Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sharon Care Center during CMS and state inspections, most recent first.
A resident with DM and an order for sliding-scale Novolog had blank MAR entries for insulin on two occasions, with no documentation that the doses were given or refused. The resident reported insulin and other meds were sometimes late or missed, blood glucose checks were done after meals, and an LPN said the resident had complained that staff did not give meds on time or at all. The DON confirmed the MAR should document refusals or missed doses and stated the blank entries could cause confusion and a medication error.
Failure to update a resident’s LAWN care plan with ordered interventions. A resident with dementia, severely impaired cognition, and poor safety awareness was identified by the IDT as at risk for LAWN, and a Wander Guard elopement device plus hourly whereabouts monitoring were ordered. However, the care plan was not revised to include the Wander Guard intervention or the monitoring interventions, and the DON confirmed the LAWN care plan had not been updated.
Failure to Assess Elopement Risk and Supervise a Resident With Dementia: A resident with dementia, severely impaired cognition, and a history of exit-seeking was identified as at risk for LAWN, but the IDT did not assess him as an elopement risk or place his photo and ID in the elopement binder per policy. Staff described the resident as confused, wandering, and able to self-propel a wheelchair or ambulate without supervision at times. The resident left the facility unsupervised through the front door and was later found down the street and returned by staff.
Delayed Administration of Ordered Bumetanide: A resident with CHF, respiratory failure with hypoxia, and severe cognitive impairment did not receive ordered bumetanide on multiple scheduled doses after admission. The MAR showed several missed doses, while the DON stated the medication should have been verified and continued on admission, with the physician notified and the issue documented if it was not received as ordered.
Incomplete BiPAP Order and Delayed Respiratory Treatment: A resident admitted with CHF and acute/chronic respiratory failure with hypoxia had a BiPAP order for bedtime use, but the respiratory needs form was blank and the TAR showed the BiPAP treatment did not start until two days after admission. The order summary listed BiPAP with sterile water for sleep apnea, but the order lacked specific mode and settings. The RT stated BiPAP should be set up and started at bedtime when ordered, and the DON confirmed the order was incomplete and not started on admission.
A resident who required total assist, 2 staff, and a Hoyer lift for transfers slipped from the bed to the floor during a transfer to the wheelchair when only 1 CNA was present. The resident landed on both knees, had severe pain and inability to bear weight, and was sent to the ER where imaging showed bilateral distal femur fractures; hospital records described the event as a mechanical fall during the transfer.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
Failure to Attempt or Document GDR for Risperidone: A resident with schizoaffective disorder remained on risperidone with dose increases over time, but the record showed no GDR attempts and no documented clinical contraindication for the antipsychotic. The MDS reflected continuous antipsychotic use without a GDR, a pharmacist requested a GDR, and the MD later stated she had confused prior lithium GDR attempts with risperidone when declining the recommendation. The DON confirmed there was no record of a risperidone dose decrease being attempted.
The facility failed to maintain annual employee evaluations and medication administration competency records for an RN and an LVN. During record review and interviews, the DSD and DON could not provide current documentation showing when the two nurses last completed annual evaluations or medication administration competency checks, and the DON could not confirm that the LVN had ever had medication administration competency performed. Facility policy required nursing staff to participate in competency-based training and to have facility- and resident-specific competency evaluations upon hire and annually.
Medication administration errors exceeded the allowable rate, with an RN and an LVN giving incorrect doses, omitting ordered meds, and administering some meds late during observed passes. Errors included wrong-dose thiamine, missed vitamin D and multivitamin, incorrect aspirin/fish oil/vitamin D/ferrous sulfate doses, late carvedilol and levothyroxine, and omitted clopidogrel. Staff stated some meds were given from what was on hand, some were missed by oversight, and some were delayed during busy medication rounds.
A facility failed to serve kosher pureed meal trays that met residents’ nutritional and religious diet requirements. Two kosher trays were served only side items with no protein, and one kosher tray included lasagna made with beef and turkey plus cheese, which staff and the RD described as not consistent with kosher dietary rules. Staff stated they did not serve meat on kosher trays, had no kosher meal alternatives, and the menu did not include a kosher option.
Unsafe food storage and temperature control were observed when bulk dry goods were kept in bins lined with non-food-grade trash bags, lunch beverages were left at room temperature instead of being held cold, and resident food stored in a utility-room refrigerator lacked labels and receive dates. The DS, RD, MTD, and IPN all confirmed the improper storage conditions, and facility policy required dry goods and outside food to be stored and labeled according to food safety standards.
A resident with heart failure and pleural effusion, who was alert and cognitively intact, consented twice to receive influenza and PNA vaccines and had active MD orders for both. Facility records and CAIR showed the last flu and PNA vaccines were given years earlier, and there was no documentation that the ordered vaccines were administered or that the resident refused them in accordance with facility P&P requiring annual flu vaccination and routine PNA vaccination. The IPN reported the resident refused when re-offered and that vaccines were readily available from the pharmacy, while the DON acknowledged the vaccines should have been given promptly after consent.
Failure to Renew Psychotropic Medication Informed Consent: A resident with severe cognitive impairment and diagnoses including depression and anxiety remained on Mirtazapine for depression and appetite stimulation, but the signed informed consent from the responsible party was not renewed. Staff confirmed the resident lacked capacity for medical decisions, the most recent consent in the chart was the only signed consent, and the DON acknowledged the facility did not renew the consent as required by policy and AFL guidance.
A resident with a history of falls, weakness, impaired mobility, and near syncope had a call light left unanswered for several minutes while staff were nearby and assisting other residents. The resident was on droplet precautions for parainfluenza and stated staff did not respond in a timely manner. The DON later confirmed the facility policy required call lights to be answered as soon as possible, but no later than 5 minutes, and stated staff did not follow the policy.
Incomplete and Missing Advance Directive Acknowledgement Documentation: The facility failed to complete or maintain advance directive acknowledgement forms for two residents. One resident’s form was incomplete because the choice to wish or decline an advance directive was left blank, despite intact cognition and ability to communicate. Another resident, who had severely impaired cognition and multiple diagnoses including contractures and anemia, had no advance directive acknowledgement form in the chart. The DA, SWD, and DON confirmed the documentation was incomplete or missing, and the facility policy required admission staff to inquire about advance directives and provide the form.
Confidential resident information was left accessible in two separate incidents. A resident’s meal ticket, showing the resident’s name, room number, mealtime/date, and diet order, was found in an open glove box in the front lobby near the visitor sign-in sheet, and another resident’s EMR was left open and unattended at a nurse station. RN staff and the DON acknowledged that resident information should be protected and that EMRs should be logged off when not in use.
A resident with severe cognitive impairment and extensive assistance needs was discharged to the hospital, but the facility did not complete and submit the discharge MDS within the required timeframe. The MDSC acknowledged the assessment was completed too late, the DON confirmed it was outside the 14-day limit, and the late submission meant CMS was not notified of the discharge in a timely manner and the assessment was not accurate.
Inaccurate MDS Coding for Wounds and Tobacco Use: The facility failed to accurately code the MDS for two residents. One resident had documented PVD wounds in the ICC, H&P, progress notes, body check, and physician orders, but the MDS recorded 0 venous and arterial ulcers. Another resident’s care plan, interview, and staff observations showed tobacco use, but the MDS indicated no tobacco use. The DON and MDSC acknowledged the MDS entries were not accurate.
A resident at risk for falls had a physician order for a low bed with bilateral floor mats for safety, but the care plan was not updated to include those interventions. The resident had bilateral contractures, anemia, calculus, severely impaired cognition, and required maximal assistance with mobility. An LVN and the DON confirmed the care plan did not reflect the ordered safety measures, and a CNA stated the low bed and floor mats were used as fall precautions.
Failure to Complete Activity Assessment: A resident admitted with hydrocephalus, HLD, HTN, and muscle weakness was not given an activity assessment to identify preferences. The resident stated he was bored and there were no activities to do, while the AD said the assessment should have been completed soon after admission but had not yet been done. The DON stated activity assessments were done within 72 hours and were needed to better serve resident needs and preferences.
Low Air Loss Mattress Care Not Maintained for Two Residents: Two residents at risk for pressure injuries had problems with their LAL mattresses. One resident's mattress was set above the weight-based setting noted by staff and the DON, despite an order to keep it within the resident's weight. Another resident's mattress was observed deflated and later unplugged, and the resident reported feeling the metal bar on her back and discomfort. Staff stated the mattress should have been on and that improper use increased pressure injury risk.
Failure to Document Foley Catheter Infection Monitoring: A resident with a Foley catheter, UTI history, BPH, and obstructive uropathy had a physician order for q shift monitoring for signs and symptoms of infection, but the MAR did not show that this monitoring was documented. RN and DON both confirmed the lack of documentation, and the resident was observed with a Foley catheter and clear yellow urine.
Unlabeled oxygen tubing and humidifier were observed for a resident receiving O2 via NC PRN with a weekly tubing-change order. RN and DON stated the tubing and humidifier should be changed weekly for infection control, but there was no date label to show when they were last changed. The resident had multiple chronic conditions, including ALS, dementia, and a history of TIA/CVA.
Outdated dialysis access orders and care plan: A resident with ESRD receiving HD had conflicting chart documentation about the correct access site, including references to different fistulas and Permacaths, while staff observed a right chest Permacath and the resident reported a new right arm AV fistula that was not yet usable. Staff interviews confirmed the chart was not updated to clearly identify the access arm and BP restrictions, and the DON stated the dialysis care policy requiring accurate access-site precautions was not followed.
A resident with essential HTN was prescribed amlodipine 5 mg daily with SBP and HR hold parameters. A pharmacist recommended removing the HR hold parameter because amlodipine is not routinely monitored for HR, but the record showed no apparent response from the physician or facility, and the DON confirmed the recommendation had not been addressed. The facility policy stated medication regimen review recommendations are to be acted upon and documented.
The facility failed to ensure two residents were free from unnecessary drugs. One resident with GERD received metoclopramide continuously for over a year even though the care plan stated treatment should be limited to 12 weeks or less due to TD risk, and the record lacked a documented clinical rationale or monitoring of nausea and vomiting. Another resident with ESRD and HD dependence had repeated missing BP checks and documentation before scheduled midodrine doses, despite an order to hold the medication if SBP was above 100 mmHg.
Expired Inhaler Left on Medication Cart: Surveyors found one open fluticasone/salmeterol inhaler for a resident on Medication Cart 3 that had been open longer than the manufacturer’s one-month limit. An LPN confirmed the inhaler was expired, and the facility policy required outdated medications to be removed from stock and disposed of according to procedure.
Improper Preparation of Minced and Moist Meal Items: A resident ordered a cardiac diet with minced and moist texture and moderately thickened liquids was served lasagna and green beans that were not prepared to IDDSI Level 5 standards. The cook acknowledged the food was not minced and moist, the resident had to mash the lasagna on the plate, and the RD and dietary supervisor confirmed the green beans contained large pieces and were not minced as required by the facility recipe and diet order.
Food preferences were not honored for two residents. One resident with a documented dislike of beef was served lasagna containing ground beef, and the DON and DS verified the meal included beef despite the resident’s stated preference. Another resident who stated she was vegetarian and had documented dislikes of multiple meats was served lasagna with meat, while her dietary profile had not been updated quarterly and her tray card did not reflect her dislikes. The DS and DON stated the resident received meat even though she should not have because she was vegetarian and did not like meat.
A resident with ESRD and HD dependence had scheduled midodrine orders for hypotension before dialysis, but the MAR had blank entries showing no documentation of whether the medication was administered or held on two occasions. An LVN verified the missing entries and stated the nurse should have documented administration status and, if not given, the reason; the DON also stated MAR documentation is important for tracking medication provided to residents.
A resident with stroke, epilepsy, and dysphagia was dependent on staff for ADLs and had capacity to make medical decisions, but his assigned closet was being used to store facility pillows. During observation, his backpack was on the floor and clothing was piled on a chair because the pillows took up most of the closet space. Staff and the DON acknowledged that residents have a right to private closet space and that resident belongings were supposed to be stored in the resident’s own closet or alternative storage furniture.
A resident with altered mental status, generalized weakness, difficulty walking, lack of coordination, and failure to thrive had a call light observed on the floor and out of reach. CNAs stated it should not have been there, RN stated the resident would not be able to call staff if it was on the floor and noted an infection control issue, and the DON acknowledged the resident was cognitively impaired, no rounding log was available, and the facility did not follow its call light policy.
A facility failed to ensure 14 of 33 resident rooms met the required 80 sq ft per resident for multiple-bed rooms. Although the ADM requested a room waiver and staff, residents, and the ADON, DON, DOR, and ADOR stated there was enough room for care, movement, ADLs, and therapy, the Client Accommodation Analysis showed several three-bed rooms measured only 72.1 to 79.8 sq ft per resident, below the required standard.
A resident with severe cognitive impairment and documented lack of decision-making capacity was admitted with multiple diagnoses, including benign neoplasm of the meninges, altered mental status, and adult failure to thrive. The facility’s IPN stated that policy requires a signed consent from the resident or representative before administering vaccines such as influenza, pneumonia, and COVID, to confirm education on risks and benefits. However, there was no documented evidence that the resident’s representative was provided or signed any immunization consent, despite facility IPCP policies specifying procedures for obtaining direct and proxy consent for vaccinations.
A resident with muscle wasting, lack of coordination, and ESRD had multiple assessments showing bilateral leg weakness, dependence for sit-to-stand and bed-to-chair transfers, and a need for a total (Hoyer) lift with two-person assist. Despite this, staff routinely transferred the resident with one-person assist using a gait belt, and the resident was not on fall precautions. The care plan was not updated after a prior fall or after readmission assessments to reflect the need for a Hoyer lift and two-person assistance, and on one occasion the resident sustained an assisted fall during a wheelchair-to-bed transfer performed by a CNA using a gait belt alone.
A resident with Parkinson’s disease and other conditions was receiving Mirtazapine 15 mg for depression, and their MDS documented frequent depressive symptoms, yet depression was not coded as an active diagnosis and no depression-related care plan was in place. During interviews, an LVN, the DON, and the MDS nurse confirmed that the depression diagnosis from the hospital and continued psychotropic order were not reflected in the MDS or care plan, and the IDT conference notes did not document a medication review, contrary to the facility’s psychotropic medication policy requiring documented indication and evaluation on admission or readmission.
A resident admitted with type 2 DM and a history of MI had an active DM diagnosis documented on the MDS, but no corresponding diabetes care plan was developed when the diagnosis triggered in the assessment system, contrary to facility policy requiring individualized care plans with measurable objectives and timetables. During surveyor review with the DON and MDS nurse, no care plan appeared when searching under "Diabetes Mellitus," and a diabetes care plan dated the day before the interview was found only when searching under "diabetes." The DON admitted she created this plan after overhearing the surveyor request it and that it was incomplete, and the MDS nurse confirmed there was no explanation for the earlier omission and that, without a diabetes care plan, the resident’s care would be incomplete.
A resident with dementia, rheumatoid arthritis, anemia, and HTN, who required partial to moderate assistance with ADLs and had a family member as DPOA, did not receive timely access to requested medical records through the resident representative. The facility’s policy required access to personal and medical records within 24 hours and copies within two business days of a request, but the Medical Records Director delayed processing a mailed request until returning from vacation, and records were not provided until many days later. The Facility Administrator confirmed that the delay occurred because the facility waited for corporate office clearance, and although a medical records consultant was available when the MRD was off, that consultant was responsible for many other facilities, resulting in the resident representative being denied timely access to the records as required by policy.
A resident with epilepsy, a femur fracture, ESRD, and a three-year history of left ear hearing loss did not have a comprehensive care plan addressing the hearing deficit. An MDS documented adequate hearing, while an ENT consult noted chronic hearing loss, wax removal, and recommended follow-up. The resident later voiced concern about persistent hearing loss and lack of further interventions. Review by the MDS nurse and DON confirmed there were no care plan problems, goals, monitoring parameters, or orders related to hearing loss, despite facility policy requiring individualized care plans for all identified problems.
A resident with multiple medical conditions and at risk for malnutrition experienced significant unplanned weight loss after the facility failed to follow physician orders for a Restorative Nursing Aide (RNA) feeding program at both breakfast and lunch. Instead, only breakfast was covered by RNAs, while lunch was handled by CNAs, contrary to the care plan and physician orders. Staff interviews and documentation confirmed the deviation from prescribed care, resulting in continued poor oral intake and weight loss.
Failure to notify MD of a resident’s declining PO intake and change in condition. A resident with dementia, severe cognitive impairment, and a sacrococcyx PU repeatedly ate less than 50% of meals or refused meals, with documentation of worsening wound status and poor intake. Staff and family reported the resident became increasingly confused, stopped eating, and later refused IV access; the resident was ultimately transferred to the hospital with dehydration, AKI, sepsis, hypernatremia, and bacteremia. The DON confirmed the MD was not notified after repeated low intake.
A resident with dementia, RA, anemia, and HTN had worsening sacrococcyx skin breakdown while staff failed to consistently change soiled briefs, follow an IV fluid order, implement an RD consult, or notify the MD and proxy about markedly decreased PO intake. Records showed repeated meals under 50% or refused, and interviews confirmed the resident was often found soaked in urine and that the IV order was not carried out when refused. The resident was later transferred for failure to thrive and sacral wound, where she was diagnosed with dehydration, AKI, sepsis, bacteremia, hypernatremia, and osteomyelitis.
A resident with dementia, severe cognitive impairment, and multiple chronic conditions had decreased PO intake, refused some care, and was noted to have skin alterations. The IDT care conference included only the DON and treatment nurse, with no resident or proxy participation, and ordered labs, IV access, and IV hydration were not carried out after refusals. Staff also confirmed there was no documented notification to the MD or healthcare proxy about the refusals or the resident’s progressive decline in intake.
Failure to Carry Out Physician Orders for Labs and IV Hydration: A resident with dementia, poor intake, weight loss, and a sacral wound had orders for CBC, BMP, UA, urine C&S, and IV hydration after decreased appetite and fluid intake were noted. Staff did not complete the ordered labs or IV fluids because the resident reportedly refused, and there was no documented notification to the MD or healthcare proxy. The resident was later transferred to the hospital for FTT, AMS, and a sacral wound, and the EMT report noted the facility had not obtained a full set of VS before transfer.
A facility failed to revise one resident’s care plan after a Foley catheter was discontinued and later reinserted for urinary retention, leaving the plan without updated catheter monitoring guidance. The facility also failed to update another resident’s COPD care plan after a hospital return for acute respiratory failure with hypoxia. Staff and the DON confirmed the care plans were not revised to reflect the changed conditions.
Failure to Dispose and Label Enteral Feeding Supplies: An LPN failed to discard used tube feeding formula and tubing for a resident with dysphagia and a G-tube. The DON observed the feeding connected to an empty formula bottle and a bag of water with no labels showing when they were first used, and the LPN acknowledged she turned off the feeding but did not dispose of the tubing and formula per policy.
A resident with a fractured arm and other medical conditions experienced ongoing pain despite receiving Oxycodone-Acetaminophen every six hours. The resident repeatedly requested more frequent pain medication, but staff did not notify the physician or adjust the medication schedule as required by the care plan and facility policy, resulting in unmanaged pain and discomfort.
A resident with non-Hodgkin lymphoma and requiring assistance with ADLs did not have transportation arranged in advance for a scheduled chemotherapy appointment. Staff only became aware of the oversight on the morning of the appointment after the resident reminded them, leading to a last-minute call for backup transportation. Facility policy requires transportation to be scheduled promptly after appointments are set, but this was not followed.
Incomplete Insulin Documentation on MAR
Penalty
Summary
The facility failed to accurately document the administration of Novolog insulin for one resident with diagnoses including heart failure, hyperlipidemia, and Type 2 DM. The resident’s record showed a BIMS score of 14 and documentation that the resident was cognitively intact and had capacity to make medical decisions. The care plan identified diabetes and the need to remain free of hypo- and hyperglycemia, with medication administration as ordered. The physician order required Novolog sliding scale insulin before meals based on blood glucose results, with documentation of the dose, concentration, injection site, and whether the resident tolerated the medication. Review of the May 2026 MAR showed Novolog was not documented as given or refused on May 24 at 6:30 a.m. and May 26 at 11:30 a.m., leaving the entries blank. The resident stated medications were sometimes missed, insulin was not administered on time, blood glucose checks were done after meals instead of before meals, and 9:00 a.m. medications were often given one to two hours late. An LVN stated the resident was knowledgeable about daily medications and had complained that staff did not give medications on time, could not locate medications, or failed to administer them. The DON stated blood sugar should be checked before meals, insulin given with food or shortly after if needed, and any refusal or medication not given must be documented on the MAR and in progress notes; the DON acknowledged the blank MAR entries and stated they could cause confusion among staff and potentially result in a medication error. Facility policy also required documentation of blood glucose, dose, concentration, injection site, tolerance, and refusal if a drug was withheld, refused, or given at a time other than scheduled.
Failure to Update LAWN Care Plan With Ordered Interventions
Penalty
Summary
The facility failed to revise Resident 1’s care plan to address leave of absence without notice (LAWN) after the resident was identified as at risk for LAWN. Resident 1 was admitted with diagnoses including unspecified dementia and hypotension, and the MDS indicated severely impaired cognition, that the resident sometimes made himself understood and sometimes understood others, and that he self-propelled a manual wheelchair. The care plan report dated 5/11/2026 identified Resident 1 as at risk for LAWN, and the LAWN evaluation form dated 5/17/2026 stated the interdisciplinary team determined the resident was at risk for LAWN and that the plan of care should be reviewed and updated to address specific interventions and application of Wander Guard. The record showed that a Wander Guard elopement device was ordered on 5/17/2026 due to poor safety awareness, and later orders directed staff to monitor the Wander Guard device for placement and function every shift and to monitor the resident’s whereabouts at least every hour. However, the care plan report did not include updated interventions for the Wander Guard device or monitoring of the resident’s whereabouts. During interviews, the LVN and DON stated the care plan should have been updated with the Wander Guard intervention and other LAWN-related interventions, and the DON confirmed the LAWN care plan was not revised to include the ordered interventions.
Failure to Assess Elopement Risk and Supervise a Resident With Dementia
Penalty
Summary
The facility failed to ensure that one resident with unspecified dementia and severely impaired cognition was assessed by the interdisciplinary team as being at risk for elopement. The resident’s record showed diagnoses including dementia, hypotension, and hyperlipidemia, and the resident was documented as sometimes making himself understood, sometimes understanding others, and self-propelling a manual wheelchair. A nursing document evaluation dated 5/11/2026 identified the resident as at risk for Leave of Absence Without Notice and noted a history of exit-seeking behavior, but it did not indicate interdisciplinary team considerations. The care plan also identified the resident as at risk for Leave of Absence Without Notice and directed staff to monitor the resident’s location with visual checks during routine care and as needed. The resident’s history and physical dated 5/13/2026 stated that he did not have the capacity to make decisions. On 5/17/2026, staff last saw the resident at approximately 10:45 AM, and later a receptionist received a call from rehab staff that the resident had been found down the street from the facility. Staff brought the resident back to the facility at 11:24 AM. An interdisciplinary care conference dated 5/19/2026 identified the likely root cause as an unsupervised exit through the facility’s front door and noted that the resident was known to walk throughout the facility as part of his daily routine. Interviews with staff described the resident as confused, forgetful, and able to ambulate or self-propel his wheelchair throughout the facility without assistance or supervision at times. A CNA stated the resident required frequent reminders and reorientation, and an activities assistant stated the resident liked to wander throughout the facility and frequently went out to the patio area. A LVN stated the resident demonstrated significant cognitive impairment, exhibited wandering behavior, and could have benefited from increased supervision; the LVN also stated a Wander Guard device could have been placed if the resident’s wandering behavior had been assessed as an exit risk. The DON stated the facility’s LAWN assessment replaced the elopement risk evaluation, that the resident was assessed as high risk for history of exit-seeking behavior, and that the resident’s photograph and identification information were not included in the elopement risk binder in accordance with facility policy.
Delayed Administration of Ordered Bumetanide
Penalty
Summary
The facility failed to ensure that the physician’s order for bumetanide oral tablet was carried out timely for one resident. The resident was admitted with diagnoses including acute on chronic diastolic CHF, acute and chronic respiratory failure with hypoxia, and insomnia. The MDS dated 8/18/2025 indicated the resident’s cognitive skills for daily decisions were severely impaired and that the resident required maximal assistance with ADLs. The resident’s medication list from the hospital indicated bumetanide 0.5 mg, 1 tablet by mouth in the morning and 1 tablet before bedtime, and the facility’s OSR dated 8/12/2025 showed bumetanide 0.5 mg every 12 hours. The resident’s MAR showed bumetanide was not given on 8/12/2025 at 9 p.m., 8/13/2025 at 9 a.m., 8/13/2025 at 9 p.m., 8/14/2025 at 9 a.m., and 8/15/2025 at 9 p.m. A progress note dated 8/13/2026 stated that, per NP, it was okay to continue bumetanide since the resident received it at the hospital and tolerated it well. During interview, the DON stated the admitting nurse should verify medications to be continued or started with the referral facility, that the resident should have been on bumetanide upon admission as ordered, and that if medications were not received as ordered, the physician should be notified and the issue documented in the medical record. The DON also stated staff should call the pharmacy to deliver medications and follow up if medications were not available.
Incomplete BiPAP Order and Delayed Respiratory Treatment
Penalty
Summary
The facility failed to provide necessary respiratory care services for one sampled resident who was admitted with acute on chronic diastolic CHF, acute and chronic respiratory failure with hypoxia, and insomnia. The resident’s MDS indicated severely impaired cognitive skills for daily decisions and maximal assistance needed for ADLs. The history and physical documented that the resident was to continue BiPAP at bedtime, with acute respiratory orders listing BiPAP mode with IPAP 15, EPAP 5, and FiO2 21 at bedtime every six hours. The nursing documentation evaluation dated 8/12/2025 showed the respiratory needs form was blank, although it also noted the resident was a new admit from an acute care hospital and was on BiPAP at nighttime. The order summary report dated 8/13/2025 listed a physician order for BiPAP to be filled with sterile water at bedtime for sleep apnea. The TAR showed the BiPAP order started on 8/14/2025, but the order did not include a specific BiPAP mode and settings. The care plan initiated 8/14/2025 identified the resident as at risk for respiratory complications related to asthma and acute and chronic respiratory failure with hypoxia using BiPAP at nighttime. During interview, the RT stated that if there is an order for BiPAP treatment upon admission, the machine should be set up and the treatment started at bedtime, and if not started, the physician should be notified. The DON reviewed the record and confirmed the BiPAP order was incomplete and was started two days after admission, and stated there should have been documentation and physician notification explaining why BiPAP was not started upon admission.
Failure to Use Required Two-Person Hoyer Lift Transfer
Penalty
Summary
The facility failed to provide care and services to prevent a fall for a resident who required total assistance with transfers, two staff participation, a Hoyer lift, and a yellow medium sling for transfers. The resident was cognitively intact, normally used a wheelchair, and had diagnoses including type 2 diabetes, end stage renal disease, and dependence on renal dialysis. Her care plan and assessment documents identified impaired mobility, generalized weakness, polyneuropathy, impaired balance, and the need for assistance with toileting and transfers. On the morning of the incident, a CNA was transferring the resident from the bed to the wheelchair so she could go to dialysis. The report states that only one CNA was present in the room, despite the care plan calling for two-person assistance and use of a Hoyer lift. During the transfer, the resident slipped from the bed to the floor and landed on both knees. The resident was observed on the floor by the charge nurse, reported pain in both knees, and was assisted back into the wheelchair by three people using a bed sheet. The resident was then taken to the lobby and left the facility in stable condition. After the fall, the NP was notified and the resident was sent to the ER for further evaluation related to knee pain. Hospital imaging showed a mildly displaced comminuted extra-articular fracture of the right distal femoral meta diaphysis and a displaced comminuted peri-implant fracture involving the distal left femur. The resident reported severe pain and inability to bear weight, and hospital documentation described the event as a mechanical fall while trying to get back into the wheelchair. The resident underwent surgery on the right leg and was scheduled for surgery on the left leg.
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Attempt or Document GDR for Risperidone
Penalty
Summary
The facility failed to attempt a gradual dosage reduction (GDR) or document a clinical rationale that a GDR was contraindicated for a resident’s risperidone use. Resident 4 was admitted on 3/2/2021 and readmitted on 8/26/2024 with diagnoses including schizoaffective disorder, bipolar type. The record showed risperidone was first ordered on 9/15/2022 at 1 mg by mouth at bedtime, increased on 1/26/2023 to 2 mg by mouth every evening, and increased again on 7/12/2024 to 2 mg by mouth every 12 hours. The resident’s H&P dated 9/16/2025 noted mildly impaired cognitive status, and the current order summary dated 4/29/2026 showed risperidone 2 mg by mouth every 12 hours for schizoaffective disorder. Review of the clinical record showed no attempts to use a lower dose of risperidone since it was initially prescribed. The MDS dated 2/20/2026 indicated the resident had been receiving an antipsychotic continuously, that a GDR had not been attempted, and that there was no date in the record documenting that a GDR on risperidone was clinically contraindicated. A pharmacist recommendation dated 3/30/2026 asked the physician to attempt a GDR for risperidone, and the physician declined, citing prior failed attempts that reportedly resulted in violent behaviors. During interview, the DON stated the resident had been taking risperidone continuously since September 2022, that the dose had been increased twice, and that there was no record of any dosage decrease being attempted. The DON also stated she could not explain why the physician’s response referenced previously failed GDR attempts when there was no evidence in the clinical record that risperidone had ever been reduced. The psychiatrist stated she had attempted a GDR on the resident’s lithium in the past but not on risperidone, and that she had mistakenly responded to the pharmacist recommendation by confusing the two medications.
Missing Annual Medication Administration Competencies for Two Nurses
Penalty
Summary
The facility failed to ensure that two of six sampled employees, RN 1 and LVN 1, had current annual employee evaluations and medication administration competency documentation in their files. During a concurrent interview and record review with the DSD, the employee records showed that both nurses had current licenses and CPR, but the records did not show when either nurse last had an annual evaluation or medication administration competency review. The DSD stated the DON was responsible for monitoring timely and proper medication administration by licensed staff and had the documentation for when RN 1 and LVN 1 last received evaluation or education for medication administration competency and annual evaluation. During an interview with the DON, she stated that the DSD, the facility pharmacy, and the DON were responsible for evaluating licensed staff for medication administration competency. The DON said she asked the PC to evaluate RN 1 and LVN 1 and to train licensed staff on medication administration about three months earlier, but she could not recall when RN 1 and LVN 1 last received medication administration education and could not provide proof that they received the training. The DON also admitted that she did not have RN 1 and LVN 1's medication administration competencies readily available and stated that if she did not have those records, she could not guarantee they could give medications safely. A later concurrent interview and record review showed RN 1 had a medication administration competency dated [DATE], but the DON could not provide documentation of annual medication administration competency for RN 1 for 2025 or 2026. The DON also could not provide documentation that LVN 1 ever had medication administration competency performed. Facility policies reviewed during the investigation stated that performance evaluations measure job performance and that nursing staff must participate in competency-based training, with facility- and resident-specific competency evaluations conducted upon hire, annually, and as needed based on the facility assessment.
Medication administration errors exceeded allowable rate
Penalty
Summary
The facility failed to keep its medication error rate below 5%, with 10 errors out of 29 opportunities for an overall error rate of 34.48% affecting six sampled residents. The errors involved incorrect doses, omitted medications, and late administrations during observed medication passes. The report states that the deficient practice was failing to administer medications in accordance with physician orders or professional standards. For one resident with atrial fibrillation, LVN 1 administered thiamine 100 mg instead of the ordered 250 mg. During interview, LVN 1 stated she gave the dose she had on hand rather than clarifying the order and acknowledged she did not check the cart medications against the physician’s orders. For another resident with a history of stroke, RN 1 omitted vitamin D 2000 IU and a multivitamin during the 9 AM medication pass, although these were listed on the order summary as scheduled medications. For a resident with hypertension, LVN 1 prepared aspirin, fish oil, vitamin D, and ferrous sulfate in doses that did not match the orders. The observation showed aspirin powder spilled and not replaced, fish oil was crushed in a pouch with residual medication left behind, vitamin D 400 IU was given instead of 1000 IU, and ferrous sulfate 325 mg was given instead of 75 mg. For another resident, RN 1 gave carvedilol late, and for a resident with hypertensive chronic kidney disease, RN 1 omitted clopidogrel during the 9 AM pass. For a resident with hypothyroidism, RN 1 gave levothyroxine later than the ordered 6 AM time and stated the order was wrong and should have been written for 6:30 AM.
Kosher Pureed Meal Trays Lacked Required Protein and Included Meat With Dairy
Penalty
Summary
The facility failed to ensure that residents on pureed texture and kosher diets received meals that met their assessed nutritional needs and prescribed dietary requirements. During lunch tray line observation, two kosher pureed trays were served pureed green beans, pureed bread, and mashed potatoes without a protein source. The tray cards for those trays indicated pureed texture and kosher diets, and the facility menu for lunch listed pureed lasagna, green beans, garlic bread, frosted cupcake, and a beverage for the pureed diet. One kosher tray was also observed with pureed lasagna, and the cook stated the lasagna contained ground beef and turkey combined with three types of cheese. The cook stated kitchen staff did not serve meat on kosher diet trays and only served side dishes such as green beans, bread, and mashed potatoes. The Dietary Supervisor stated the facility no longer provided ready-made frozen kosher meals, had no other food alternatives or options for the kosher diet, and that the two residents on kosher diets did not receive protein with every meal. The Registered Dietitian stated the kosher diet was a religious diet and that meats and dairy products were not to be cooked in the same area or served together. The RD also stated the facility menu did not indicate a kosher option and the residents on pureed texture and kosher diets did not receive an alternative meal that was nutritionally equivalent to the regular diet. Facility policy stated menus were to be planned in advance to meet nutritional needs and reviewed by a registered dietitian, and the individual meal plan was to be adjusted for cultural, religious, or ethnic preferences as appropriate.
Unsafe Food Storage and Temperature Control
Penalty
Summary
Safe and sanitary food storage and preparation practices were not maintained in the kitchen when bulk dry goods, including sugar, flour, and breadcrumbs, were observed stored in large bins lined with plastic trash bags. During the observation, the Dietary Supervisor stated the liners were regular trash bags and were not specific for food storage, and stated there was no policy regarding food storage liners. The Dietary Supervisor also stated the bags could tear and could have chemicals in the plastic touching food. The facility policy for dry goods required food to be stored in accordance with FDA Food Code, and the FDA Food Code cited in the record stated that unacceptable materials could adversely affect food safety and quality. During lunch service, bottled juice and a gallon of milk were observed sitting out at room temperature rather than being maintained cold. A temperature check showed the juice at 54 degrees F and the milk at 46.7 degrees F. The Dietary Supervisor stated the beverages were usually kept in the refrigerator for lunch service but were not that day, and stated that if milk sat out too long it could go bad. The Regional Registered Dietitian stated beverages had to be kept on ice during lunch service to maintain temperatures at 41 degrees F or below. The facility policy for food preparation required cold foods to be held at less than 41 degrees F, consistent with the FDA Food Code. Food brought in for residents from outside the facility, including leftovers and frozen dinners, was found in the resident refrigerator in the utility room without labels or receive dates. One container of soup was sitting on top of the refrigerator with no label, and inside the refrigerator were multiple small containers of leftover soup and stews with no date, along with two store-bought frozen dinners with no date; one box was broken and the contents were exposed. The Maintenance Director and Infection Prevention Nurse stated the soup on top of the refrigerator should not have been there, and the Infection Prevention Nurse removed the unlabeled and contaminated items to discard. The Infection Prevention Nurse stated food brought in by visitors or ordered from outside was to be checked by nursing staff, labeled with the resident's name and receive date, and stored for 48 hours. The facility policy also required labeling and dating of food brought in by visitors and daily monitoring of refrigerated storage duration.
Failure to Implement Flu and Pneumococcal Vaccination Practices
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to influenza and pneumococcal immunizations for one resident. The resident was admitted with diagnoses including a left radius fracture, heart failure, and pleural effusion, and was documented as alert and oriented with intact cognition for daily decision-making. On two separate vaccine consent forms, the resident consented to receive both influenza and pneumococcal (PNA) vaccines. The resident’s Order Summary Reports contained physician orders for a yearly Fluzone influenza vaccine and a Pneumococcal 13 vaccine, both to be given intramuscularly as needed for vaccination. The facility’s policies, reviewed on 12/18/2025, required that influenza vaccines be offered annually between October 1 and March 31 and that all residents be offered pneumococcal vaccines. Record review and interviews showed that, despite the resident’s consent and existing physician orders, there was no documentation that the influenza or pneumococcal vaccines were administered or refused in accordance with facility policy and current standards of practice. The California Immunization Registry (CAIR) indicated the resident’s last influenza vaccine was received in 2024 and the last pneumococcal vaccine in 2014, with recommendations for additional doses of both vaccines. The Infection Preventionist Nurse stated that the facility could obtain flu and PNA vaccines from the pharmacy without issues and reported that the resident refused the vaccines on one date when they were re-offered, but this refusal was not supported by documentation of administration or refusal consistent with the policies. The DON acknowledged that the resident should have received the flu and PNA vaccines as soon as consent was obtained and that the resident was at risk for flu and PNA infections.
Failure to Renew Psychotropic Medication Informed Consent
Penalty
Summary
The facility failed to renew the informed consent for an antidepressant medication for one resident with severe cognitive impairment. Resident 78 was admitted with diagnoses including adult failure to thrive, unspecified mood affective disorder, major depressive disorder, and anxiety. The resident had an order for Mirtazapine 7.5 mg by mouth at bedtime for depression manifested by loss of appetite, and the medical record showed a signed psychotropic medication informed consent dated 11/15/2024 from the resident’s responsible party by telephone. During record review, the signed informed consent for Mirtazapine had not been renewed after 11/15/2024, even though the resident remained on the medication. The resident’s care plan indicated that informed consent should be provided to the resident or healthcare decision maker, but it did not specify a renewal timeframe. The resident’s MDS dated 2/6/2026 indicated severe cognitive impairment, and staff confirmed the resident did not have capacity to make medical decisions and had a POA/responsible party involved in care decisions. In interviews, the ADON, RN 2, and DON stated informed consent was required for antidepressants and psychotropic medications, and that consent should be obtained from the resident if capable or from the family/representative if not. The DON confirmed the most recent signed informed consent in the record was dated 11/15/2024 and acknowledged the facility did not renew it. The facility policy stated it applied to residents prescribed psychotropic drugs, including new initiations, dose increases, or changes, and the reviewed AFL stated facilities must include the written consent form in the resident’s record and renew the consent form every six months thereafter.
Delayed Response to Resident Call Light
Penalty
Summary
The facility failed to answer a resident’s call light as soon as possible, but no later than five minutes, as required by its policy. Resident 103 was admitted with diagnoses including history of falling, acute on chronic diastolic congestive heart failure, malignant neoplasm of the stomach, muscle weakness, essential hypertension, syncope and collapse, pleural effusion, and acute kidney failure. The resident’s care plan identified risk for falls and injury related to history of falls, impaired mobility, weakness, and near syncope, and included interventions for staff to assist with getting in and out of bed, ambulation, toileting needs, and reminders to use the call light when attempting to ambulate or transfer. Resident 103 also had a care plan intervention for staff to encourage use of the call light for assistance. The resident’s history and physical noted fluctuating capacity to make medical decisions, and an order summary showed isolation with droplet precautions due to parainfluenza. During an interview, Resident 103 stated staff did not answer the call light in a timely manner and believed staff did not go to the room because of an infectious disease. During observation, Resident 103 pressed the call light at 9:47 AM. CNA 11 was observed assisting other residents and cleaning the room across from Resident 103’s room while the call light remained on. The Activities Director was heard asking whose resident it was because the call light was on, then walked away. No staff responded until 9:54 AM, when the DON and CNA 11 answered the call light. CNA 11 stated any staff could have answered it, and LVN 7 stated call lights should be answered within three minutes and promptly to avoid residents soiling themselves or attempting to get up alone. The DON reviewed the facility policy stating calls for assistance are answered as soon as possible, but no later than five minutes, and stated staff did not follow the policy.
Incomplete and Missing Advance Directive Acknowledgement Documentation
Penalty
Summary
The facility failed to ensure that advance directive acknowledgement documentation was completed and present in the active medical record for 2 of 4 sampled residents, identified in the report as Resident 43 and Resident 78. The deficiency involved the residents’ right to request, refuse, or discontinue treatment and to be informed about advance directives. The facility’s policy stated that, upon admission, staff or a designee would inquire about the existence of an advance directive and provide the resident an opportunity to complete the form upon request. Resident 43 was admitted with diagnoses including muscle weakness, gait abnormalities, and a history of falling. The MDS dated 3/5/2026 indicated the resident was able to make self-understood and understood others, and that cognitive functioning was intact. The resident’s advance directive acknowledgement form dated 2/28/2026 was reviewed and the check box indicating whether the resident wished or declined to execute an advance directive was left blank. During interview, the DA stated the form was incomplete, that the blank check box meant no education on advance directives was offered or followed up on, and that all boxes on the acknowledgement form should have been completed. Resident 78 was admitted with diagnoses including bilateral contractures, anemia, and calculus. The MDS indicated the resident sometimes made herself understood and sometimes understood others, and that cognition was severely impaired. During interview and record review, the DA confirmed there was no advance directive acknowledgement form in the resident’s medical record. The SWD and DON also stated the form was missing and that every resident was required to have a completed advance directive acknowledgement form, with the DON stating there was a failure to provide the advance directive information form documentation to Resident 78.
Confidential Resident Information Left Accessible
Penalty
Summary
The facility failed to protect private health information by leaving confidential resident information accessible in two separate instances. For Resident 9, who was admitted with diagnoses including atherosclerotic heart disease, dementia, and hypertension and was assessed as severely cognitively impaired, the resident’s meal ticket was found in an open box of medium-sized gloves on a table in the front lobby next to the visitor sign-in sheet. The meal ticket displayed the resident’s full name, room number, mealtime/date, and diet order. RNA 1 stated this was a HIPAA violation because visitors signing in and out could easily see the resident’s personal information, and RN 1 stated the document should not have been in the glove box and that resident information must be disposed of in designated shred bins. For Resident 40, who had diagnoses including ESRD, epilepsy, and anemia and was documented as having intact cognition for daily decision-making and capacity to make medical decisions, the resident’s EMR was left open and unattended at nurse station B during observation. RN 1 stated the EMR should not be left unattended and that staff should log off when not needed or stepping away to protect privacy and confidentiality. The DON stated staff should log off right away or close residents’ EMR when leaving the workstation, and the facility’s policies on Resident Rights and Protected Health Information state that resident information must be protected from unauthorized release or disclosure.
Late MDS Discharge Submission
Penalty
Summary
The facility failed to submit the complete Minimum Data Set (MDS) for Resident 84 within the required timeframe after discharge from the facility. Resident 84 had been admitted and later readmitted with diagnoses including encephalopathy, chronic kidney disease, muscle wasting and atrophy, generalized muscle weakness, hypertension, hypothyroidism, unspecified dementia with psychotic disturbance, mood disturbance, anxiety, osteoporosis, and anemia. The resident’s MDS indicated severe cognitive impairment and required partial/moderate assistance from staff for toilet transfer, chair/bed transfers, toileting hygiene, tub/shower transfer, showering/bathing, lower body dressing, and footwear. The clinical census showed Resident 84 was discharged to a general acute care hospital on 2/2/2026, and the clinical MDS indicated the resident was discharged from the facility with return not anticipated. However, the MDS summary showed the discharge MDS was completed on 4/28/2026, and the clinical MDS did not include a completion date. During interview, the MDS Coordinator stated the discharge MDS was completed on 4/28/2026 and acknowledged that this was too long of a timeframe, stating she did not know the required submission timeframe and that CMS was not notified of the discharge in a timely manner. The DON stated the discharge assessment had to be completed within 14 days of discharge and confirmed that the 4/28/2026 completion date was not within that timeframe. The DON also stated the late completion could have caused a billing problem and that the discharge assessment was completed too late and was not accurate. Facility policy stated MDS data must be submitted to iQIES as required, and the CMS RAI Manual stated that for non-admission OBRA and PPS assessments, the MDS completion date must be no later than 14 days.
Inaccurate MDS Coding for Wounds and Tobacco Use
Penalty
Summary
The facility failed to accurately code the MDS for Resident 10 by not documenting the resident’s peripheral vascular disease wounds. Resident 10 was admitted with multiple diagnoses including MS, osteoarthritis, hypertension, anemia, cervical spondylosis, and atherosclerosis of the left leg arteries. Records reviewed during the survey showed multiple references to PVD-related wounds, including an ICC note identifying a left lateral lower leg wound and a right dorsal foot wound, an H&P noting a left lateral ankle PVD wound and PVD, and later progress notes and physician orders describing right dorsal foot fragile tissue, left lateral malleolus to foot PVD with fragile tissue, and multiple scattered open wounds to the lower leg and foot. During interview and record review, the MDS Coordinator and DON reviewed Resident 10’s body check and MDS assessment. The body check dated 2/6/2026 indicated right dorsal foot to plantar PVD scattered fragile tissue, and both the MDSC and DON verified the resident had a right dorsal foot to plantar PVD wound. However, the MDS Assessment Section M – Skin Conditions dated 3/13/2026 showed the facility entered 0 for the total number of venous and arterial ulcers. The MDSC and DON stated the assessment was not accurate and should have indicated PVD wounds. The DON also stated the facility did not follow its policy requiring each individual completing a portion of the MDS to certify the accuracy of that portion. The facility also failed to accurately code Resident 43’s tobacco use on the MDS. Resident 43 was admitted with diagnoses including muscle weakness, gait abnormalities, and history of falling. The MDS indicated the resident did not use tobacco, but the care plan stated the resident smoked independently and required monitoring for compliance with the smoking policy. The resident stated she smoked and had been informed about her smoking schedule and the risks of smoking. The Activities Director also stated the resident smoked, and the DON acknowledged that the care plan and her own observations showed the resident smoked, while the MDS incorrectly indicated the resident was not a tobacco user.
Care plan not updated to reflect physician-ordered fall safety interventions
Penalty
Summary
The facility failed to update and revise 1 of 3 sampled residents’ care plans after a physician ordered a low bed with bilateral floor mats for safety. Resident 78 was admitted with diagnoses including bilateral contractures, anemia, and calculus. The resident’s MDS dated 3/5/2026 indicated the resident sometimes made herself understood and sometimes understood others, had severely impaired cognition, and required maximal assistance with mobility from facility staff. The resident’s order summary showed that low bed with bilateral floor mats for safety had been ordered on 8/24/2024, but the care plan titled "The resident is at risk for fall" dated 7/9/2025 did not document updated interventions for that order. During interview and record review, LVN 6 stated the care plan should be initiated on admission and updated when there was a change of condition or a new physician order, and acknowledged that Resident 78’s care plan did not reflect the low bed and bilateral floor mats intervention for safety. CNA 12 stated the floor mats were used as fall risk precautions and the bed was kept low for precaution if a resident tried to get out of bed. The DON also confirmed that the care plan was not updated with the physician’s orders for low bed with bilateral floor mats and stated this was a failure to update the resident’s safety needs ordered by the physician. Facility policies on comprehensive care planning and fall management stated that the comprehensive care plan includes services to attain or maintain the resident’s highest practicable well-being and that individualized plans of care are to be developed, reviewed, and revised as indicated.
Failure to Complete Activity Assessment
Penalty
Summary
The facility failed to ensure an activity assessment was completed for one sampled resident to evaluate the resident’s preferences for activities. The resident was admitted on 4/22/2026 with diagnoses including hydrocephalus, hyperlipidemia, hypertension, and muscle weakness. The resident’s H&P dated 4/23/2026 indicated the resident was alert and oriented times two. During a concurrent interview and record review on 4/27/2026, the resident was observed sitting up in bed and stated he was bored and that there were no activities to do in the facility. On 4/28/2026, the resident was observed in the activities room sitting at a table coloring and talking with the Activities Director. On 4/29/2026, the Activities Director stated the resident came to the activities room every morning, followed instructions, and answered questions, and that an activity assessment was supposed to be completed within five days of admission but had not yet been done. Later that day, the resident was observed sitting in a wheelchair in the activities room, not participating in any activity and staring at the ceiling. The DON stated activity assessments were done within 72 hours of admission and that assessing activity preferences was needed to better serve resident needs and preferences.
Low Air Loss Mattress Care Not Maintained for Two Residents
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was deficient for two residents who were on low air loss mattresses for skin and pressure injury prevention. Resident 2 was admitted with diagnoses including gastrostomy, malnutrition, and generalized muscle weakness, and the record showed impaired cognition, dependence for activities of daily living, and risk for pressure ulcer development. The resident had a physician order for a low air loss mattress every dayshift for wound care management, with the setting not to exceed current weight, and the care plan identified risk for skin breakdown with a low air loss mattress intervention. During a concurrent observation and interview, Resident 2's low air loss mattress was found set at 150 lbs. Licensed Vocational Nurse 3 stated it should have been set at 80 lbs. based on the resident's weight. The Director of Nursing stated the mattress should have been set according to the resident's comfort and weight for pressure injury prevention and emphasized following the manufacturer's guidelines. The operator's manual indicated the facility needed to determine the patient's weight and set the control knob to the specific weight setting. Resident 8 was admitted with diagnoses including heart failure, aftercare following joint replacement surgery, and osteoarthritis, and the record showed the resident required maximum assistance with activities of daily living and was at risk for pressure ulcers with a pressure-reducing bed device. The resident's care plan and order summary included a low air loss mattress. During observation, the mattress was deflated and the resident stated she felt the metal bar on her back and that it was uncomfortable; later, the mattress was found not plugged into the wall socket. LVN 6 stated the mattress should have been on and that improper functioning increased the risk for pressure ulcers. The DON stated the facility's policy was not followed because the mattress was unplugged and deflated.
Failure to Document Foley Catheter Infection Monitoring
Penalty
Summary
The facility failed to ensure that one sampled resident with an indwelling Foley catheter received the ordered monitoring for signs and symptoms of infection. The resident was admitted with diagnoses including UTI, benign prostatic hyperplasia, and obstructive uropathy, and had a physician order dated 1/21/2026 to monitor the Foley catheter for signs and symptoms of infection every shift and notify the physician if any were noted. The resident’s care plan identified the Foley catheter and stated the resident was at risk for infection, with interventions to monitor for signs and symptoms of infection and manage the catheter to minimize infection risk. The resident’s MDS dated 4/2/2026 indicated the resident was cognitively intact and had an indwelling catheter. During a concurrent observation and interview on 4/27/2026, the resident was seen sitting up in bed with a Foley catheter and privacy bag, with clear yellow urine in the tubing. Review of the MAR for 4/1/2026 through 4/29/2026 did not show documentation that the Foley catheter was monitored for signs and symptoms of infection. During interviews and record review, RN 1 stated the order to monitor for signs and symptoms of infection should have been documented on the MAR and that there was no such documentation for the resident’s Foley catheter. The DON also confirmed there was no monitoring documented on the MAR and stated the monitoring should be documented there so nurses would be prompted to look for signs of infection. The facility’s urinary catheter policy did not address care of or monitoring for signs and symptoms of infection for a urinary catheter, and the physician orders policy stated that licensed nurses receiving orders would be responsible for documenting and implementing them.
Unlabeled Oxygen Tubing and Humidifier
Penalty
Summary
Failure to label the oxygen tubing and humidifier with a date was identified for one resident who had an order for oxygen at 2 liters per minute via nasal cannula as needed and a weekly order to change the oxygen tubing. The resident’s record showed a history that included amyotrophic lateral sclerosis, morbid obesity, malignant neoplasm of the breast, muscle weakness, unspecified dementia, and a personal history of transient ischemic attack and cerebral infarction. The resident’s H&P noted variable capacity to make medical decisions, and the MDS indicated the resident could make herself understood and understand others. During a concurrent observation and interview, the resident’s oxygen tubing and humidifier were observed without a label showing the last change date. RN 1 stated the facility would not be able to determine when the tubing and humidifier were last changed without a label and date, and stated they should be changed weekly for infection control. The ADON stated the tubing and humidifier needed to be changed weekly. The DON reviewed the facility’s infection prevention and control policy and the policy for changing disposable humidifier bottles, and stated the resident’s oxygen tubing and humidifier should be changed weekly; the DON also stated that without a date the resident was at risk for respiratory infection because the tubing and humidifier could be contaminated.
Outdated dialysis access orders and care plan
Penalty
Summary
The facility failed to obtain updated HD access site monitoring orders for a resident with ESRD who received dialysis. The resident was cognitively intact and had a history of dialysis access changes, including a left upper arm AV fistula that was documented as permanently unusable and a right upper arm AV fistula that had been placed, while the resident was still receiving dialysis through a right chest Permacath. The record also contained conflicting and outdated documentation about the resident’s dialysis access site and arm restrictions. The resident’s Order Summary Report and care plan contained inconsistent information about the access site, including references to a left arm shunt, a left chest Permacath, and instructions not to perform BP measurements, venipunctures, or IV therapy on the access arm without clearly identifying the correct arm. During observation, the resident had a Permacath on the right upper chest and stated the left upper arm AV fistula had been removed and the right upper arm fistula could not yet be used. Staff interviews confirmed that new orders should have been obtained to prevent BP measurements on the right upper arm with the AV fistula and that the AV shunt site should have been updated in the chart. The DON reviewed the facility’s dialysis care policy, which required the IDT to ensure the care plan documented the resident’s renal condition and precautions such as shunt site, no BP on the affected side, and other access-related restrictions. The DON stated the policy was not followed because the resident’s orders and care plan were not updated to reflect the resident’s current condition. The MDSC also stated the dialysis order, AV fistula location, and BP restrictions should have been clarified with the doctor, and that orders and care plans must be updated for accuracy of care.
Failure to Respond to Pharmacist Recommendation for Amlodipine Hold Parameters
Penalty
Summary
The facility failed to respond to a pharmacist’s recommendation to remove heart rate hold parameters from a resident’s amlodipine order. Resident 4 was admitted on 3/2/2021 and readmitted on 8/26/2024 with a diagnosis of essential hypertension. The resident’s H&P dated 9/16/2025 also listed essential hypertension. The current Order Summary Report dated 4/29/2026 showed amlodipine 5 mg by mouth daily for hypertension with hold parameters for SBP less than 110 mmHg and HR less than 60 beats per minute. A pharmacist recommendation dated 2/23/2026 advised consulting the physician about removing the HR hold parameters because amlodipine was not routinely monitored for HR. Review of the clinical record showed no apparent physician or facility response to that recommendation, and the DON confirmed there was no apparent response. The facility policy on Medication Regimen Review stated recommendations are to be acted upon and documented by facility staff and/or the prescriber, with the physician accepting, acting upon, or rejecting the suggestion with an explanation by the next physician visit.
Unnecessary Medication Use and Missing BP Monitoring Before Midodrine
Penalty
Summary
The facility failed to ensure that two sampled residents were free from unnecessary drugs. For one resident with GERD, the record showed metoclopramide 5 mg by mouth before meals and at bedtime for nausea and vomiting had been given continuously since 3/27/2025, which was over one year. The resident’s care plan for GERD, dated 2/8/2026, identified metoclopramide as a targeted intervention and stated that the medication increased the risk of tardive dyskinesia and should be limited to 12 weeks or less. The clinical record did not contain a provider-documented rationale showing that the benefits of continuing metoclopramide beyond 12 weeks outweighed the risks. The MAR for April 2026 also did not show the facility was monitoring or documenting episodes of nausea and vomiting related to the resident’s use of metoclopramide. During interview, the DON stated the resident had been on metoclopramide for 13 months continuously, that the facility was not monitoring the resident for nausea and vomiting to determine whether the medication was still needed, and that there was no evidence or clinical justification documented for continuing it longer than 12 weeks. For the second resident, who had ESRD and was dependent on HD, the physician ordered midodrine 5 mg by mouth every Monday, Wednesday, and Friday for hypotension before dialysis, with instructions to hold if SBP was more than 100 mmHg. The MAR showed multiple instances across January, February, and March 2026 where BP monitoring and documentation were missing before midodrine administration. Interviews with an LVN and the DON confirmed that BP should be checked, monitored, and documented before giving midodrine and that giving the medication without this monitoring was inappropriate.
Expired Inhaler Left on Medication Cart
Penalty
Summary
The facility failed to remove one expired fluticasone/salmeterol inhaler from Medication Cart 3 for Resident 6. During a concurrent observation and interview with LVN 2, surveyors found one open fluticasone/salmeterol inhaler labeled with an open date, and the product labeling indicated that opened inhalers should be used or discarded within one month of opening. LVN 2 stated the inhaler was expired because it had been open longer than one month. A review of the facility’s Storage of Medications policy showed that medications and biologicals are to be stored safely, securely, and properly according to manufacturer recommendations, and that outdated, contaminated, or deteriorated medications are to be immediately removed from stock and disposed of according to procedure. During the interview, LVN 2 stated that failing to remove expired inhalers from the medication cart increased the risk that the inhaler might not work as intended for Resident 6’s breathing problems.
Improper Preparation of Minced and Moist Meal Items
Penalty
Summary
The facility failed to ensure that a minced and moist texture green bean was prepared according to IDDSI Level 5 requirements for a resident receiving a cardiac diet with minced and moist texture and moderately thickened liquids. During a kitchen observation, a cook removed lasagna and chopped it into small, mashable pieces with a flat square-end utensil, then served green beans that were prepared as soft and bite-size pieces rather than minced and moist. The tray card for lunch identified the resident’s ordered diet as cardiac, minced and moist texture, and moderately thickened liquid consistency, and the facility menu/spreadsheet listed minced and moist lasagna and minced and moist green beans for that meal. During the concurrent observation and interview, the cook stated minced and moist foods had to be very soft and small, almost the size of a grain of rice, and should fit between fork gaps, but acknowledged the lasagna and green beans were not prepared to minced and moist standards. The cook stated the resident had to mash the lasagna on the plate and that the green beans were not small enough and did not fit through the fork gaps. The regional RD and dietary supervisor also stated the green beans were not minced and moist and could cause swallowing problems for residents on that diet. The facility recipe for green beans specified mincing regular cooked portions to 4 mm x 4 mm and using the slot between fork prongs to determine correct size, and the facility policy described mechanically altered diets as requiring the prescribed texture modification.
Food Preferences Not Honored for Two Residents
Penalty
Summary
The facility failed to provide food that accommodated resident preferences for two sampled residents. Resident 68 had a dietary profile listing beef and pork as dislikes, and during interview he stated he did not want to eat red meat and had told the facility this preference, but the facility continued to give him red meat. Review of the noon tray card and the lasagna recipe showed that Resident 68 was served lasagna containing ground beef, and the Dietary Supervisor and DON both verified that the lasagna contained ground beef and that the resident received it despite his stated dislike. Resident 68’s record showed he was originally admitted on 6/21/2023 and readmitted on 11/6/2023 with diagnoses including seizures, monoplegia following cerebral infarction affecting the right dominant side, muscle weakness, hyperlipidemia, anemia, and gastro-esophageal reflux without esophagitis. His H&P indicated he had capacity to make medical decisions, and the MDS indicated he usually could make himself understood and usually had the ability to understand others. The facility’s policy stated the Dietary Manager would complete a Dietary Profile upon admission, readmission, quarterly, annually, or as needed, and that the Dietary Department would provide meals consistent with resident preferences as indicated on the tray card. Resident 72’s record showed she was admitted on 3/12/2025 with diagnoses including type 2 DM, protein-calorie malnutrition, cirrhosis of the liver, hyperlipidemia, hypertensive heart disease, and dysphagia. Her Dietary Profile listed dislikes of chicken, beef, pork, turkey, and fish, and she stated she was a vegetarian and had been buying her own food because the facility did not accommodate her diet. She also stated she refused meal trays because the meals from the kitchen always contained meat. Observation of her lunch tray showed lasagna with meat, while her tray card did not list dislikes and her physician diet order did not identify her as vegetarian. The DS stated Resident 72’s Dietary Profile had last been completed a year earlier and should have been updated quarterly, and both the DS and DON stated the resident received meat when she should not have because she was vegetarian and did not like meat.
Incomplete MAR Documentation for Scheduled Midodrine
Penalty
Summary
The facility failed to maintain accurate and complete medical records for one of five sampled residents, Resident 94, by not documenting whether midodrine was administered or held on 2/13/2026 and 2/25/2026. Resident 94 was admitted on 11/8/2025 and later re-admitted with diagnoses including a right hip wound, ESRD, and dependence on HD. The H&P dated 1/2/2026 indicated Resident 94 had the capacity to make medical decisions, and the MDS dated 2/10/2026 indicated intact cognition for daily decision-making with varying levels of assistance needed for ADLs. Resident 94 had a physician order for midodrine 5 mg by mouth every Monday, Wednesday, and Friday for hypotension before dialysis, which was later discontinued and replaced with an order to give the medication in the morning every Monday, Wednesday, and Friday and hold if SBP was more than 100 mmHg. Review of the MAR showed blank documentation for the medication on 2/13/2026 and 2/25/2026. During interview and record review, LVN 5 verified there was no documentation indicating whether the midodrine was administered or held on those dates, and stated the nurse should have documented if the medication was not administered and the reason why. The DON stated it was important for nurses to document on the MAR whether medication was administered and, if not, the reason it was not given.
Insufficient Private Closet Space Due to Facility Pillows Stored in Resident Closet
Penalty
Summary
The facility failed to ensure accessible and adequate private closet space for Resident 88, who was readmitted with diagnoses including cerebral infarction, epilepsy, and dysphagia and was dependent on staff for ADLs. The resident’s H&P indicated he had capacity to make medical decisions. His care plan included a goal that resident rights would be honored and respected, and the facility’s Resident Rights policy stated residents should retain and use personal possessions to the maximum extent space and safety permit. During interview, Resident 88 stated he wanted his own closet and did not want to share closet space with his roommate because he wanted a place for his belongings instead of having them scattered around the room. Observation of the room showed his backpack on the floor, clothing piled on a chair, and multiple pillows and two sweaters stored on hangers in his closet. Staff stated the pillows took up most of the closet space, leaving insufficient room for the resident’s personal belongings. The Housekeeping Manager stated it was not appropriate to store facility pillows in residents’ closets, and the DON stated resident belongings were to be stored in their own assigned closet or alternative storage furniture. The facility’s Dignity policy stated residents’ private space and property are respected at all times.
Call Light Not Within Reach
Penalty
Summary
The facility failed to ensure a working call light was within reach for Resident 51, whose call light was observed resting on the floor in the resident’s room. Resident 51 was admitted with diagnoses including benign neoplasm of meninges, altered mental status, generalized muscle weakness, difficulty walking, lack of coordination, and adult failure to thrive. The resident’s H&P stated the resident did not have the capacity to understand and make decisions, and the MDS indicated the resident sometimes could make herself understood and sometimes could understand others, while needing supervision or touching assistance for care. During a concurrent observation and interview, CNA 4 and CNA 5 both stated the call light should not have been on the floor. RN 1 stated that if the call light was on the floor, Resident 51 would not be able to call staff, and also stated it could pose an infection control issue. The DON stated that if the call light was on the floor, Resident 51 could not call for help, and stated the facility did not have a rounding log for Resident 51. The DON also stated the facility’s policy required residents to have a means to call staff for assistance, and acknowledged the facility did not follow its call light policy.
Insufficient Space in Multiple-Resident Rooms
Penalty
Summary
The facility failed to ensure 14 of 33 residents' rooms met the required space standard of at least 80 square feet per resident in multiple-bed rooms. During review of the facility's room waiver request letter dated 4/29/2026, the Administrator requested a waiver for multiple rooms listed on the Client Accommodation Analysis form, stating the rooms had no projections or obstructions that would interfere with wheelchair movement, that there was enough space for care, dignity, and privacy, and that the rooms would not adversely affect residents' health and safety. The waiver request covered rooms with three-bed capacities, and the facility stated the rooms were in accordance with the special needs of the residents. During interviews, CNA 1, Resident 73, Resident 83, CNA 2, LVN 3, the ADON, the DOR, the ADOR, the DON, and the ADM all stated there was enough room in the rooms for care, movement, ADLs, and therapy. However, the concurrent observation and review of the Client Accommodation Analysis dated 4/29/2026 showed the listed rooms measured below the required square footage per resident, ranging from 72.1 to 79.8 square feet per resident in rooms with three beds. The analysis indicated that a three-bed room required at least 240 square feet total, and the Department recommended continuation of the room waiver request.
Failure to Obtain Immunization Consent for Resident Lacking Decision-Making Capacity
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control policy and procedures related to immunization consent for one resident. Resident 4 was admitted with diagnoses including benign neoplasm of the meninges, altered mental status, and adult failure to thrive. A history and physical dated 6/17/2025 documented that the resident did not have the capacity to understand and make decisions, and a Minimum Data Set dated 12/24/2025 indicated severe cognitive impairment. The same MDS showed the resident mostly required supervision or touching assistance for ADLs such as oral hygiene, toileting hygiene, showering/bathing, lower body dressing, personal hygiene, and putting on/taking off footwear. During an interview, the Infection Prevention Nurse stated that before administering vaccinations such as influenza, COVID, or pneumonia, a resident or their representative must sign a consent form to indicate they have been educated on the benefits and risks. The IPN confirmed there was no documented evidence that the resident’s representative had been given the consent. Review of the facility’s Infection Prevention and Control Program policy, last reviewed on 12/18/2025, showed that the program included immunization policies and procedures, including obtaining direct and proxy consent and specifying how often this should occur. The lack of documented consent for influenza, pneumonia, and COVID vaccinations for Resident 4, who lacked decision-making capacity, constituted a failure to follow the facility’s infection control policies and procedures.
Failure to Update Fall Risk and Transfer Care Plan Leading to Assisted Fall
Penalty
Summary
The deficiency involves the facility’s failure to update and revise a resident’s fall risk and transfer care plan to reflect current assessments and needs. The resident was admitted with diagnoses including muscle wasting and atrophy, lack of coordination, and end-stage renal disease. A care plan dated 11/12/2025 identified a deficit in activities of daily living and required two staff for transfers using a Hoyer lift with a medium sling. A Lift Transfer Reposition assessment dated 1/22/2026 documented that the resident could not transfer independently or with supervision without a device, was unable to bear at least 50% weight on one or both legs, and required a total (Hoyer) lift with a medium sling. Nursing documentation on the same date noted bilateral leg weakness and fall risk factors, including a history of falls within six months. A subsequent MDS dated 1/29/2026 indicated the resident was alert and oriented with good recall, and was dependent for sit-to-stand and chair/bed-to-chair transfers, requiring assistance of two or more helpers. A physical therapy note dated 1/31/2026 also documented that the resident was dependent with 100% assist or two or more helpers for sit-to-stand and chair/bed-to-chair transfers. However, a Restorative Nursing Weekly/Monthly Progress Report dated 2/24/2026 stated the resident’s function was improving and that the resident could sit and stand with one-person assist using a gait belt. Despite the earlier assessments indicating dependence and need for a total lift, the care plan in effect on 2/26/2026 still listed the resident as at risk for falls/injury due to impaired mobility with interventions including two-person transfers using a Hoyer lift, and this intervention was not created until 2/27/2026, after the assisted fall. On 2/26/2026, the resident experienced an assisted fall while being transferred from a wheelchair to a bed by a CNA using a gait belt with one-person assist. The CNA reported that this one-person gait belt transfer was the usual practice, that the resident was not on fall precautions, and that she was only aware of the second fall. The LVN also stated the resident was a one-person transfer with a gait belt and not on fall precautions. The DON later acknowledged that the Lift Transfer Reposition assessment on readmission indicated the need for a total Hoyer lift and that this status should have been updated in the care plan at admission/readmission, and also stated that the care plan had not been updated after a prior fall on 12/23/2025. Facility policies required that comprehensive care plans be developed within seven days of the comprehensive assessment and be reviewed and revised as the resident’s condition changed, including after significant changes and at least quarterly, but the resident’s fall risk and transfer care plan was not updated to reflect current assessments and prior falls before the assisted fall occurred.
Failure to Accurately Code Depression and Care Plan for Psychotropic Use on MDS
Penalty
Summary
Surveyors identified that the facility failed to ensure an accurate MDS assessment and related care planning for a resident with a documented diagnosis of depression. The resident was admitted with Parkinson’s disease, muscle weakness, and difficulty walking, and had an active order for Mirtazapine 15 mg for depression manifested by overconcern with health issues. The resident’s MDS indicated they felt little interest or pleasure in doing things and felt down, depressed, or hopeless half or more of the days, but depression was not coded as an active diagnosis on the MDS. During interview and record review, an LVN confirmed there was no care plan addressing depression and that the diagnosis of depression was not triggered on the MDS, despite the resident receiving a medication ordered for depression. Further review with the DON and MDS nurse showed that the resident had received a depression diagnosis from the hospital and that a psychiatrist at the GACH had continued the Mirtazapine upon readmission. The MDS nurse stated that once the order was entered into the electronic chart, there was no alert to trigger the depression diagnosis in the MDS. Review of the IDT care conference documentation showed no recorded review of medications, and the DON and MDS nurse confirmed there was no care plan documented for depression or for the use of Mirtazapine. The DON and MDS nurse stated that without a care plan, something could be missed, and that the care plan is the comprehensive plan of care for the resident. The facility’s psychotropic medication use policy required that residents not receive psychotropic medications without a clinically indicated, documented condition and that the IDT evaluate and document the resident’s underlying condition and medications on admission or readmission, which was not reflected in the records reviewed for this resident.
Failure to Develop Comprehensive Diabetes Care Plan for a Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan addressing diabetes mellitus for a resident admitted with type 2 DM and a history of myocardial infarction. The admission record showed the resident was admitted with type 2 DM, and the MDS dated 12/31/2025 documented the resident as alert, oriented, with good recall, and with an active diagnosis of diabetes. Facility policy required that areas of concern triggered during the resident assessment be evaluated and incorporated into an individualized comprehensive care plan with measurable objectives and timetables to meet medical, physical, mental, and psychosocial needs. Despite the diabetes diagnosis being triggered in the MDS, there was no corresponding diabetes care plan in place for this resident. During an interview and concurrent record review with the DON and the MDS nurse on 1/21/2026, the surveyor requested the resident’s diabetes care plan. Initial review of the Care Plan Report under "Diabetes Mellitus" showed no care plan. When the MDS nurse searched under "diabetes," a care plan was visible, but it was dated 1/20/2026 and had been created by the DON after she overheard the surveyor ask for the resident’s diabetes care plan. The DON acknowledged that the diabetes care plan she created was incomplete. The MDS nurse stated there was no indication why the care plan had not been developed when type 2 DM was triggered in the MDS and confirmed that care plans are the comprehensive plan of care for the resident and that, without the diabetes care plan, the resident’s care would be incomplete.
Failure to Provide Timely Access to Resident Medical Records
Penalty
Summary
The facility failed to follow its own policy and procedure for providing timely access to a resident’s medical records when a resident representative requested records for one of the sampled residents. The resident, admitted with rheumatoid arthritis, anemia, HTN, and later documented with dementia without behavioral disturbance, required partial to moderate assistance with ADLs and had a family member designated as DPOA for medical decisions. The facility’s policy, revised in late 2025, stated that residents have the right to access their personal and medical records within 24 hours (excluding weekends and holidays) of a request and to obtain copies within two business days of an oral or written request. The policy also allowed a legal representative to grant others access to the resident’s records through a written request specifying what information should be released and to whom. The Medical Records Director reported that the facility received a written medical records request from the resident’s representative by mail on 12/31/2025. However, the MRD did not begin processing the request until returning from vacation on 1/5/2026 and ultimately provided the records to the resident’s representative on 1/12/2026. The MRD stated that records are typically provided within two business days after corporate office review and approval. The Facility Administrator confirmed that the records were not released within the two-day timeframe specified in the facility’s policy because the facility was waiting for clearance from the corporate office. The FA also stated that a medical records consultant was available when the MRD was off, but that consultant was responsible for 60 other facilities. As a result, the resident’s representative was denied timely access to the requested medical records in accordance with the facility’s own policy.
Failure to Develop Comprehensive Care Plan for Resident’s Hearing Loss
Penalty
Summary
The deficiency involves the facility’s failure to develop a comprehensive, individualized care plan addressing a resident’s left ear hearing loss. The resident was admitted with diagnoses including epilepsy, a femur fracture, and end stage renal disease, and an MDS assessment dated 10/25/2025 documented that the resident had adequate hearing and cognitive skills for daily decision making, with varying levels of assistance needed for ADLs. An ENT consult dated 12/25/2025 documented a three-year history of hearing loss, wax removal, patient education, and a recommendation for follow-up in six months or more. Despite this documented history and evaluation, the resident’s medical record contained no care plan problem, goals, monitoring parameters, comfort measures, or physician notification requirements related to hearing loss. During an observation and interview, the resident, seated in bed, expressed concern about ongoing hearing loss in the left ear and reported having received treatment once at the facility, but questioned whether additional interventions would be offered since the hearing loss persisted and had begun prior to admission. The MDS nurse confirmed that a review of the record revealed no care plan, orders, or guidance to address the resident’s hearing loss, and stated that the resident should have a care plan for each current diagnosis and problem. The DON similarly stated that a comprehensive care plan should have been initiated for the resident’s hearing loss to guide nurses in monitoring for worsening hearing, communicating effectively with the resident, and notifying the provider if the problem worsened. The facility’s policy required the interdisciplinary team to develop an individualized comprehensive care plan for each identified problem area within seven days of completing the comprehensive MDS and to update it with significant changes or at least quarterly, which was not done for this resident’s hearing loss.
Failure to Implement RNA Feeding Program as Ordered
Penalty
Summary
A deficiency occurred when the facility failed to implement physician orders for a Restorative Nursing Aide (RNA) feeding program for both breakfast and lunch for a resident at risk for dehydration and malnutrition. The resident, who had multiple diagnoses including chronic kidney disease, Alzheimer's disease, anemia, myelodysplastic syndrome, and muscle wasting, experienced significant unplanned weight loss over a three-month period. The resident's care plan and physician orders specifically required RNA assistance with feeding at both breakfast and lunch to address poor oral intake and nutritional risk. Despite these orders, observations and interviews revealed that the RNA feeding program was only provided at breakfast, with Certified Nursing Assistants (CNAs) feeding the resident at lunch instead of RNAs. Staff interviews confirmed that RNAs were not assigned to feed the resident during lunch, and that this practice was not in accordance with the physician's orders or the resident's care plan. Documentation from multiple care conferences and progress notes indicated ongoing poor oral intake and continued weight loss, but did not address whether the RNA feeding program was being fully implemented as ordered. The facility's own policies required that physician orders be accurately transcribed and implemented, and that restorative nursing services be individualized and resident-centered as outlined in the care plan. However, the failure to provide RNA feeding at both prescribed meals resulted in the resident experiencing a 9.4% weight loss over three months, with weights dropping from 82.8 lbs to 75 lbs. Staff acknowledged that not following the physician orders could negatively affect the resident's nutritional status.
Failure to Notify MD of Declining Oral Intake and Change in Condition
Penalty
Summary
The facility failed to notify the MD when a resident had a change in condition related to poor oral intake, despite repeated documentation that the resident was eating less than 50% of meals and at times refusing meals altogether. The resident had a history that included rheumatoid arthritis, anemia, hypertension, and dementia without behavioral disturbance, and the H&P indicated the resident could make needs known but could not make medical decisions, with the family member serving as DPOA. The MDS documented severe cognitive impairment and the resident required partial to moderate assistance with multiple ADLs. Record review showed the resident’s oral intake declined over multiple meals, including several meals documented as 0%, 25%, or refused, with a total of 17 out of 32 meals missed or consumed at less than 50%. Nutritional assessment notes documented an average oral intake of approximately 58% for 18 meals and identified pressure injuries as a risk factor. Interdisciplinary care conference notes indicated skin alterations, and SBAR documentation described an enlarging sacrococcyx pressure injury with poor PO intake and decline in condition. Subsequent SBAR notes documented that the pressure injury increased in size and later became 100% slough. The resident was later transferred to the hospital for failure to thrive, altered mental status, and a sacral wound. Hospital records documented dehydration, acute renal failure, sepsis with acute renal failure, severe sepsis, bacteremia, encephalopathy, hypernatremia, lactic acidosis, metabolic acidosis, and uremia. EMS reported the resident had not eaten since the prior night and had not taken medications, and hospital labs showed markedly abnormal sodium, chloride, BUN, creatinine, lactate, and WBC values. Interviews with CNA 1, RN 1, the family members, and the DON confirmed the resident had poor intake, refused an IV insertion, and that the physician had not been notified when the resident’s intake dropped below 50% for repeated meals. The facility policy required immediate notification of the resident, physician and/or NP, and resident representative when there was a significant change in condition or a need to alter treatment.
Failure to Manage Pressure Injury, Incontinence, and Poor Intake
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and failed to prevent deterioration of a sacrococcyx pressure injury for one resident with rheumatoid arthritis, anemia, hypertension, and dementia with severe cognitive impairment. The resident’s record showed poor oral intake over multiple days, with many meals documented as less than 50% eaten or refused, and the resident also had a history of needing partial to moderate assistance with ADLs. A skin assessment documented sacro-coccyx MASD with denuded skin, and later wound documentation showed the pressure injury had reopened and increased in size with slough and moderate serosanguinous drainage. The record and interviews showed the resident was found soiled in urine on multiple occasions and was not consistently changed when incontinent briefs were wet. A treatment nurse stated the resident was noncompliant with care, especially getting changed when soiled, and that on a few occasions she was found completely soaked in urine from the night before. A CNA stated the resident sometimes fought care and refused brief changes, and that the resident would remain soiled. The wound was observed to seem worse when the resident was found in that condition. The facility also failed to follow physician orders and notify the physician and healthcare proxy about the resident’s decline in intake and condition. The record showed an order for RD consult and an order for IV D5 1/2 NS for hydration support, but staff interviews confirmed the IV was not carried out as ordered and the physician was not notified when the resident refused the IV. The DON stated the physician had not been notified after the resident consumed less than 50% of meals on repeated occasions, and there was no documented evidence that the physician or healthcare proxy was notified of the decreased intake. The resident was later transferred to the hospital for failure to thrive, altered mental status, and sacral wound, where she was diagnosed with dehydration, acute renal failure, sepsis, bacteremia, hypernatremia, lactic acidosis, metabolic acidosis, uremia, and sacral ulcer with gas and osteomyelitis; the resident later expired.
Failure to Include Resident or Proxy in IDT Care Planning and to Address Refusals
Penalty
Summary
The facility failed to conduct an interdisciplinary team (IDT) care conference that included the resident and/or the resident’s responsible party for one sampled resident. The resident was admitted with diagnoses including rheumatoid arthritis, anemia, hypertension, and later documentation noted dementia without behavioral disturbance and severe cognitive impairment. The resident’s record also showed partial to moderate assistance needed for several activities of daily living, and the facility’s own care conference on 10/27/2025 included only the DON and the treatment nurse, with no documentation that the resident or healthcare proxy participated. The resident had documented decreased oral intake and refusal of care. CNA observations and interviews indicated the resident sometimes fought care, refused incontinence brief changes, remained soiled at times, ate about 25% of meals, and would only drink coffee. The DON stated that when a resident consumes less than 50% of meals, the physician must be notified after two to three meals, and confirmed the resident had consumed less than 50% on 10/28/2025 and progressively decreased several times afterward, but the physician had not been notified. Physician orders dated 11/5/2025 and 11/6/2025 included CBC with diff, BMP, urine culture, urinalysis, peripheral IV insertion for hydration, and IV D5 1/2 NS for hydration support. RN 1 stated the outgoing RN had endorsed that the IV and fluids were ordered for decreased oral intake but had not been carried out because the resident refused, and that the lab orders also had not been carried out. RN 1 confirmed there was no documented evidence that the physician or healthcare proxy had been informed of the refusals. The DON also confirmed the IV, fluids, and lab orders had not been carried out and that the resident’s healthcare proxy and the resident were not invited to any of the IDTs reviewed over the last year.
Failure to Carry Out Physician Orders for Labs and IV Hydration
Penalty
Summary
The facility failed to meet professional standards of quality by not carrying out a physician’s orders for a resident with a history of rheumatoid arthritis, anemia, hypertension, and dementia with severe cognitive impairment. The resident’s record showed decreased appetite and fluid intake, weight loss, and a sacral wound, and the physician ordered CBC with diff, BMP, UA, urine C&S, and permission to insert a peripheral IV for hydration. The physician also ordered transfer to the ER for failure to thrive, altered mental status, and sacral wound. The record and staff interviews showed the ordered labs and IV hydration were not completed because the resident reportedly refused, but there was no documented evidence that the physician or the resident’s healthcare proxy was informed of the refusal. RN 1 stated the physician should have been notified at the first refusal so further orders could be given, and the DON confirmed that the IV fluids and lab orders had not been carried out and that no notification was documented. The DON also stated that the physician must be immediately notified to ensure the next steps are known. The resident was later transported to the hospital for failure to thrive, AMS, and sacral wound. The EMT report noted the nursing staff had not checked a full set of vital signs before transfer and had only checked BP and HR; during the EMT assessment, the resident had an O2 saturation of 91% on room air and was placed on oxygen. Facility policies reviewed in the record stated that the facility must immediately inform the physician and resident representative of significant changes in condition and that physician orders are to be documented and implemented.
Failure to Update Care Plans After Catheter Changes and Hospital Readmission
Penalty
Summary
The facility failed to revise the comprehensive care plan for a resident after the resident’s urinary catheter was discontinued and later reinserted for urinary retention. The resident was admitted with multiple diagnoses including COPD with acute exacerbation, chronic respiratory failure with hypoxia, atrial fibrillation, severe protein-calorie malnutrition, hypertension, dementia, and benign prostatic hyperplasia without lower urinary tract symptoms. The admission history and physical stated the resident had the capacity to understand and make decisions, while the MDS indicated moderate cognitive impairment and dependence for toileting hygiene, bathing, and lower body dressing, with substantial/maximal assistance needed for several bed mobility tasks. The resident’s care plan, initiated on admission, addressed enhanced barrier precautions related to the Foley catheter, but the record review showed the care plan was not updated after the urinary catheter was discontinued and then reinserted. The order summary showed an order to discontinue the urinary catheter and a later order for an indwelling urinary catheter for urinary retention. During interview, LVN 3 confirmed the care plan had not been revised to reflect the catheter changes and stated that any licensed nurse could have updated it. LVN 3 also stated that without an updated care plan there would not have been guidance for catheter care, including monitoring output, color, sediment, and changes such as infection or distention. The facility also failed to update the comprehensive care plan for another resident with COPD after the resident returned from the hospital following an episode of respiratory failure. The resident had been admitted with COPD and later readmitted with acute respiratory failure with hypoxia. The MDS showed intact cognitive skills, independence in several self-care and bed mobility areas, and supervision needed for toileting, lower body dressing, footwear, and transfers. The care plan dated 5/30/2025 included oxygen administration for COPD, but no revisions were found after the resident returned from the hospital. RNS 2 confirmed the care plan had not been updated after the return from the hospital, and the DON stated care plans were to be updated when there was a change in condition, quarterly, and after readmission from a hospital stay.
Failure to Dispose and Label Enteral Feeding Supplies
Penalty
Summary
Licensed nurses failed to dispose of used tube feeding formula and tubing and failed to discard remaining formula and tubing per facility policy for Resident 3. Resident 3 was admitted with dysphagia, a gastrostomy tube, COPD, and respiratory failure, and the MDS dated 8/20/2025 indicated severely impaired cognitive skills for daily decision making and dependence on staff for multiple activities of daily living, including oral hygiene, toileting, showering, dressing, personal hygiene, and rolling left and right. During a concurrent observation and interview on 11/19/2025 at 1:18 PM, the DON verified that Resident 3's tube feeding was connected to an empty formula bottle and a bag with water, and no labels were present on the tubing, formula bottle, or bag of water to show when they were first used. The DON stated the tubing should be dated and initiated by the staff who hung the formula and tubing, and that it should be disposed of once turned off. During an interview later that day, LVN 1 stated she turned off Resident 3's feeding in the morning but failed to dispose of the feeding tubing and empty bottle of formula, and acknowledged she should have discarded them according to facility policy. The facility policy on Enteral Feedings Safety Precautions required enteral nutrition to be labeled with the date and time formula was prepared, along with initials, date and time the formula was hung, and initials that the label was checked against the order.
Failure to Notify Physician and Adjust Pain Management for Resident
Penalty
Summary
A deficiency occurred when the facility failed to manage pain effectively for a resident with a recent fall and a fractured left arm, as well as other medical conditions including heart failure and hypertension. The resident was prescribed Oxycodone-Acetaminophen 10-325 mg every six hours for moderate to severe pain. Despite this, the resident repeatedly reported that the pain medication wore off after three to four hours and requested more frequent dosing for better pain relief. Staff interviews confirmed that the resident consistently complained of pain and requested medication before the scheduled time, but the physician was not notified of the ongoing pain or the resident's request for a change in medication timing. The care plan for the resident included monitoring the effectiveness of pain interventions and notifying the physician if pain was not controlled. However, the assigned LVN did not report the resident's continued pain or request for more frequent medication to facility leadership or the physician, despite being instructed to do so by the RN and DON. The facility's pain management policy required documentation of the effectiveness of PRN medications and physician notification if pain was not managed, but these steps were not followed, resulting in the resident remaining uncomfortable and waiting for the next scheduled dose while in pain.
Failure to Arrange Timely Transportation for Chemotherapy Appointment
Penalty
Summary
The facility failed to arrange transportation for a resident's scheduled chemotherapy appointment, as required by physician orders and facility policy. The resident, who was admitted with diagnoses including non-Hodgkin lymphoma, a left fibula fracture, and a history of falls, was cognitively intact but required moderate to maximum assistance with activities of daily living. The resident's chart indicated a chemotherapy appointment was scheduled, but on the morning of the appointment, staff discovered that transportation had not been arranged in advance. The resident had to remind staff about the appointment, prompting a last-minute call to the facility's backup transportation service. Interviews with facility staff, including the Registered Nurse Supervisor, Facility Administrator, and Director of Nursing, confirmed that transportation arrangements were not made until the day of the appointment, contrary to facility policy which requires transportation to be scheduled as soon as possible after an appointment is set. The facility's policy and procedures specify that the Social Services Department is responsible for organizing transportation in collaboration with the resident's family representative. The failure to arrange timely transportation could have resulted in the resident missing the chemotherapy treatment.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Los Angeles
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Beverly Hills Rehabilitation Centre | 0.4 mi | ★★★★★ | 3 | 0 |
| Guardian Rehabilitation Hospital | 0.7 mi | ★★★★★ | 17 | 0 |
| Kennedy Care Center | 0.9 mi | ★★★★★ | 12 | 0 |
| West Hollywood Healthcare & Wellness Centre, Lp | 1.1 mi | ★★★★★ | 2 | 0 |
| Miracle Mile Healthcare Center, Llc | 1.2 mi | ★★★★★ | 46 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.