job expectations.
Two residents with significant mobility and health needs experienced repeated delays in staff response to their call lights, contrary to facility policy. Both residents reported waiting extended periods for assistance, leading to discomfort and feelings of neglect. Staff interviews confirmed that delayed responses were common, especially during shift changes or when staffing was reduced.
A resident with severe psychiatric conditions and identified as an elopement risk was able to leave the facility without staff notification. Documentation regarding the resident's intent to leave AMA was incomplete, and staff were not consistently monitoring resident whereabouts, especially during shift changes. The resident's absence was discovered during rounds, and their whereabouts remain unknown.
Maintenance staff did not report nonfunctioning thermostats or temperature regulation issues to administration, resulting in the air conditioning being turned off at night and residents experiencing excessive heat. Despite multiple residents with complex medical needs complaining about the temperature, staff failed to offer available portable AC units or follow facility policy for reporting and documentation.
Two residents with significant mobility impairments and intact cognition were forcefully removed from their motorized power wheelchairs by corporate staff, placed into manual wheelchairs without consent or clinical justification, and denied access to their preferred mobility devices. The residents experienced emotional distress, loss of autonomy, and were confined to bed for extended periods, resulting in psychosocial harm.
The facility did not keep the phone ringers at an audible volume at all nursing stations, resulting in staff being unaware of incoming calls until overhead pages were made. LVNs confirmed the phone volumes were turned down, and calls from doctors, family, and patients could not be promptly answered, contrary to facility policy.
A resident with multiple chronic conditions did not receive IV fluids as ordered, with the infusion not running for an extended period and staff unaware of the order. The IV bag remained partially full and uninfused, and the nurse supervisor had not remembered the order, contrary to facility policy requiring proper administration and monitoring of IV therapy.
Failure to In-Service CNA on Merry Walker Safety for High-Fall-Risk Resident
Penalty
Summary
The facility failed to ensure CNA 1 was in-serviced and given clear instruction on the protocols for mitigating physical and environmental hazards, including falls, for a resident who had a history of falls and was using a Merry walker for ambulation. Resident 1 had diagnoses including encephalopathy, protein calorie malnutrition, dementia, muscle weakness, disorder of bone density and structure, a prior fracture of the fifth metacarpal of the left hand, Alzheimer's disease, anxiety disorder, depression, hypertension, and adult failure to thrive. The resident's MDS dated 5/15/2026 indicated severely impaired cognition and need for varying levels of assistance with activities of daily living, including supervision for upper body dressing, partial moderate assistance with toileting hygiene, showering, bathing, and personal hygiene, substantial/maximal assistance with lower body dressing, and dependence for putting on and taking off footwear. The resident's record showed 12 separate falls in the facility, and the care plan identified unavoidable fall risk related to gait and balance problems, dementia, and non-compliance using a walker, with interventions including a helmet during ambulation, a Merri walker for ambulation, and a 1:1 sitter. On 6/12/2026, CNA 1 was assigned to monitor and supervise the resident while ambulating with the Merry walker. CNA 1 stated the resident stopped to rest, sat on the walker seat for about 2 minutes, then abruptly stood, held the front of the walker, and started walking; the resident lost balance and fell face forward. CNA 1 stated she had worked at the facility for 1 month and had not received in-services on the risks and hazards associated with a resident using a Merry walker, and she was not provided a report explaining why the resident was using the device or what behaviors and risks to watch for. The resident sustained a nasal fracture and a laceration to the forehead and was transferred to a GACH for further evaluation and management.
Failure to Honor Resident Rights and Use Proper Interpretation for Consent
Penalty
Summary
The facility failed to follow its Bioethics Committee- Residents Rights and Dignity policy by not honoring the rights of a resident with fluctuating capacity to make decisions. The resident was admitted with diagnoses including hemiplegia, hemiparesis following CVA, CKD stage 4, and DM. The history and physical documented fluctuating capacity to make medical decisions, and the MDS later described severe cognitive impairment and dependence on staff for most ADLs. A psychotherapeutic drug informed consent form for mirtazapine 7.5 mg at bedtime was completed for depression manifested by poor oral intake, and the form showed the resident signed it while the licensed nurse signature and interpreter sections were left blank. A later physician order changed the indication to appetite stimulant. Staff interviews showed the resident was Farsi speaking, did not understand English, and the facility used the resident’s family member as translator even though no family members or responsible parties were listed in the chart. One LVN also stated she used an unapproved interpreter application and at other times asked other residents’ private caregivers to interpret. Additional interviews and observation showed communication support was not in place. A CNA stated she did not understand the resident and was unaware of any translation services. The DON stated the resident did not speak but could say yes and no, and could not explain how the facility determined the resident was alert to self only when the language spoken could not be identified. During a room observation, the DON confirmed there was no communication board posted, and the resident responded to a greeting in Armenian. The facility’s language access policy required assessment of LEP individuals, use of approved translation services, and stated family or friends should not be relied upon for interpretation unless explicitly requested by the resident with written consent.
Loss of Resident Personal Belongings
Penalty
Summary
The facility failed to follow its Resident Rights policy by not preventing the loss of a resident’s compression hose and other personal belongings. Resident 1 was admitted and readmitted with diagnoses including metabolic encephalopathy, COPD, and DM, and her MDS indicated severe cognitive impairment and dependence on staff for most ADLs. Her inventory list dated 9/20/2024 included 4 pairs of compression hoses, but during interview her representative stated that the resident’s personal blanket and several pairs of compression hose were missing, and that the facility had not resolved the issue to replace the missing items. During interview, the Social Worker stated the facility’s procedure for protecting personal items was to have staff or family label belongings, although not all residents and families agreed to that process. The Social Worker also stated she had been made aware of the missing compression hose and two nightgowns, and that the facility had purchased some compression socks that the representative said were not the correct ones. The facility was in the process of purchasing the specific brand requested, and the Social Worker was awaiting an email response regarding the nightgowns. The facility policy stated employees shall treat residents with kindness, respect, and dignity and that residents should be free from misappropriation of property and retain and use personal possessions to the maximum extent that space and safety permit.
CNAs Lacked Competency in English and Abuse Reporting
Penalty
Summary
The facility failed to ensure two CNAs were competent to care for residents, could speak English according to the CNA job description, and were able to identify and report abuse. During record review, CNA 2’s employment application was incomplete, including missing responses about prior health care licensure/certification and no details under employment experience, education, or the experience, training, qualifications, or skills claimed on the form. CNA 2’s payroll/personal/emergency contact form identified CNA 2 as a new graduate with no experience. CNA 1’s employment application stated English a little and showed no prior CNA work experience. The facility’s CNA job description required the ability to read, write, speak, and understand English, and the P&P on job descriptions and performance evaluation stated the objective was to prevent misunderstanding about job responsibilities. During interview, CNA 1 could not name at least five types of abuse and stated, when asked what a mandated report is, “I don't know.” CNA 1 also stated, “I only give blankets, the food to…people,” and said he spoke only little English. CNA 2 also could not name at least five types of abuse and stated that abuse meant not giving a resident a shower on the expected day. CNA 2 stated, “I am not a mandated reporter,” and when asked if required to report witnessing inappropriate behavior toward residents, replied, “no, I don't report then.” The report states that this failure resulted in CNA 1 and CNA 2’s inability to name types of abuse, with the potential for residents to suffer abuse resulting in psychological trauma, pain, and physical injuries.
Inaccurate Elopement Risk Assessment and Resident Elopements
Penalty
Summary
The facility failed to accurately assess a resident for elopement risk after the resident attempted to elope from the facility on 3/30/2026. The resident had diagnoses including DM, paroxysmal AFib, heart failure, and acute myocardial infarction, and the MDS dated 5/6/2026 documented severe cognitive impairment, need for staff assistance with most ADLs, and supervision or touching assistance for walking. The resident’s H&P dated 2/2/2025 described mild cognitive impairment of uncertain or unknown etiology. The resident’s SBAR dated 3/30/2026 documented a post-wandering event and that a wander guard was placed on the right wrist, but the elopement risk assessment dated that same period indicated the resident was not an elopement risk. During interview, an LVN confirmed the assessment was inaccurate, including that questions were answered incorrectly regarding whether the resident was cognitively intact and whether the resident wandered around the unit. The LVN stated the resident should have been considered a high elopement risk after the attempted elopement, and that no care plan had been in place for elopement before 5/28/2026. The resident successfully eloped from the facility on 5/27/2026 and again on 6/2/2026. Nursing notes and SBARs documented that the resident was missing during routine observation, searches of the room, bathrooms, and facility were conducted, law enforcement and the DON were notified, and the resident was later found at GACH 1. The resident stated she left the facility using the back elevator and the side gate on the smoking patio, and she reported not hearing any alarm. Observation of the smoking patio gate showed brown paper jammed into the locking mechanism of one gate, preventing the alarm from triggering, and kitchen staff and maintenance staff stated the gate alarm had been disarmed or left unarmed at times. The resident was observed without a wander guard, and staff confirmed she needed to always wear one because she was at risk for elopement.
Failure to Assess Chest Pain, Recheck After Nitroglycerin, and Report Critical Potassium
Penalty
Summary
The facility failed to accurately assess a resident who had a history of diabetes mellitus, paroxysmal atrial fibrillation, heart failure, acute myocardial infarction, and cognitive impairment. The resident’s record showed severe cognitive impairment on the MDS and required staff assistance or supervision for multiple ADLs and walking. The resident also had a history of wandering and elopement, including a prior attempt to leave the facility, and the chart reflected a wander guard order and later an elopement-focused care plan after a successful elopement had already occurred. On one occasion, the resident was found missing during a shift change, and staff searched the facility and surrounding area before law enforcement and the resident’s family were notified. The resident was later located at a general acute care hospital after leaving the facility. On another occasion, the resident complained of chest pain and was given nitroglycerin 0.4 mg. The nursing note documented that after 5 minutes the resident said she was doing okay, but the record did not show a comprehensive licensed nurse assessment after the chest pain complaint or a reassessment after nitroglycerin administration. The resident’s discharge/readmission information also showed a potassium level of 2.7 mmol/L, which was not identified or reported to the physician by the desk nurse or reviewed by the DON at the time described in the report. The DON and LVN both stated that this value was significantly low and should have been reported promptly. The resident later stated that she left the facility because she was experiencing chest pain and felt staff were not appropriately addressing it, and she was observed without a wander guard after removing it and leaving it on the bedside table.
Failure to assess chest pain, report critical lab value, and prevent elopement
Penalty
Summary
The facility failed to provide appropriate treatment and care according to orders, resident preferences, and goals for a resident with diabetes mellitus, paroxysmal atrial fibrillation, heart failure, acute myocardial infarction, and severe cognitive impairment. The resident had a history of wandering and elopement, including a prior successful elopement and an attempted elopement, but the elopement risk assessment was documented inaccurately and did not identify the resident as an elopement risk. The record also showed that no care plan was in place for elopement until after the resident had already eloped from the facility. On one occasion, the resident was found missing during the night and was later located at an acute care hospital after leaving the facility without staff knowledge. On another occasion, the resident complained of chest pain at night and was given nitroglycerin 0.4 mg, but the resident was not comprehensively assessed afterward and was not re-assessed after the medication was administered. The resident later left the facility again and went to the same hospital seeking medical services. The resident stated that she used the back elevator and the side gate on the smoking patio to exit and that she did not hear any alarm trigger when she left. The record also showed that the resident’s discharge summary from the hospital identified hypokalemia with a potassium level of 2.7 mmol/L, but the abnormal value was not reviewed, identified, or reported to the physician at the time of readmission. Interviews with nursing leadership confirmed that the discharge summary had not been reviewed and that the low potassium level was significantly low. Facility observations also found a gate on the smoking patio with brown paper jammed into the locking mechanism, preventing the gate from locking and preventing the alarm from engaging, and the door to the patio was observed unlocked.
Failure to Prevent Elopement and Secure Exit Gate
Penalty
Summary
The facility failed to provide adequate supervision and effective elopement prevention for a resident with severe cognitive impairment who had a history of wandering and attempted elopement. The resident’s record showed diagnoses including diabetes mellitus, paroxysmal atrial fibrillation, heart failure, and a prior myocardial infarction. On 3/30/2026, the resident attempted to elope, but the elopement risk assessment completed that day was inaccurate and indicated the resident was not an elopement risk. Staff documented that a wander guard was placed after the wandering episode, but the resident did not have an elopement care plan in place until after later elopements occurred. The resident subsequently eloped from the facility on 5/27/2026 and again on 6/2/2026 during the night. On both occasions, staff discovered the resident missing during routine observation or shift change, searched the facility and surrounding areas, and contacted law enforcement. The resident was later found at General Acute Care Hospital seeking medical attention. Nursing notes and staff interviews showed the resident frequently walked around the unit, went to the nurses’ station, and was known by staff to need close monitoring because of wandering behavior and chest pain complaints. Staff also confirmed that the resident was able to remove the wander guard and leave the facility without staff knowledge. The facility also failed to ensure that the patio gate leading to the alley had a functioning alarm system to alert staff when opened. During observation, one gate was found with brown paper jammed into the locking mechanism, preventing the alarm from triggering, and another gate was observed propped open with a plastic bag. Staff stated that kitchen staff sometimes disarmed the gate alarm and did not rearm it, and that the door should have been locked. The resident stated she left the facility using the back elevator and side gate and did not hear any alarm when she exited.
Missing Comprehensive Care Plans for Multiple Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, individualized person-centered care plans with measurable objectives and timetables for five sampled residents. The report identified missing care plans for Resident 2’s cephalexin treatment for a urinary tract infection, Resident 10’s dementia, Resident 11’s PTSD, Resident 17’s repeated refusals to participate in restorative nursing services and mobility concerns, and Resident 47’s indwelling urinary catheter. Facility staff, including the LVN, ADON, RNS, MDS nurse, and DON, confirmed that these conditions and treatments were not care planned as required. Resident 2 was admitted and readmitted with diagnoses including hemiplegia, hemiparesis, gait and mobility abnormalities, obstructive and reflux uropathy, and unspecified dementia. The resident’s MDS indicated intact cognition but dependence on staff for toileting and self-care. The resident received cephalexin 500 mg every 12 hours for 10 days for a UTI, and the chart also documented a failed voiding trial after catheter removal with urinary retention and the catheter remaining in place. Review of the care plan showed no plan for cephalexin use, and the LVN and DON both confirmed that no patient-centered care plan existed for the antibiotic treatment. Resident 10 was admitted and readmitted with diagnoses including dementia, DM, and HTN. The H&P documented memory loss and lack of capacity to make medical decisions, and the MDS indicated cognitive impairment and substantial to maximal assistance with ADLs. The ADON and DON stated that Resident 10 did not have a dementia care plan, and both stated that a dementia plan was needed for safety and individualized care. Resident 11 was admitted and readmitted with diagnoses including dementia, bipolar disorder, and anxiety, and the H&P documented PTSD. The resident stated she had a history of PTSD after an assault. RNS staff and the DON confirmed that Resident 11 did not have a PTSD care plan, despite the diagnosis being documented in the record and staff stating that triggers and individualized interventions needed to be identified.
Respiratory Care and BiPAP Storage Deficiencies
Penalty
Summary
The facility failed to provide respiratory care for a resident with COPD and respiratory failure when staff did not follow the physician’s oxygen order. The resident’s order required oxygen saturation to be monitored every shift and oxygen to be administered at 2 liters per minute via nasal cannula as needed only when the oxygen saturation was below 92%. Review of the resident’s May 2026 MAR showed oxygen saturation levels were no lower than 97% for all shifts from 5/1/2026 through 5/20/2026, yet the resident was observed receiving oxygen while lying in bed. A CNA stated the resident wore oxygen at all times, and the RNS stated the resident should not have been receiving oxygen because the saturation level had never been below 97%. The resident’s record showed diagnoses including respiratory failure, COPD, muscle weakness, and dementia, and the H&P noted fluctuating capacity to understand and make decisions. The resident’s care plan directed staff to provide oxygen as ordered. During interview, the DON stated that based on the physician order, the resident should only receive oxygen when the oxygen saturation was below 92%, and stated that over oxygenation could increase the resident’s carbon dioxide level. The facility’s Oxygen Administration policy required staff to verify a physician order and observe the resident to ensure oxygen was being tolerated. The facility also failed to properly label and date the storage bag for another resident’s BiPAP equipment. The resident had diagnoses including COPD, Afib, and diabetes, and was dependent on staff for ADLs with cognitive impairment. The care plan and physician orders required BiPAP tubing care and weekly cleaning. During observation, the BiPAP machine was on the nightstand while the mask and part of the tubing were stored in a Ziplock bag in the nightstand drawer that was not labeled with the resident’s name or dated. The resident stated she used the breathing machine at night but did not know when it was cleaned. An LVN stated staff were responsible for washing the BiPAP mask and tubing every Monday and placing them in a bag labeled with the resident’s name and date, and the DON stated the bag needed to be dated and labeled for oncoming staff to know when it was cleaned.
SB6 Texture-Modified Meals Not Prepared to IDDSI Standards
Penalty
Summary
The facility failed to ensure that 35 of 132 Soft-and-Bite-Sized (SB6) texture-modified lunch trays were prepared according to the IDDSI Level 6 standard and the facility’s Diet Descriptions. During tray line observation in the kitchen, an SB6 tray was seen with several irregularly shaped strands and chunks of Braised Pork Shoulder. The Registered Dietitian stated that the SB6 recipe should contain instructions for the appropriate texture and retrieved a printed recipe from the Dietary Supervisor’s office, but that recipe did not include instructions for preparing the SB6 texture. A review of the facility’s menu software showed that the SB6 Braised Pork Shoulder recipe specified use of the food processor knife setting to produce pieces no larger than 15 mm x 15 mm. However, a sample SB6 tray observed later contained several pieces of pork larger than 15 mm x 15 mm. The Dietary Supervisor observed the tray and stated it could put residents at risk for choking. The Speech-Language Pathologist also observed the tray and agreed that the chunks were not aligned with SB6 dietary guidelines and may pose a choking risk for residents with dysphagia. The facility’s Diet Manual stated that SB6 is used for residents with difficulty chewing and/or swallowing and requires soft, tender, moist food no greater than 15 mm x 15 mm.
Unsanitary food handling and kitchen sanitation
Penalty
Summary
Kitchen staff failed to follow sanitary glove-use practices during meal preparation. During observation, a cook assembled lunch meals while wearing the same gloves across multiple tasks, including opening the steam oven, reaching into pans, plating vegetarian patties, handling soft-and-bite-sized meatloaf, and separating meat with thumb and index finger. The Dietary Supervisor stated that the glove policy was not followed and that the food handling created a risk for cross-contamination. The facility policy and the 2022 FDA Food Code both identified single-use gloves as items to be used for one task and then discarded. The kitchen also had multiple instances of wet, pink-colored cloths and towels left on food preparation and food-contact surfaces. Cloths were observed crumpled on a prep counter near thawing meat, spread across the wooden countertop section of the steam table, hanging over the edge of a prep counter above an open drawer of clean utensils, and bundled on the steam table surface. A wet cloth was also found in a pan with a honeydew melon before the melon was peeled and diced, and another used towel was left on a rack with beverage pitchers and ceramic bowls. The Dietary Supervisor stated that rags and towels were supposed to be kept submerged in sanitizer solution in red buckets, and the FDA Food Code required in-use wiping cloths to be held in chemical sanitizer between uses. The manual can opener blade had built-up debris on the tip, edge, and face while it was being used to open several cans for lunch service. The Dietary Supervisor stated the blade was supposed to be cleaned every other day, but the blade did not appear to have been cleaned routinely, and the weekly and monthly cleaning schedules did not include it. In addition, the kitchen floor had visible debris under the steam table, stove, oven, and between equipment, including dough, a sealed juice, food patties, diced carrot, peas, and corn. The Dietary Supervisor and Maintenance Supervisor both described deep cleaning of the floors, but no logs, policies, or documentation were produced to support the statement.
Failure to Ensure Resident Wore ID Armband
Penalty
Summary
The facility failed to ensure that Resident 63 was wearing an identification (ID) armband in accordance with the facility’s Resident Identification System policy. Resident 63’s admission record showed diagnoses including dementia, psychotic disturbance, hypertension, and anxiety. The resident’s MDS dated 3/23/2026 indicated severe cognitive impairment. During an observation in Resident 63’s room on 5/18/2026 at 8:45 A.M., Resident 63 was not wearing an ID armband. During interviews, LVN 1 stated that Resident 63 can remove his own ID armband and that not wearing one can cause harm due to mistaken identity or medication error. RNS 1 stated that if a resident does not wear an ID armband, the resident could receive the wrong medication or wrong therapy services. The DON stated that if a resident is not correctly identified, staff will not be able to identify the resident and the resident can receive the wrong medication or services. The facility’s Resident Rights policy stated the resident has a right to communication with and access to people and services, and the Resident Identification System policy stated the facility uses a wristband identification system to help assure medications and treatments are administered to the right resident.
Failure to Preserve Resident Dignity During Feeding
Penalty
Summary
The facility failed to maintain dignity and respect for one resident when CNA 2 stood over the resident while feeding her. Resident 80 was admitted on 11/27/2024 and readmitted on 10/27/2026 with diagnoses including GERD, TBI, and anxiety. The resident's MDS dated 2/27/2026 indicated cognitive impairment and that she required setup/clean up to dependence on staff assistance with ADLs. During an observation on 5/19/2026 at 8:02 A.M. in the resident's room, CNA 2 was seen standing over Resident 80 while placing a spoonful of food into her mouth. When interviewed at that time, CNA 2 stated she needed to be seated when helping the resident eat per facility policy and for the resident's dignity. The DON later stated that staff were expected to be sitting when assisting residents with eating for dignity, and that standing while doing so could make residents feel belittled. The facility's Dignity policy stated that residents are to be treated with dignity and respect at all times and provided with a dignified dining experience.
Call Lights Not Within Reach
Penalty
Summary
The facility failed to ensure call lights were within reach for two residents. Resident 110 was admitted with diagnoses including atrial fibrillation, anxiety disorder, hypertension, dysphagia, and schizophrenia. The MDS dated 04/17/2026 indicated severe cognitive impairment, dependence for eating and toileting, partial/moderate assistance needed for oral hygiene and upper body dressing, and substantial/maximal assistance needed for bathing, lower body dressing, footwear, and personal hygiene. During an initial tour on 5/18/2026, Resident 110’s call light was observed clipped to the roommate’s bed sheet, while the roommate had two functional call lights on her bed. An LVN removed Resident 110’s call light from the roommate’s bed, sanitized it, and handed it to Resident 110. The DON stated call lights must be accessible to residents when in bed and that failure to do so could delay care and lead to poor outcomes and unnecessary hospitalization. Resident 122 was admitted with diagnoses including right-sided hemiplegia, encephalopathy, muscle weakness, and COPD. The MDS indicated total physical assistance was required for bed mobility, transfer, and toileting, and the care plan directed staff to encourage the resident to use a bell to call for assistance. On 5/18/2026, Resident 122’s call light was observed hanging under the bed and out of reach. On 5/20/2026, the resident stated that sometimes they sat wet and wanted to be changed, and that it was frustrating when the call light was out of reach; the resident also stated feeling humiliated sitting in their own urine. A CNA observed the call light out of reach and stated that unmet needs could leave the resident frustrated and neglected. The RNS and DON both stated that when a call light is out of reach, the resident cannot call for help or assistance, and the DON stated the resident’s needs would not be met. Facility policy required call lights to be accessible when residents are in bed, and the resident rights policy required residents be treated with kindness, respect, and dignity.
Failure to Report Repeated Refusals of Ordered Care and Safety Measures
Penalty
Summary
The facility failed to report changes in condition to the physician for two residents who repeatedly refused ordered care. One resident was admitted with muscle wasting and atrophy, osteoarthritis, and lack of coordination, and his MDS showed he was cognitively intact but dependent for several ADLs and transfers. He had physician orders for restorative nursing aide (RNA) active assistive range of motion exercises to both arms and both legs five times a week. In April 2026, the RNA flowsheets documented repeated refusals of both arm and leg ROM sessions on multiple consecutive days, and staff interviews confirmed the resident consistently refused because he wanted to walk and get out of bed instead of doing ROM exercises. RNA staff stated they documented the refusals and discussed them in weekly RNA meetings, and the DOR, ADON, and DON all acknowledged that multiple consecutive refusals should have been treated as a change in condition and reported to the physician. The ADON confirmed the resident refused RNA services 17 times for both legs and 18 times for both arms during the month. The DON stated that after repeated refusals, a licensed nurse should have initiated a change in condition evaluation, notified the physician and family or responsible party, and implemented interventions, but the physician was not notified and the resident did not receive the ordered restorative services. The second resident had dementia, muscle weakness, and Alzheimer’s disease, and was identified as a high fall risk with a history of multiple falls. A physician ordered the resident to wear a helmet at all times when walking with a merry walker. The eMAR progress notes documented repeated refusals to wear the helmet on multiple days in May 2026, including several consecutive days and multiple refusals on some days. Staff observed the resident walking in the hallway without a helmet, and LVN and ADON interviews confirmed the resident repeatedly refused the helmet despite staff awareness of the order. Staff stated the refusals were not reported to the physician, even though the facility’s policy required notification for repeated refusals of treatment and the change in condition policy required physician notification after two or more consecutive refusals.
Unattended Computer Screens Exposed Resident Information
Penalty
Summary
The facility failed to protect residents’ right to privacy when laptop computer screens were left open and unattended on medication carts, displaying residents’ personal and medical information. During observation and interview on 5/19/2026 at 10:01 AM, a laptop on top of a medication cart displayed Resident 81’s full name, room number, date of birth, code status, phone number, and vital signs. LVN 6 was identified as the user logged into the screen and stated that no one else had the password, but denied leaving the information open and unattended. During another observation and interview on 5/19/2026 at 10:34 AM, a laptop on a medication cart displayed Resident 46’s full name, room number, date of birth, code status, phone number, and vital signs while unattended in the hallway. LVN 7 was not immediately visible and was later observed coming from a resident’s room. LVN 7 confirmed the name on the screen and stated the computer had been left open while helping another resident. LVN 7 stated that exposing patient information in this way risks the resident’s information being stolen and can expose medical condition and personal information. On 5/20/2026 at 10:21 AM, another laptop on a medication cart displayed Resident 105’s full name, room number, date of birth, code status, phone number, and vital signs while unattended. LVN 8 confirmed the name on the screen and stated the tab had been left open while helping other nurses. During interviews, LVN 9 and the DON stated that HIPAA requires resident information to be kept safe and not shared, and that the computer screen must be hidden. Facility policies titled Resident Rights and Confidentiality of Information and Personal Privacy stated that resident personal and medical records must be kept private and confidential.
Unnecessary Physical Restraint Used Without Physician Order
Penalty
Summary
Resident 126 was admitted and later re-admitted to the facility with diagnoses including dementia, Alzheimer's disease, anxiety disorder, depression, and failure to thrive. The resident's MDS dated 5/20/2026 indicated severely impaired cognition, independence with eating and oral hygiene, need for moderate assistance with toileting hygiene, showering/bathing, and personal hygiene, supervision/touching assistance with upper body dressing, substantial/maximal assistance with lower body dressing, dependence for footwear, and ambulation not attempted. During a facility tour on 5/18/2026, Resident 126's bed was observed in the lowest position with the left side pushed against the wall. A bedside table and a Merri walker were placed directly behind each other on the right side of the bed and against the bed railing, blocking the resident's ability to get out of bed or sit at the edge of the bed with feet on the floor. An LVN stated the items had been placed there to prevent Resident 129 from getting out of bed and ambulating, and the roommate stated that if the bedside table and Merri walker were moved, she would get up and try to walk. The DON stated this arrangement constituted a physical restraint and that Resident 129 did not have a physician's order for physical restraints.
Inaccurate and Late MDS Assessments
Penalty
Summary
The facility failed to ensure that MDS entries related to PASRR were accurately documented for two sampled residents. For Resident 5, the record showed admission on 9/20/2018 and readmission on 1/10/2026 with diagnoses including schizophrenia, major depressive disorder, and psychosis. The MDS dated 2/25/2026 indicated the resident was cognitively impaired and dependent on staff for ADL care, but the MDS section asking whether the resident was currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability was marked "No." Resident 5’s PASRR level I screening dated 4/6/2023 indicated a positive level I screening and that a level II mental health evaluation was required. The PASRR level II screening dated 5/5/2023 indicated specialized services were recommended. During interview and record review, the MDS Nurse stated the MDS section A was not accurate because the PASRR level I and level II assessments showed the resident was positive for mental illness, schizophrenia. The MDS Nurse stated the inaccurate MDS assessment could lead to the resident being provided with the wrong services and plan of care. For Resident 127, the record showed original admission on 2/27/2025 and readmission on 1/24/2026 with diagnoses including COPD, difficulty swallowing, and cerebral infarction. CMS Final Validation Reports showed the annual MDS ARD was 3/7/2026 and that the assessment was completed late, with no prior record within 366 days of the submitted record. The MDS Nurse stated the annual MDS was submitted on 4/8/2026, that it was started on 3/7/2026, and that it should have been completed by 3/21/2026. The DON stated that the MDS should be accurate and submitted on time.
Failure to Submit Required Death in Facility MDS Assessment
Penalty
Summary
The facility failed to submit the required complete Minimum Data Set (MDS) information for one resident within 14 days after the resident’s discharge/expiration date. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis after cerebral infarction. The discharge summary stated that a CNA noticed the resident was not breathing, an LVN found the resident unresponsive, CPR was started, and paramedics arrived at the facility and continued chest compressions before pronouncing the resident dead at 7:28 PM on the date of death. During a concurrent interview and record review, the MDS Nurse stated that when a person dies in the facility, a death in the facility assessment is required. The MDS Nurse stated that no death in the facility assessment was started, completed, or transmitted for the resident, and that it should have been completed within 14 days of death and transmitted by the required deadline. The DON stated that the MDS must be accurate and submitted on time to reflect the care the resident received. The facility policy stated that the Resident Assessment Coordinator was responsible for ensuring timely and appropriate resident assessments, including federally mandated OBRA-required assessments such as discharge assessments.
MDS Assessments Were Inaccurately Coded for Insulin Use and ROM Limitations
Penalty
Summary
The facility failed to accurately assess and code MDS assessments for three residents. For one resident admitted with UTI, muscle weakness, and fibromyalgia, the MDS dated 5/7/2026 indicated the resident received insulin injections during the last seven days or since admission, but review of physician orders and the MAR showed the resident never received insulin. The MDS nurse confirmed the MDS was incorrect, and the DON stated the MDS needs to be accurate because it reflects the resident’s plan of care and that an inaccurate MDS can lead to ineffective patient care. For another resident with left-sided hemiplegia and hemiparesis following cerebral infarction and muscle weakness, the OT evaluation documented ROM impairments in the left shoulder, elbow, forearm, wrist, and hand. During observation, the resident was lying in bed with a splint to the left hand and elbow, the left elbow was bent to 90 degrees, the wrist was bent downward, and the fingers were curled inward. The resident stated he was unable to move the left arm independently and needed staff assistance to move it. However, Section GG 0115A on the MDS was coded as 0, indicating no ROM limitations in both arms. The MDS nurse confirmed the coding was incorrect and stated it should have been coded as 1 because the resident had ROM limitations in the left arm. For a third resident with right-sided hemiplegia and hemiparesis following cerebral infarction, aphasia, and muscle weakness, the JMA showed ROM limitations in both shoulders, elbows, wrists, hands, hips, knees, and ankles. During observation, the resident was in bed with both arms at the sides and both knees bent. A family member stated the resident was paralyzed in the right arm and right leg, could not move the left leg independently, and minimally moved the left arm; the COTA stated the resident’s both knees and right elbow were contracted and that the resident did not move the left arm functionally and had no active movement in the right arm. Despite this, Section GG 0115A and GG 0115B were coded as 0, indicating no ROM limitations in both arms and both legs. The MDS nurse confirmed both sections were coded incorrectly and stated they should have been coded as 2.
PASRR Level II Not Completed After Positive SMI Screen
Penalty
Summary
The facility failed to ensure that a PASRR Level II evaluation was completed for Resident 11 after the resident’s PASRR Level I screening was positive for serious mental illness. Resident 11 was admitted on 1/10/2025 and readmitted on 2/17/2026 with diagnoses including dementia, bipolar disorder, and anxiety. The resident’s MDS dated 4/20/2026 indicated the resident was cognitively intact and required staff assistance with ADLs. The PASRR Level I dated 4/22/2025 identified a positive screen for SMI and indicated that a Level II mental health evaluation was required. A notice of attempted evaluation dated 4/27/2025 stated that the Level II evaluation could not be completed. During interview and record review on 5/22/2026, the MDS Nurse stated that the resident’s PASRR Level II was not done and that he would apply for it. The DON stated that completion of PASRR Level II is important to determine whether the resident is appropriately placed in the nursing home and to support proper referral to psychiatry services and care planning.
Failure to Support Mobility and Communication Needs
Penalty
Summary
The facility failed to provide treatment and services to maintain or improve residents’ abilities to perform ADLs for two sampled residents. One resident, admitted and readmitted with diagnoses including muscle wasting and atrophy, osteoarthritis, and lack of coordination, was cognitively intact but required varying levels of assistance with eating, dressing, hygiene, bathing, rolling, sit-to-stand, and bed-to-chair transfers according to the MDS. During multiple observations, he was found lying in bed, and he stated that staff did not assist him out of bed and that he wanted to get out of bed more often. Interviews with nursing staff showed that the resident was not getting out of bed regularly and was only being assisted out of bed for showers twice weekly and appointments. A restorative nursing aide stated the resident did not get out of bed regularly and only got out of bed for appointments, and a CNA stated he was always in bed and was assisted out of bed for showers twice a week and appointments only. The CNA also stated the resident should be out of bed every day to improve mobility. The DON stated staff should offer to assist residents out of bed into a chair at least one to two times a day despite refusals to prevent physical and functional decline. A second resident, admitted and readmitted with diagnoses including dementia, muscle weakness, and Alzheimer’s disease, had severe cognitive impairment and was rarely or never understood, and could rarely or never understand others. During observation, the resident was lying in bed, reaching out her arms, and speaking in Farsi. CNA 7 and the ADON both stated they did not know what the resident needed because she spoke only Farsi and they did not know how to communicate with her. The ADON stated the resident was supposed to have a communication board with pictures and phrases in Farsi, but none was present in the room. CNA 7 continued feeding the resident lunch while the resident shook her head at certain foods and tried to communicate in her primary language, but staff stated they could not determine what she wanted. The ADON and SS both stated the communication board should always be in the resident’s room and accessible to both the resident and staff, and the facility’s policy stated that residents with limited English proficiency should have meaningful access to information and services.
Delayed hospital transfer and improper splint application
Penalty
Summary
Resident 11 experienced a change of condition on 2/13/2026 for increased generalized weakness, and the attending physician was notified with a new order to transfer the resident to the hospital for further evaluation. The physician order was written the same day for transfer to GACH, but the resident was not transferred until the next day. The transfer summary documented that the resident was picked up by gurney on 2/14/2026 and sent to the hospital for increased generalized weakness and further evaluation. Hospital records from the emergency department noted the resident came from the SNF due to generalized weakness. During interview and record review, Registered Nurse Supervisor 2 stated the facility process required notifying the physician if the resident could not be transferred to GACH as ordered. RNS 2 stated there was no documented evidence that the physician was notified why Resident 11 was not transferred on the day the order was written. The DON also stated that if staff were not able to transfer a resident to GACH as ordered, the ordering physician needed to be notified for further instructions. Resident 105 had diagnoses including right-sided hemiplegia, hemiparesis following cerebral infarction, aphasia, and muscle weakness. The OT evaluation dated 2/18/2026 did not indicate goals or an assessment for the resident's right-hand splint. The MDS dated 3/12/2026 showed severe cognitive impairment and dependence on staff for eating, hygiene, bathing, dressing, rolling, and transfers. An OT treatment encounter note dated 4/3/2026 showed a COTA applied a splint to the resident's right hand for one hour. During observation on 5/20/2026, the resident was in bed with the right arm and leg affected by paralysis, and the family member stated the right hand had progressively become tighter, was very painful, and rested in a fisted position. The COTA provided PROM to all extremities and applied splints to the right hand and both knees at the end of the session. The DOR, who was an OT, stated a licensed OT or PT must assess a resident's need for splints, determine wear tolerance, and establish the splinting plan of care before the plan is transitioned to nursing and RNA staff. The DOR confirmed the OT did not assess Resident 105 for the right-hand splint and stated the COTA was the first staff to apply the splint. The DON stated Rehab was responsible for splint assessments and determining the correct type of splint and wear time, and that a formal assessment was required before issuing splints.
Low Air Loss Mattress Set Incorrectly for Resident at High Risk for Pressure Ulcers
Penalty
Summary
The facility failed to ensure that low air loss mattress guidelines were followed for appropriate pressure redistribution support for Resident 80. Resident 80 was admitted on 11/27/2024 and readmitted on 10/27/2026 with diagnoses including GERD, TBI, and anxiety. The resident’s Braden Scale dated 12/4/2025 showed a score of 12, indicating high risk for pressure ulcers, and the MDS dated 2/27/2026 indicated the resident was cognitively impaired and required setup/clean up to dependence on staff for ADLs. A physician order dated 3/16/2026 indicated a low air loss mattress for wound management. During observation on 5/18/2026 at 11:01 A.M., the low air loss mattress setting in Resident 80’s room was 320 lbs, while the label on the mattress pump indicated the resident’s setting should be 150-180 lbs. During a concurrent observation and interview, the Treatment Nurse stated she changed the setting from 320 lbs to 180 lbs, which was the closest setting to the resident’s current weight of 187 lbs. The Treatment Nurse stated the low air loss mattress is used for residents who are not able to move on their own to prevent pressure injuries, and that if the mattress is too firm at 320 lbs for a resident weighing 187 lbs, it may cause pressure injuries. The DON stated that the mattress setting is based on the resident’s weight or within range, and that if the setting is not within the resident’s weight range, it may not be effective; the DON also stated that a setting higher than the resident’s weight may overinflate the mattress and put the resident at risk for developing pressure ulcers. The facility’s Support Surface Guidelines dated 1/29/2026 stated support surfaces are used for pressure redistribution, shear reduction, and in some cases temperature/moisture control for residents at risk of pressure injury.
Failure to assess ROM accurately and follow splint orders
Penalty
Summary
The facility failed to provide treatments and services to maintain or improve ROM and mobility for two residents with ROM and mobility concerns. One resident had diagnoses including right-sided hemiplegia, hemiparesis following a cerebral infarction, aphasia, and muscle weakness. The resident was dependent on staff for multiple ADLs and had severe cognitive impairment. During review of the resident’s JMA dated 1/22/2026, Section I for Joint Mobility Screening was not signed or completed, and the assessment did not include both legs. The resident’s OT evaluation dated 2/18/2026 documented impaired ROM in both shoulders, elbows, forearms, wrists, hands, thumbs, and fingers, and the PT evaluation dated 2/18/2026 documented impaired ROM in both knees. The DOR stated that impaired joints should have been measured with a goniometer to establish an objective baseline and monitor for changes, but the evaluations did not include those measurements. During observation, the resident was seen lying in bed with both arms at the sides and both knees bent, and the COTA provided PROM to both arms and both legs while noting contractures in both knees and the right elbow. For the second resident, the facility failed to follow the physician’s order for splint application and applied a splint without a physician’s order. The resident had diagnoses including right-sided hemiplegia and hemiparesis following a cerebral infarction and aphasia, severe cognitive impairment, and functional limitations in ROM. The physician’s order directed RNA staff to apply a right elbow splint two hours, five times a week, but RNA staff instead applied a right-hand roll splint to the resident’s right hand and wrist. RNA 1 stated she did not apply the ordered right elbow splint and confirmed she had been placing the right-hand roll splint without an order for that device. The DOR and DON confirmed that the RNA was expected to follow the order exactly as written and that RNAs are not qualified to modify the RNA program.
Failure to Supervise High Fall Risk Resident and Enforce Helmet Use
Penalty
Summary
A resident identified as a high fall risk was observed walking in the hallway in a merry walker without the ordered helmet and without staff supervision. The resident had diagnoses including dementia, muscle weakness, and Alzheimer’s disease, and the fall risk assessment documented a history of three or more falls in the prior three months with a score of 18. The resident’s MDS indicated severe cognitive impairment, and the care plan identified the resident as at risk for subsequent falls related to impaired safety awareness, limited ability to recognize hazards, impaired judgment, and the need for an assistive device, with staff monitoring and supervision included as an intervention. The physician’s order required the resident to wear a helmet at all times when walking with the merry walker. During observation, the resident walked about 400 feet in the hallway without a helmet and unattended, taking a few steps, closing her eyes, placing a hand on her forehead, and sitting down repeatedly. No staff member was observed in or near the hallway providing supervision or monitoring while the resident walked. The DOR, LVN, ADON, and DON each observed the resident walking unsupervised without a helmet and confirmed that the resident was supposed to be supervised and wear the helmet when walking. The DOR stated being unaware of the helmet requirement, while the ADON stated staff knew of the order but did not enforce it because the resident constantly refused. The DON stated supervision meant the resident should always be in a staff member’s direct line of sight, and confirmed that staff did not supervise the resident when she walked alone in the hallway.
Lidocaine Patches Left On Beyond Ordered Time
Penalty
Summary
The facility failed to ensure that one sampled resident received lidocaine external patches according to physician orders and the facility’s medication administration policy. Resident 147 had diagnoses including Parkinson’s disease, multiple sclerosis, protein calorie malnutrition, depression, and osteoarthritis, and the MDS indicated the resident was cognitively intact, non-ambulatory, and required extensive assistance with several activities of daily living. During a facility tour, the resident was observed with undated lidocaine patches on the left upper arm. Record review showed physician orders for lidocaine external patch 5% to be applied to the right elbow and left ankle once daily for pain management, with 12 hours on and 12 hours off, and removed per schedule. During interview, LVN 1 stated the patches on the right elbow and outer left ankle were last applied on 5/17/2026 at 11:48 a.m. and that LVN 1 did not administer or apply them. The EMR also showed LVN 3 documented removal of the patches, while LVN 1 stated the patches were left on in excess of 12 hours. The DON stated the patches are supposed to be changed every 12 hours, with 12 hours on and 12 hours off, and the facility policy required medications to be administered safely, timely, and in accordance with prescriber orders.
Failure to Provide Ordered PT and OT Evaluations
Penalty
Summary
The facility failed to ensure specialized rehabilitative services were provided as ordered for one resident. Resident 17 had diagnoses including muscle wasting and atrophy, osteoarthritis, and lack of coordination. The resident’s MDS dated 3/5/2026 showed cognitive intactness, partial/moderate assistance with eating, substantial/maximal assistance with upper body dressing, and dependence for hygiene, bathing, lower body dressing, rolling, sit-to-stand, and bed-to-chair transfers. Resident 17’s care plan identified an ADL performance deficit and included interventions for PT and OT evaluations and treatment per physician’s orders. The physician entered orders on 4/4/2026 for PT to evaluate the resident as indicated and for OT to evaluate the resident as indicated. During observation and interview on 5/18/2026, the resident was lying in bed, moved both upper and lower extremities fully, and stated he had no concerns about ROM but was unable to sit, walk, or care for himself and needed PT and OT services rather than RNA ROM exercises. During interview and record review with the DOR on 5/21/2026, the DOR confirmed the PT and OT evaluations ordered by the physician were not conducted. The DOR stated the evaluations should have been completed but were not done because he was unaware of the orders. The DON also stated residents should receive skilled rehab evaluations as ordered to ensure appropriate care and services. Facility policies stated therapy services are provided upon written physician order and that residents with limited mobility and ADL deficits are to receive appropriate services to maintain or improve function.
Therapy Records Not Readily Accessible
Penalty
Summary
The facility failed to ensure that PT and OT records prior to 2/2026 were systematically organized and readily accessible for three sampled residents. Resident 17 was admitted on 5/23/2025 and re-admitted on 6/20/2025 with diagnoses including muscle wasting and atrophy, osteoarthritis, and lack of coordination. Resident 50 was initially admitted on 5/19/2021 and re-admitted on 3/29/2025 with diagnoses including right-sided hemiplegia and hemiparesis following cerebral infarction and aphasia. Resident 105 was initially admitted on 12/10/2024 and re-admitted on 6/18/2025 with diagnoses including right-sided hemiplegia and hemiparesis following cerebral infarction, aphasia, and muscle weakness. During interviews, the MRD stated the facility had a new rehab company that began at the end of 2025 and that she did not have access to therapy records prior to 11/2025. The ADM stated the facility did not have therapy records readily accessible and had to request records from the previous rehab company for Residents 17, 50, and 105. The DOR stated therapy documentation had been on a different electronic charting system and did not officially switch to the current system until 2/2026, making prior records difficult to obtain and often taking several days. The DON stated staff must have immediate access to all therapy records because they are part of the medical record and allow staff to track progress, understand baseline function, and review medical history. The facility policy stated current medical records were to be filed in the Medical Records Department and maintained by the Medical Records Clerk.
Failure to Develop and Update Fall Risk Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident who was admitted with diagnoses including toxic encephalopathy, dementia, and falls, and who was identified on admission as a moderate fall risk. The resident’s admission fall risk assessment showed the resident was at moderate risk for falls, but no fall risk care plan was developed at that time. The resident’s record also showed severe cognitive impairment and the need for staff supervision or assistance with most ADLs, while the resident was able to walk. The resident later had an unwitnessed fall and was transferred to a GACH. A physician order dated after the fall indicated a spine brace for a T12 to S1 fracture to stabilize the spine, reduce pain, and restrict movement. An SBAR documented that the resident had aimless wandering, was bumping into walls, objects, and other residents in the hallway, and was unable to navigate the environment safely, resulting in risk of falls or injury. The DON stated that a fall risk care plan should have been developed upon identifying the resident as at risk for falls and that the care plan should have been updated after the fall. The resident later developed an injury of unknown origin involving discoloration, limited movement, pain, and a skin tear to the left upper extremity, including the wrist and shoulder area, and was again transferred to acute care for further evaluation. The SBAR stated no witnessed fall or incident was reported prior to discovery and that the cause of injury was unknown at that time. The DON confirmed that no fall risk care plan had been developed upon admission and that there was still no care plan in place after the fall and the later injury.
Failure to Maintain Clean Ventilation Intake Screens in Resident Rooms
Penalty
Summary
The facility failed to maintain clean and sanitary ventilation intake screens in resident rooms, resulting in thick dust accumulation on the intake screens above the beds of two sampled residents. During an observation in one resident’s room, the ventilation intake screen above the foot of her bed was covered with a thick layer of dust, which the resident confirmed had been present for quite a while and expressed concern about dust potentially falling on her and being inhaled. In another resident’s room, the intake screen above the foot of his bed was also observed with a layer of dust; this resident, who had been at the facility for four years, stated he had never seen anyone clean it. The Maintenance Supervisor observed a similar dust layer on a ventilation intake screen in another room and acknowledged that this condition could expose residents to allergens. These conditions occurred despite the facility’s policy and procedure titled “Homelike Environment,” which states that residents are to be provided with a safe, clean, comfortable, and homelike environment and that staff and management will maximize a clean, sanitary, and orderly environment.
Failure to Label, Date, and Properly Store Resident Food in Nutrition Room Refrigerators
Penalty
Summary
The deficiency involves failure to follow the facility’s P&P for resident refrigerator/freezer storage and food handling in resident nutrition rooms. During an observation and concurrent interview with the Infection Preventionist Nurse (IPN) in the 2nd floor nutrition room, surveyors observed an undated and unlabeled open box of cornflakes and an undated and unlabeled open bag of potato chips stored in a cabinet. The IPN acknowledged these items should not have been stored there in that condition and stated they should have been labeled with the resident’s name and an expiration date, and that everything should have a name and an open date. Further observation in the same 2nd floor nutrition room revealed a variety of bags inside the resident refrigerator that were not appropriately labeled and dated. The IPN verified that the food in the refrigerator should be labeled with the resident’s name and an open date so staff know when to discard it, and stated that they clean it out every three days. In the 3rd floor nutrition room, the resident refrigerator contained an opened plastic to-go container with no resident name or received date, along with various bags of food without proper dates and crowded in the refrigerator, despite a posted sign instructing that all resident food be labeled with name, date, and expiration date and that unlabeled food or food left more than 72 hours would be discarded. Review of the facility’s P&P for Resident’s Refrigerator/Freezer Storage – Dietary Services showed requirements that food items be stored to allow air circulation, avoid overcrowding, not be stored beyond 72 hours from date received, and that all items be properly covered, dated, and labeled with delivery and open dates, which were not followed in these observations.
Failure to Respect English-Speaking Residents’ Communication and Dignity Rights
Penalty
Summary
The deficiency involves staff failing to honor residents' rights to dignity, self-determination, communication, and use of their primary language during care. For Resident 3, the Admission Record dated 3/24/26 showed admission with HTN, anemia, hemiplegia and hemiparesis following a stroke, and identified English as the primary language. An MDS dated 2/18/26 documented intact cognition and a need for supervision, touching assistance, or substantial/maximal assistance with ADLs and bed mobility. During interview, Resident 3 stated she hears everything and has heard staff speaking in other languages among themselves. Resident 5’s Admission Record dated 3/24/26 documented admission with muscle weakness, osteoarthritis of the knee, asthma, spinal stenosis, and lymphedema, and identified English as the primary language. An MDS indicated mild memory problems, a need for set-up or clean-up assistance with eating, and substantial/maximal assistance to dependence for other ADLs and bed mobility. During interview, Resident 5 reported that two staff members were in her room that morning speaking a foreign language to each other, and stated she only speaks English and does not know what they are saying and that they could be talking about her. A CNA interviewed stated staff should not be speaking a different language with each other that is different from the one the resident speaks. The facility’s Resident Rights policy, reviewed 6/2/25, stated employees shall treat all residents with kindness, respect, and dignity and support residents in exercising their rights, including the right to be treated with respect.
Failure to Implement Wandering Care Plan Resulting in Resident Elopement
Penalty
Summary
The deficiency involves the facility’s failure to follow an established care plan for a resident identified as being at risk for wandering and elopement, which resulted in an elopement incident. The resident had multiple diagnoses, including encephalopathy, Parkinson’s disease, epilepsy, schizophrenia, and anemia, and the History and Physical documented that the resident did not have the capacity to understand and make decisions. An MDS assessment indicated short- and long-term memory problems, with the resident requiring varying levels of assistance for ADLs. An Elopement Risk Evaluation dated 3/8/26 identified the resident as at risk for elopement, with comments specifying use of a Wanderguard and frequent visual checks. A wandering risk care plan initiated the same day included interventions such as a bracelet alarm for alarmed doors, checking the resident’s location every 30 minutes, and ensuring all staff were aware of the elopement risk. Despite these identified risks and care plan interventions, the facility did not implement the ordered Wanderguard or ensure monitoring consistent with the care plan prior to the elopement. A registered nurse supervisor reported receiving a physician’s order for a Wanderguard and, because the resident could not consent, contacting the resident representative for consent and endorsing follow-up to the next shift. Progress notes for the following day showed no evidence that any shift followed up on obtaining consent or implementing the Wanderguard before the resident eloped in the early morning hours of 3/10/26. A LVN confirmed that there was no order in the order summary for monitoring a Wanderguard or wandering behaviors through 3/17/26, and therefore no related documentation or monitoring occurred. The facility’s own wandering and elopement policy stated that residents at risk would have care plans including strategies and interventions to maintain safety, but the documented interventions were not carried out for this resident.
Improper Linen Handling and Storage Breaching Infection Control Practices
Penalty
Summary
The deficiency involves the facility’s failure to handle and store clean linen in accordance with its infection prevention and control policies and its in-service training on proper linen handling. An anonymous complaint was received alleging insufficient linen and blankets. During review of an in-service titled “Proper handling of Linen,” the facility’s guidance stated that clean linen should be stored in a designated clean area or cart, kept covered when transported to a patient room, and that only the amount of linen needed for each resident should be brought to the room. The sign-in sheet for this in-service did not include the name of CNA 1. The facility’s Laundry and Linen policy required separation of soiled and clean linen at all times and protection of clean linen from environmental contamination by covering clean linen carts. During observation and interview in a resident room, surveyors noted a large, open plastic bag filled with multiple bed pads, gowns, towels, and sheets placed on the nightstand next to the bed of a female resident with multiple diagnoses including hemiplegia and hemiparesis following cerebral infarction, DM, metabolic encephalopathy, CKD stage 4, dementia, muscle weakness, and polyneuropathies. This resident’s MDS showed impaired cognition and total dependence on staff for toileting, showering, bathing, and transfers. CNA 1 stated that the resident had already received a bed bath and explained that she gathered all linen for all of her residents in the morning, placed it in one bag, brought that bag into this resident’s room, and then used that bag as a source of linen for other residents by transferring items into separate plastic bags. CNA 1 stated this was common practice. Another CNA reported gathering linen for each resident separately and placing each bag in the respective resident’s closet for infection control. An LVN stated CNAs were educated to gather linens in a plastic bag and place them inside each resident’s room so each resident would have their own separate bag, and acknowledged that having all linen for every resident in one room could lead to cross contamination because once linen is taken into a room it is considered dirty. Additionally, on a separate floor, two linen carts were observed with their covers flipped up, leaving clean linen exposed, contrary to the facility’s policy to keep clean linen hygienically clean and protected from environmental contamination.
Failure to Provide and Document Required Feeding Assistance and Intake Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to follow its policy and procedures for assisting residents with in-room meals, including providing needed feeding assistance, documenting meal intake, and ensuring appropriate reporting of decreased intake. For three cognitively impaired residents with significant functional limitations, staff did not consistently assist with feeding as required by their assessments and care plans, nor did they document meal intake percentages as directed. The facility also failed to ensure that a CNA notified licensed nursing staff when a resident had decreased meal intake. Resident 1 was admitted with multiple diagnoses including metabolic encephalopathy, dementia, diabetes, muscle weakness, anemia, hypertension, a pressure ulcer, and GERD. The MDS showed cognition was not intact and that Resident 1 required maximal assistance with eating and was dependent for toileting, showering, and transfers. A nutrition assessment indicated total assistance was required for eating, and the care plan identified decreased self-feeding abilities related to metabolic encephalopathy and dementia, as well as nutritional risk with an intervention to document PO intake at every meal. On observation, Resident 1 was found lying flat in bed with eyes closed, chewing with orange material in the mouth and on the lips, and a half-eaten piece of potato on the sheet next to the face. The meal tray was on the bedside table with the cover still on; the plate contained mostly uneaten food and an unopened juice. CNA 1, who was assigned to Resident 1 and stated this was the first time caring for this resident, did not begin feeding until later, after being redirected to assist other residents in the dining room, and there was no documentation of meal intake for Resident 1 on the cited date, nor evidence that decreased intake was reported to an LVN. Resident 3 had diagnoses including right-sided hemiplegia/hemiparesis, encephalopathy, UTI, COPD, diabetes, muscle weakness, aphasia, dysphagia, hyperlipidemia, anxiety disorder, and hypothyroidism, with an MDS indicating cognition was not intact and that supervision or touch assistance was required with eating. The care plan identified nutritional risk with an intervention to document PO intake at every meal, and a physician order specified a fortified regular pureed diet, level 4 texture, thin consistency, and that the resident was a feeder. Meal intake documentation for the referenced date showed “resident not available.” Resident 4, with hemiplegia/hemiparesis after cerebral infarction, asthma, epilepsy, protein-calorie malnutrition, muscle weakness, dysphagia, UTI, aphasia, hyperlipidemia, and hypertension, also had impaired cognition and required moderate assistance with eating. The care plan for Resident 4 included documenting PO intake at every meal, yet the same date’s intake record also indicated “resident not available.” Interviews revealed that CNA 1 was simultaneously assigned to Residents 1, 3, and 4 and was pulled to the dining room to assist Residents 3 and 4 when no restorative nursing assistants were present, leaving Resident 1 without timely feeding assistance and contributing to the lack of proper intake documentation and reporting for all three residents. Staff interviews further clarified the breakdown in supervision and adherence to policy. CNA 1 reported starting to feed Resident 1 but being told to go to the dining room to assist Residents 3 and 4, who also needed feeding assistance, and only returning later to finish feeding Resident 1. LVN 1 confirmed that Resident 1 required assistance with feeding and stated that CNA 1 did not request help or report any decreased intake, despite the expectation that CNAs report intake of less than 50% and complete a “stop and watch” form. The RNA stated that there are usually three RNAs assigned to the dining area to pass trays and feed residents, but on the day in question one RNA had called off and the remaining RNA was sent out with another resident to an appointment and did not return until mid-afternoon, leaving the dining room without RNA coverage. LVN 2 observed there were no RNAs in the dining room and that CNAs were taking residents back to their rooms. The ADON later explained that one RNA had called off and the other was at an appointment, and that charge nurses were expected to monitor whether residents needing feeding assistance were being helped and to supervise CNAs, including adjusting assignments when a CNA had multiple residents requiring feeding assistance. Despite these expectations and the written policy on assisting residents with in-room meals and documenting intake, the facility did not ensure that Residents 1, 3, and 4 were assisted with feeding as care planned, that their meal intake percentages were documented, or that decreased intake for Resident 1 was reported to licensed nursing staff. The facility’s written policy on assisting residents with in-room meals required staff to review the resident’s care plan, ensure appropriate positioning and preparation for meals, assist residents as necessary while encouraging self-feeding, and document the date and time of the procedure, the staff involved, the percentage of the meal consumed, the resident’s participation, and any special requests. Observations and record reviews showed that these steps were not followed for the three residents on the date in question. Resident 1 was not positioned upright as specified in the policy when first observed with food in the mouth and on the bed, and the tray remained covered and largely uneaten until CNA 1 returned. For Residents 1, 3, and 4, the required documentation of meal intake percentages was either missing or recorded as “resident not available,” and there was no evidence that CNA 1 notified an LVN or RN of Resident 1’s decreased intake, contrary to facility expectations and the care plan interventions. These combined observations, interviews, and record reviews demonstrate that the facility did not implement its own policy and procedures for assisting residents with in-room meals and did not ensure that residents were assessed and supported appropriately for feeding assistance, that meal intake was documented as care planned, or that decreased intake was reported to licensed staff for further evaluation.
Failure to Notify Physician After Repeated Refusal of Vital Psychotropic Medications
Penalty
Summary
Surveyors identified a deficiency in which the facility failed to ensure a resident was free from significant medication errors by not notifying the physician after repeated refusals of vital psychotropic medications. The resident had documented diagnoses of schizophrenia, bipolar disorder, history of alcohol abuse, medical noncompliance, and severely impaired cognition. Multiple clinical documents, including the history and physical, psychiatry evaluations, and physician progress notes, indicated the resident lacked capacity to make medical decisions, had a history of refusing care, and was being treated with Depakote for bipolar disorder and risperidone for paranoid schizophrenia. Review of the resident’s care plan showed a problem for altered behavior patterns related to schizophrenia and psychotropic medication use, with an intervention to notify the physician of any risk or consequences related to non-compliance. The physician’s orders included Depakote 500 mg, two tablets at bedtime for bipolar disorder, and risperidone 3 mg every 12 hours for paranoid schizophrenia. Review of the Medication Administration Record for the month showed that Depakote doses were refused on nine occasions and risperidone doses were refused multiple times for both morning and evening administrations over the review period, including several instances of refusals on three or more consecutive days. Interviews with an LVN and the DON confirmed that facility policy titled “Preparation and General Guidelines” required physician notification when consecutive doses of a vital medication were refused, and that nursing staff were to document the notification and the physician’s response. The LVN stated that if the resident refused Depakote and risperidone for at least three consecutive days, the physician should be notified and the response documented. The DON, upon review of nursing progress notes for the same period, stated that there was no documentation showing that a physician had been notified about the resident’s repeated refusals of Depakote and risperidone. The DON further acknowledged that without such notification, the physician would assume medications were being administered and would not know what other interventions to order, confirming that the required notification and documentation did not occur.
Missed Dialysis Treatments Due to Failed Transportation Arrangements
Penalty
Summary
The deficiency involves the facility’s failure to ensure reliable transportation for a resident who required thrice-weekly hemodialysis, resulting in multiple missed treatments. The resident had diagnoses including pulmonary hypertension, type 2 diabetes mellitus, end stage renal disease with dependence on renal dialysis, and required assistance with transfers. Physician orders specified dialysis on Tuesday, Thursday, and Saturday with set chair times and transportation pick-up and return times. The care plan documented that the resident missed dialysis appointments on two occasions due to transportation issues, and progress notes and SBAR forms showed that on three separate dates the resident missed scheduled dialysis because transportation either did not arrive or would arrive too late for the appointment. On at least one occasion, the missed dialysis was attributed to an expired Physician Certification Statement (PCS) form that had not been timely completed and signed by the primary physician, which was required by the resident’s insurance to authorize transportation. Interviews with staff further described the actions and inactions that led to the deficiency. The social services director stated that one missed dialysis treatment occurred because the PCS form had expired and was not completed in a timely manner by the primary physician, and that other missed treatments were due to the contracted insurance transportation not showing up on time. The social services director acknowledged that the resident’s insurance provided transportation based on the PCS certification. The RN supervisor confirmed awareness of at least one missed dialysis treatment and explained that RNs and LVNs process physician orders and work with social services for transportation, noting that some transportation companies fail to show up without warning. The DON stated that the resident had missed a dialysis treatment because transportation did not show. Facility policies on Transportation and Appointments indicated that social services would help residents obtain transportation and that the facility would assist in scheduling appointments and arranging necessary transportation, but the documented events show that these processes did not prevent the resident from missing multiple medically necessary dialysis sessions.
Failure to Provide Required SOC and Coverage Notices to Resident and POA
Penalty
Summary
The facility failed to provide required written notice of Medicaid/Medicare coverage, share of cost (SOC), and related financial obligations to a resident and the resident’s responsible party/POA. The resident, who had diagnoses including aphasia following cerebral infarction, hemiplegia, and hemiparesis, was assessed as having no cognitive impairment on an MDS dated 11/18/2025 and reported that their son was the responsible party/POA. The resident stated that while in the facility they were not provided any financial documents and no one from the facility discussed monthly billing for services. About a week prior to the interview, the resident learned from the responsible party/POA that payments were behind for the past four months. The social services director reported that due to ownership changes and high turnover in the business office and social services staff during 2025, some residents’ records had not been updated and some residents with SOC had not yet been notified, even though the business office was responsible for updating and notifying residents and responsible parties. The business office manager stated that residents with SOC are usually identified at pre‑admission, admission, and periodically, and that Resident 2’s responsible party/POA should have received monthly statements and paid the SOC that began in September 2025. However, the business office manager could not verify whether monthly statements or SOC notifications had been mailed to the resident or responsible party and acknowledged that past‑due bill notifications should come from the business office, not from a third‑party company. The responsible party/POA confirmed not receiving monthly statements, not knowing the SOC amount, and only becoming aware of four months of past‑due bills after a collection call from a third‑party company. The facility’s billing policy required monthly resident billing with itemized non‑covered services and written notification at least 60 days prior to changes in the cost of non‑covered items and services.
Failure to Perform Hand Hygiene Before Resident Feeding
Penalty
Summary
Facility staff failed to perform required hand hygiene while providing care to one of seven sampled residents, resulting in a deficiency in the infection prevention and control program. During a tour, CNA 3 was observed assisting a resident in a shared room by using the bed remote, placing the remote on the floor, then picking it up and placing it on the resident’s bed without cleaning it. CNA 3 then proceeded to feed the resident without performing hand hygiene. In a concurrent interview, CNA 3 acknowledged not performing hand hygiene and stated that infection prevention and hand hygiene are important because they prevent residents from harm. In the same room, CNA 4 was observed entering from the hallway and approaching to feed the same resident without performing hand hygiene. In a concurrent interview, CNA 4 acknowledged not practicing hand hygiene and stated that hand hygiene is very important to keep residents safe because they are weak and can easily get sick. Record review showed the resident had diagnoses including anoxic brain damage, UTI, a disorder involving the immune mechanism, and heart failure, and was cognitively impaired and dependent on staff for substantial/maximal assistance with eating and personal hygiene. The ADON stated that all staff are trained and expected to perform hand hygiene before and after resident care, and the IP stated that hand hygiene is a standard precaution and agreed that staff were supposed to perform hand hygiene before feeding a resident. The facility’s Infection Prevention and Control Program policy indicated that infection prevention includes educating staff and ensuring adherence to proper techniques and following CDC guidelines.
Failure to Develop Discharge Care Plans for Three Cognitively Intact Residents
Penalty
Summary
The facility failed to develop discharge care plans for three sampled residents, despite facility policy that discharge planning begins at admission and should be updated after discharge meetings and every three months. Interview and record review showed that Residents 1, 2, and 3, all with intact cognition, did not have discharge care plans in their medical records. The medical record assistant confirmed that no discharge care plans were found for these residents, and the director of social services stated that discharge planning is expected to start at admission. Resident 1, an older female admitted with a left humerus fracture, generalized muscle weakness, encephalopathy, cystitis, bilateral knee osteoarthritis, anxiety, hypertension, major depressive disorder, and repeated falls, was documented as dependent for toileting, bathing, and transfers. Resident 2, an older female with osteoarthritis of the knee, morbid obesity, dysphagia, schizoaffective disorder, bipolar disorder, and glaucoma, was also dependent for toileting, bathing, and transfers. Resident 3, an older female with spinal stenosis, fibromyalgia, knee osteoarthritis, diabetes mellitus, morbid obesity, anxiety, insomnia, GERD, and major depressive disorder, required maximal assistance with toileting, bathing, and transfers. Despite these documented care needs and intact cognition, no discharge care plans were developed for any of the three residents.
Failure to Timely Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an allegation of verbal abuse involving two residents to the Department of Public Health and the Ombudsman within the required two-hour timeframe, as outlined in the facility's own Abuse Investigation and Reporting policy. The incident occurred when one resident alleged that another resident hit him on the leg, and law enforcement was called to the facility. The facility became aware of the abuse allegation at approximately 5:30 AM, but the report to the state survey agency was not made until 9:09 AM, exceeding the mandated two-hour reporting window. Interviews with staff confirmed awareness of the reporting requirement and acknowledged the delay in notification. The resident who made the allegation had a history of heart failure, diabetes mellitus, and cystitis, and was dependent on staff for personal care, with intact cognitive ability. The other resident involved had diagnoses including a left thigh fracture, heart failure, and diabetes mellitus. The facility's policy required immediate reporting of abuse allegations, especially those involving abuse or resulting in serious bodily injury, but this protocol was not followed in this instance, as evidenced by the delayed fax confirmation of the report.
Failure to Provide Social Services After Abuse Allegations
Penalty
Summary
The facility failed to provide medically-related social services to four out of six sampled residents by not ensuring the Social Services Director (SSD) assessed the residents' psychosocial well-being after incidents involving physical and/or verbal abuse allegations. Specifically, after one resident alleged being hit by another and law enforcement was called, there was no documented follow-up or assessment by the SSD for either resident involved. In another incident, two residents exchanged verbal abuse in the activity room, witnessed by staff, but again, there was no documented psychosocial assessment or intervention by the SSD for those involved. Additionally, a resident reported being hit on the wrist by a roommate and stated that the SSD did not come to speak with him about his feelings, despite expressing a desire for such support. Interviews with the SSD confirmed that follow-up was not conducted with several residents involved in these incidents, and in one case, although the SSD claimed to have followed up with a resident, there was no documentation of these interactions. The facility's own policies and job descriptions require the SSD to address and document the psychosocial needs of residents, particularly following abuse allegations. The lack of timely and documented follow-up by the SSD after abuse allegations meant that the psychosocial needs of the affected residents were not assessed or addressed as required. This failure was acknowledged by both the SSD and the facility's nurse consultant, who stated that such follow-up is necessary to identify and meet residents' psychosocial needs. The omission was contrary to facility policy and the expectations outlined in the social worker's job description.
Failure to Timely Respond to Resident Call Lights
Penalty
Summary
The facility failed to provide reasonable accommodation of needs for two residents by not ensuring their call lights were answered in a timely manner, as required by facility policy. Resident 4, who had systemic lupus erythematosus, pain from orthopedic devices, generalized muscle weakness, and partial traumatic amputation of both feet, was dependent on staff for mobility and toileting. Resident 4 reported that it often took twenty to thirty minutes for staff to respond to call lights, resulting in prolonged periods of being wet and soiled, which exacerbated pain and discomfort. Resident 4 stated that despite raising concerns with staff, the issue persisted. Resident 5, diagnosed with cardiomyopathy, hypertension, and anxiety disorder, was also dependent on staff for transfers and mobility. Resident 5 reported frequent delays in call light response, particularly at night, and expressed feelings of neglect after complaints to the night shift charge nurse did not resolve the issue. Interviews with CNAs confirmed that residents commonly complained about delayed call light responses, especially during shift changes or when staffing was reduced due to call-outs. The DON acknowledged that facility policy required immediate or prompt response to call lights, and that call lights were the primary means for residents to request assistance.
Failure to Supervise High-Risk Resident Resulting in Elopement
Penalty
Summary
The facility failed to adequately supervise and monitor the whereabouts of a resident who was admitted with significant psychiatric diagnoses, including bipolar disorder with psychotic features, schizoaffective disorder, and a recent history of hearing voices instructing self-harm. Upon admission, the resident was identified as being at risk for elopement, and behavioral monitoring was indicated as a primary focus. Despite these risk factors, the resident was able to leave the facility without notifying staff, and their whereabouts remained unknown following the incident. Record reviews revealed inconsistencies and incomplete documentation regarding the resident's expressed desire to leave against medical advice (AMA). Although the resident signed an AMA form, it was missing a date and staff witness signatures, and the physician order summary did not indicate a discharge. Staff interviews indicated that the resident had previously expressed a wish to leave, but was convinced to stay, leading to the incomplete processing of the AMA form. On the day of the incident, staff discovered the resident missing during routine rounds, and subsequent searches and notifications were made to authorities and facility leadership. Observations during the survey found that staff were not consistently monitoring resident whereabouts, particularly during shift changes. No staff were observed making rounds or present at key monitoring locations such as nurses' stations, and certain facility areas, such as a service elevator, were not visible from staff workstations. Staff interviews confirmed that resident accountability was not ensured during shift changes, increasing the risk of elopement for residents identified as high risk.
Failure to Report and Address Nonfunctioning Thermostats and Temperature Regulation
Penalty
Summary
Facility maintenance failed to report nonfunctioning thermostats to administration for three sampled residents, resulting in the air conditioning unit being turned off at night due to an inability to regulate building temperatures. This led to resident complaints about excessive heat during nighttime hours. Observations and interviews confirmed that maintenance staff routinely turned the HVAC system on and off from the roof, as there were no functioning thermostats to regulate temperature, and staff were unaware of the last time the HVAC system was serviced. Maintenance staff also did not inform administration about the nonfunctioning thermostats or the ongoing temperature regulation issues. Residents affected by this deficiency included individuals with significant medical conditions such as peripheral neuropathy, migraines, obesity, cardiovascular disease, stroke with hemiplegia, major depressive disorder, anxiety, hypotension, COPD, spinal stenosis, fibromyalgia, osteoarthritis, diabetes mellitus, morbid obesity, cellulitis, insomnia, GERD, hypertension, and nicotine dependence. Some residents required maximal assistance with activities of daily living and had impaired cognition, while others were dependent on staff for toileting and bathing. Multiple residents reported discomfort due to heat at night, and observations confirmed that fans in resident rooms were not always functional or circulating air. Despite the presence of 55 portable air conditioning units in storage, maintenance staff did not offer these units to residents who complained about the heat, nor did they notify administration of the temperature control issues. Facility policy required that all temperature complaints and malfunctions be reported to administration and documented, but this process was not followed. The maintenance supervisor and assistant were aware of the portable units but did not distribute them or escalate the issue, resulting in continued resident discomfort and noncompliance with facility policy regarding temperature regulation.
Residents Subjected to Forced Removal from Power Wheelchairs and Loss of Mobility Rights
Penalty
Summary
The facility failed to protect two residents from mental and physical abuse when unidentified corporate staff forcefully removed them from their motorized power wheelchairs (MPWC) and placed them into manual wheelchairs (MWC) against their wishes and without clinical justification or consent. The incident involved multiple staff members, including corporate representatives, who attempted to physically transfer the residents despite their verbal refusals and distress. The residents were not provided with an opportunity to speak with law enforcement when the police were called, and their autonomy and right to make decisions regarding their mobility devices were disregarded. One resident, with a history of multiple medical conditions including cellulitis, pressure injuries, chronic pain, and dependence on a wheelchair, was subjected to forceful attempts to remove her from her MPWC. She repeatedly expressed her desire to keep her MPWC and asked to speak with familiar staff or her physician, but was ignored. During the incident, several staff members physically attempted to remove her from the chair, causing her emotional distress and pain in her left arm and shoulder. She was left in a manual wheelchair and confined to bed for an extended period, resulting in psychosocial harm such as anxiety, helplessness, and emotional distress. She was later transferred to a hospital for evaluation of shoulder pain. Another resident, diagnosed with multiple sclerosis, Parkinson's disease, and other conditions leading to dependence on a wheelchair, was also removed from her MPWC by a group of unfamiliar staff. She was transferred to bed using a Hoyer lift and left without her preferred mobility device for several days, which led to her remaining in bed, crying, and experiencing a loss of independence. Both residents' care plans indicated their dependence on MPWCs for mobility and participation in activities, yet these were disregarded by the staff involved. The actions taken by the facility staff resulted in both residents experiencing a loss of autonomy, dignity, and independence, as well as significant psychosocial harm.
Failure to Maintain Audible Phone Ringing at Nursing Stations
Penalty
Summary
The facility failed to maintain the nursing station phone ringers at an audible volume across all four nursing stations, as observed during multiple call attempts. When calls were transferred from the main facility phone line to each nursing station, the phones did not ring audibly at the stations, and staff only became aware of incoming calls after hearing overhead pages instructing them to answer the phone. Interviews with LVNs at each station confirmed that the phone volumes were turned down all the way, preventing them from hearing the phones ring. Staff acknowledged the importance of having the phone volume set at an audible level to ensure calls from doctors, family members, and patients could be answered promptly. A review of the facility's policy and procedures regarding telephone usage indicated that employees should exercise thoughtfulness and courtesy in using telephones and that staff should not be paged to the phone unless it is an emergency. Despite this policy, the phones at all nursing stations were not set to ring audibly, resulting in reliance on overhead paging to alert staff to incoming calls. This practice had the potential to limit or delay communication with medical professionals, family members, and staff.
Failure to Ensure Timely IV Fluid Administration
Penalty
Summary
The facility failed to provide appropriate intravenous (IV) access care according to its own policies and procedures for one resident. The resident, who had multiple diagnoses including hypertension, diabetes mellitus type 2, muscle weakness, gait abnormalities, heart failure, and asthma, was admitted with an order for Dextrose 5% IV solution to be infused at 50 ml per hour over 20 hours for hydration. On observation, the IV bag was found hanging with approximately 550 ml remaining, not infusing, and the bag was dated two days prior. The IV was connected to the resident's right forearm, but no drops were observed in the drip chamber, indicating the infusion was not running as ordered. A family member reported that the IV had not been infusing for at least 40 minutes and mentioned previous issues with the IV tubing. The Registered Nurse Supervisor was unaware of the IV order and had to check the resident's chart to confirm the order. Upon further interview, the nurse acknowledged forgetting about the IV order despite being informed by the prior shift. The facility's policy requires licensed nurses to be knowledgeable about the length of time needed to administer IV medications, to assess the IV site and system, and to review provider orders for correct administration, all of which were not followed in this instance.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 5,818 citations issued within 25 miles in the last 12 months — including the 26 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Santa Monica
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Santa Monica Health Care Center | 0 mi | ★★★★★ | 3 | 0 |
| Berkley East Healthcare Center | 0.1 mi | ★★★★★ | 15 | 0 |
| Berkley West Healthcare Center | 0.1 mi | ★★★★★ | 14 | 0 |
| Pacific Post Acute | 0.1 mi | ★★★★★ | 14 | 0 |
| Ocean Pointe Healthcare Center | 0.2 mi | ★★★★★ | 33 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Santa Monica Rehabilitation Center.
100% money-back within 48 hours.
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.