Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
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 Sherman Village Hcc during CMS and state inspections, most recent first.
A resident with chronic respiratory failure, coma, trach, and vent dependence had a POLST and physician orders for DNR, comfort-focused treatment, and no hospitalization, with RR 1 listed as the legal decision maker. When the resident developed fever, respiratory distress, and vomiting, RN called the RT and attempted to reach the first emergency contact, then called 911 and arranged transfer to the hospital after the resident worsened. Interviews showed staff relied on the emergency contact rather than the legal decision maker, and the DON stated the transfer violated the resident’s and RR’s rights.
A resident with dementia, dysphagia, heart failure, severe cognitive impairment, and dependence for ADLs had a sacrococcyx pressure ulcer care plan that was not updated to reflect current wound treatment orders. The TXN stated the plan was not resident-centered because it did not include the treatment being provided, and the DON stated nursing staff should have updated the care plan so it would guide appropriate care.
A resident with dementia, dysphagia, and HF had an inaccurate and incomplete admission assessment that did not identify existing skin issues, even though staff later stated the resident was admitted with a pressure injury to the sacrum and buttocks. The facility also gave hydralazine despite SBP readings below the ordered hold parameter, and the RN and DON confirmed staff did not follow the prescriber’s order.
A resident with dementia, dysphagia, and heart failure had an order for hydralazine 50 mg PO TID for HTN with instructions to hold the dose if SBP was less than 110 mmHg. Review of the MAR showed the medication was given on morning shifts when the resident’s SBP was below the ordered hold parameter, and RN and DON interviews confirmed staff did not follow the physician order.
A resident with multiple comorbidities, severe cognitive impairment, and dependence on staff for ADLs developed bluish discoloration on the upper arm, after which the physician ordered all blood thinners held for three days. Despite this, Eliquis 2.5 mg was documented as administered twice that day via G-tube, contrary to the order. An RN and the DON acknowledged this as a medication error with potential for bleeding, and the facility’s own medication administration policy required adherence to prescriber orders, which was not met.
Surveyors found that the facility lacked a formally appointed, properly licensed Administrator (ADM) serving as the NHA and did not have consistent on-site administrative oversight. Staff reported that the prior ADM had left, the Department Head Directory did not list an ADM, and a regional ADM only visited a few hours several times per week without a formal appointment letter. The receptionist also noted that this temporary ADM had been absent for several days due to a corporate conference, leaving the DON identified only as the Abuse Coordinator and no clearly designated ADM present to manage operations.
A resident with diabetes, neuropathy, and an amputation did not receive person-centered activity interventions as outlined in their care plan. Despite documented needs and preferences for self-directed and in-room activities, staff failed to conduct activity rounds or offer appropriate interventions unless specifically requested, resulting in a lack of activity engagement for an extended period.
A resident with diabetes, neuropathy, and an amputation, who was cognitively intact and required some assistance, did not receive a resident-centered activity program. Activity staff did not proactively offer group or in-room activities, nor did they assess the resident's preferences, resulting in a lack of engagement unless the resident specifically requested it. The DON confirmed that daily activities and proper documentation were not provided as required by facility policy.
A resident with severe cognitive impairment and multiple medical conditions was administered amlodipine despite a physician order to hold the medication for systolic blood pressure below 110 mmHg. The medication was given when the resident's blood pressure was 105/76 mmHg, contrary to the order and facility policy requiring verification of vital signs before administration.
A resident with multiple medical conditions and severe cognitive impairment did not have accurate documentation in the medical record regarding medications that were held per physician orders. Although a nurse stated she did not administer certain blood pressure and heart failure medications when the resident's blood pressure was low, the MAR reflected that the medications were given and did not indicate they were held, contrary to facility policy.
A resident on enhanced barrier precautions due to a wound and G tube received care from an LVN who failed to wear a protective gown as required by facility policy and physician orders. The LVN provided G tube care wearing only gloves, despite clear signage and protocols indicating the need for both gloves and a gown. Both the DON and IP confirmed that proper PPE was not used during this high-contact care activity.
A resident with multiple medical conditions experienced a significant change of condition, including tachycardia and oxygen desaturation, requiring transfer to a hospital. The facility failed to document complete and accurate information on the resident's Change of Condition form, omitting details about oxygen administration and vital sign monitoring, despite facility policy requiring such documentation.
A resident with cognitive impairment, dysphagia, and a history of elopement was not provided with the required supervision and monitoring as outlined in their care plan and physician orders. Staff failed to supervise the resident during meals, did not perform or document required visual checks, and were unaware of the resident's elopement risk. Inadequate handoff and documentation practices resulted in the resident's absence going unnoticed for hours, leading to the resident eloping from the facility, suffering a fall, and requiring hospital care.
Surveyors found that several residents, including those with severe mobility limitations and cognitive impairments, did not have their call lights or specialty pad call lights within reach. In multiple cases, call lights were tied to bed rails, placed on the paralyzed side, or left hanging out of reach, contrary to facility policy and care plans. Staff interviews confirmed the devices were not positioned properly, impacting residents' ability to summon assistance.
Surveyors found that several residents were subjected to physical restraints, such as raised side rails and tab alarms, without proper assessment, physician orders, or informed consent. In some cases, pillows and blankets were used as barriers under bedding without care planning, and required entrapment risk and restraint assessments were not completed. Staff interviews confirmed these practices did not follow facility policy, resulting in residents' freedom of movement being restricted without appropriate justification or documentation.
Two residents received psychotropic medications without proper evaluation, documentation, or informed consent. One resident was given PRN lorazepam without a stop date, specific behavioral criteria, or consistent monitoring for side effects, and informed consent was not properly documented. Another resident was prescribed risperidone for schizophrenia without a confirmed diagnosis in the clinical record, care plan, or MDS, and both the resident and her representative were unaware of such a diagnosis. Facility staff acknowledged these failures did not align with policy requirements for psychotropic medication use.
Four residents at risk for pressure injuries did not receive care consistent with professional standards when their low air loss mattresses were either not set according to their weight or were not promptly replaced after malfunctioning. In two cases, mattresses were set incorrectly, and in two other cases, residents remained on deflated mattresses for hours, with staff confirming the risk for skin breakdown. All residents had significant medical conditions and required total assistance, and the facility's own policies and manufacturer guidelines for mattress use were not followed.
Surveyors found that several residents did not have their urinals labeled with identifiers, and one resident's indwelling catheter tubing was not anchored as required. Staff confirmed that these actions did not follow facility policy and could result in cross-contamination and increased infection risk, particularly urinary tract infections.
Surveyors found that staff failed to properly label enteral feeding and water flush bags with required information such as resident name, room number, administration rate, date and time hung, and nurse initials. In several cases, the administration rate on the formula bottle did not match the rate set on the feeding pump. These deficiencies were observed in multiple residents with severe cognitive impairment and complex medical needs, and staff interviews confirmed that facility protocols for safe administration were not consistently followed.
The facility did not complete required entrapment risk assessments and quarterly restraint assessments for the use of bed rails and side rails for several residents, including one with severe cognitive impairment and others with significant physical disabilities. In some cases, bed rails were installed without prior assessment for entrapment risk, and all four side rails were raised for a resident without proper assessment, order, or informed consent, contrary to facility policy and best practices.
Three residents with diabetes received subcutaneous insulin injections without proper rotation of injection sites, contrary to physician orders, manufacturer guidelines, and facility policy. Nursing staff repeatedly administered insulin in the same anatomical locations, and both nursing leadership and staff acknowledged this as a medication error. Facility records and interviews confirmed that the electronic medication administration system was not used to ensure site rotation, resulting in non-compliance with professional standards.
Drugs and biologicals were not labeled according to professional standards, and medications, including controlled drugs, were not stored in locked or separately locked compartments as required.
The facility did not obtain food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards.
A resident or their representative was not informed of their choice to enter into a binding arbitration agreement or their right to refuse, as required. The facility did not provide the necessary information about the arbitration process or the option to decline participation.
Arbitration agreements for three residents lacked required language identifying a neutral arbitrator agreed upon by both parties and a venue convenient to both parties. The AC reviewed the signed agreements and stated the verbiage was missing, while the ADON confirmed the contracts should include this information so residents are properly informed before entering a binding agreement. The residents had documented capacity or intact cognition, and each had diagnoses including cerebral infarction, psychosis, anxiety, or visual loss.
Surveyors identified multiple lapses in infection control, including an unclean shower room with feces and discarded dressings, torn and taped dryer gaskets in the laundry area, failure by an LPN to use required PPE when entering a contact isolation room, another LPN not donning a gown during direct care for a resident on Enhanced Barrier Precautions, and a dirty, possibly contaminated trash can in a shared resident bathroom that was not promptly reported or replaced. These deficiencies were confirmed through staff interviews, observations, and policy reviews.
Multiple residents did not have comprehensive care plans developed or implemented for key interventions, including psychotropic medication monitoring, use of side rails, low air loss mattresses, anticoagulant therapy, fall risk management, and elopement risk. In several cases, care plans were missing, not updated in a timely manner, or not followed, leading to staff being unaware of necessary interventions and resulting in missed monitoring, environmental hazards, and an actual elopement event.
Licensed nursing staff failed to rotate insulin injection sites for several residents with diabetes, administering injections repeatedly in the same areas despite physician orders, facility policy, and manufacturer guidelines. Additionally, staff did not provide required supervision and monitoring for a resident at risk for elopement, aspiration, and falls, resulting in the resident leaving the facility unsupervised and experiencing a fall. These deficiencies were confirmed through record reviews and staff interviews.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, as observed by surveyors.
Nurses and nurse aides failed to demonstrate the competencies needed to provide care that maximizes each resident's well-being, resulting in a deficiency related to staff qualifications and skills.
Staff failed to accurately document physician responses, treatment administration, and resident status in clinical records. For example, a nurse did not record a physician's order after a resident's fall, respiratory therapy documentation was missing for two treatments, and a CNA inaccurately charted a resident's meal intake without checking the tray. Additionally, a nurse used an earlier blood pressure reading for a later time and failed to document observed crying spells as required by physician order.
Two residents were administered psychotropic medications without proper informed consent. In one case, the consent form did not match the medication preparation actually given, and in another, the responsible party was not contacted to discuss the risks or benefits of new medications before administration. Facility staff confirmed that required consent procedures were not followed, contrary to facility policy.
The facility did not ensure that residents were informed of their right to file a complaint with the State Survey Agency, and failed to provide visible, readable, and accurate contact information. Multiple residents were unaware of where to find this information, and both the AD and DON confirmed that the posted details were not accessible or correct, contrary to facility policy.
A deficiency was cited when the facility did not provide a safe, clean, comfortable, and homelike environment, nor did it ensure that treatment and supports for daily living were delivered safely to residents.
The facility did not complete the care plan within 7 days of the comprehensive assessment, and the care plan was not prepared, reviewed, and revised by a team of health professionals as required.
A resident lost the ability to perform ADLs without a documented medical reason. The facility did not ensure that the decline in the resident's functional abilities was clinically unavoidable, as required by regulations.
A resident did not receive enough food and fluids to maintain their health, as observed and documented by surveyors. The facility did not ensure the resident's nutritional and hydration needs were met.
A resident receiving continuous oxygen therapy was found with nasal cannula tubing touching the floor and an illegible change date, contrary to facility policy and infection control standards. Staff interviews confirmed the tubing should not contact the floor and must be properly labeled, but these procedures were not followed for a resident with a history of sepsis, pneumonitis, and COPD.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A discrepancy was found in the accounting of a controlled medication when a nurse failed to document the administration of an oxycodone dose immediately after giving it to a resident. Additionally, a resident with complex medical needs did not receive multiple scheduled medications on time, with a delay of nearly four hours. Both the nurse and DON confirmed that these actions were not in line with facility policy, which requires timely administration and documentation of medications.
A resident's Quarterly MDS assessment was not completed and submitted within the required 92-day timeframe, as confirmed by the MDS Director and DON. The assessment was submitted on the 93rd day, exceeding federal requirements, despite the use of an MDS Scheduler intended to track due dates.
A resident with multiple complex diagnoses had their admission MDS assessment submitted to CMS after the required timeframe. The MDS was completed and transmitted late, as confirmed by facility records and staff interviews, in violation of established policies and federal requirements.
A resident with severe cognitive impairment and a gastrostomy tube was found with the feeding tube tip lying uncovered on the floor after being disconnected, contrary to facility policy and best practices. Staff confirmed the tube should have been capped and secured to prevent infection, but this was not done.
The facility failed to prevent mice from entering residential rooms, affecting four residents with conditions like hypertension and anxiety disorder. Mice were reported by visitors and confirmed by the Maintenance Supervisor, who captured them in the rooms. The facility's pest control and infection prevention policies were not effectively implemented, as pests should not be present due to potential disease risks.
The facility failed to maintain a safe and sanitary environment by allowing mice in resident rooms, affecting four residents with conditions like hypertension and anxiety disorder. Staff interviews and photographic evidence confirmed the presence of mice, despite existing policies aimed at preventing such infestations.
The facility failed to maintain an effective pest control program, resulting in mice being found in rooms occupied by four residents with various medical conditions. Staff and visitors confirmed the presence of mice, and the Maintenance Supervisor provided photographic evidence of captured mice. The facility's pest control policy, last revised in 2008, was not effectively implemented, leading to this deficiency.
The facility failed to ensure that call lights were within reach for several residents, including those with severe cognitive impairments and high fall risks. Observations revealed that call lights were placed out of reach, contrary to the facility's policy, leading to potential delays in care. Staff interviews confirmed the oversight, highlighting a lapse in adhering to care plans and procedures.
The facility failed to provide a homelike environment by not repairing broken bathroom flooring for a resident, not providing flat sheets on pressure-reducing mattresses for two residents, and not maintaining cleanliness of a resident's desk fan. These deficiencies led to unsafe and uncomfortable conditions for the residents.
The facility failed to ensure residents were free from physical restraints without proper authorization, affecting five residents. Restraints such as bed rails and hand mittens were used without physician's orders, assessments, or informed consents, contrary to facility policy. This included improper use of side rails and mittens, posing risks to resident safety and dignity.
The facility failed to rotate injection sites for insulin and anticoagulant administration for several residents, as required by professional standards and facility policy. This deficiency was identified through interviews and record reviews, revealing repeated injections in the same areas, increasing the risk of adverse effects like lipodystrophy and bruising. The DON confirmed that licensed nurses did not follow the expected practice, placing residents at risk of harm.
Failure to Follow POLST and Honor Resident’s Decision Maker
Penalty
Summary
The facility failed to respect Resident 1’s rights by not following the resident’s POLST and physician orders for no hospitalization. Resident 1 was admitted with diagnoses including chronic respiratory failure, coma, tracheostomy, and ventilator dependence. The record showed Resident 1 lacked capacity to make decisions, was in a persistent vegetative state, and had RR 1 identified as the legally recognized decision maker on the POLST. The POLST and physician orders both indicated DNR, comfort-focused treatment, and no hospitalization, and the care plan also reflected no CPR, no hospitalization, and comfort-focused treatment. On the night of the change in condition, Resident 1 developed a fever, respiratory distress, and vomited three times. RN 1 called the respiratory therapist and attempted to contact FM 1, who did not answer. As Resident 1 worsened, RN 1 called 911, and when paramedics arrived, RN 1 called FM 1 again and requested transfer to the hospital. The resident was transferred to General Acute Care Hospital despite the POLST order for no hospitalization. During interviews, RN 2 stated RR 1 should have been notified first and, if unavailable, FM 1 should have been called after. The DON stated the POLST identified RR 1 as the legal decision maker and that the transfer to the hospital violated Resident 1’s and RR 1’s rights. RN 1 stated he called FM 1 because FM 1 was listed as the first emergency contact and believed he could transfer Resident 1 because the resident had vital signs and was in respiratory distress, even though the code status was DNR and no hospitalization. The facility policy required residents to be treated with dignity and to have their rights supported, and to notify the resident representative of significant changes and when hospital transfer was necessary.
Care plan not updated for current wound treatment orders
Penalty
Summary
The facility failed to update one resident’s care plan to reflect current wound treatment orders for a sacrococcyx pressure ulcer. The resident was admitted on 9/13/2021 and later readmitted with diagnoses including dementia, dysphagia, and heart failure. The resident’s MDS dated 10/25/2025 indicated severe cognitive impairment and dependence on staff for ADLs. The care plan titled “Actual pressure sore. Resident is noted with sacrococcyx extending right and left buttocks,” dated 10/16/2025, included a goal to minimize risk of complications and decline and an intervention to administer treatment as ordered. During a concurrent interview and record review on 5/6/2026, the TXN stated the wound care plan was not resident-centered because it did not include the treatment the resident was receiving for the sacrococcyx pressure ulcer, and that the care plan should include the current treatment orders so nursing staff would know how to properly care for the resident. The DON stated nursing staff should have updated the wound care plan to reflect the resident’s current wound order, and that without an updated care plan, nurses would not have a guide on how to provide appropriate care. The facility policy on care plans stated that care plans are revised as information about residents and their condition changes.
Incomplete Admission Assessment and Failure to Hold BP Medication
Penalty
Summary
The facility failed to ensure Resident 1 received care in accordance with professional standards of practice after readmission from the GACH. Resident 1 had diagnoses including dementia, dysphagia, and heart failure, and the MDS dated 10/25/2025 indicated severe cognitive impairment and dependence on staff for ADLs. During interview and record review, the Treatment Nurse and RN stated the clinical admission assessment was inaccurate and incomplete because it did not identify Resident 1’s skin issues on admission. They stated Resident 1 was admitted with a pressure injury to the sacrum extending to the right and left buttocks, but the assessment left many questions unanswered and did not reflect the resident’s actual skin condition. The facility also failed to follow the physician’s order for hydralazine 50 mg PO three times daily for hypertension, with instructions to hold the medication if SBP was less than 110 mmHg. Review of the MAR showed hydralazine was administered on 9/6/2025 and 9/7/2025 during the morning shift when Resident 1’s SBP was below 110 mmHg. RN 1 stated the blood pressures were 95/63 mmHg and 86/60 mmHg, and that staff did not follow the doctor’s order because giving hydralazine could lower the blood pressure further. The DON also stated nursing staff failed to follow the physician’s order and that RNs are responsible for completing thorough admission assessments.
Failure to Hold Antihypertensive Medication per Physician Order
Penalty
Summary
The facility failed to administer hydralazine in accordance with the physician order for one resident with diagnoses including dementia, dysphagia, and heart failure. The order, dated 8/10/2025, directed hydralazine HCl 50 mg by mouth three times daily for hypertension and to hold the medication if systolic blood pressure was less than 110 mmHg. Review of the resident’s MAR showed that hydralazine was given on 9/6/2025 and 9/7/2025 during the morning shift even though the resident’s systolic blood pressure was below the ordered hold parameter. During interview and record review, RN 1 confirmed that the resident’s blood pressure readings were 95/63 mmHg on 9/6/2025 at 1 p.m. and 86/60 mmHg on 9/7/2025 at 9 a.m. and 1 p.m., and stated that nursing staff did not follow the doctor’s order because the systolic blood pressure was less than 110 mmHg. The DON also stated that staff failed to follow the physician’s order and administered hydralazine when it should have been held. The facility policy on administering medication stated that medications are administered in accordance with prescriber orders, including any required time frames.
Failure to Hold Anticoagulant as Ordered, Resulting in Significant Medication Error
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when staff did not follow a physician’s order to hold a blood thinner. The resident, who had diagnoses including age-related osteoporosis with a pathological fracture of the right humerus, epilepsy, and type 2 diabetes mellitus, had a history and physical indicating they lacked capacity to understand and make decisions, and an MDS showing severely impaired cognitive skills and dependence on staff for activities of daily living. A change of condition form documented that the resident was observed with bluish discoloration on the inner upper right arm in the late evening, and the physician subsequently ordered all blood thinners to be held for three days. Despite this order, review of the resident’s MAR for April showed that Eliquis 2.5 mg was administered via G-tube at both the morning and evening administration times on the day the hold order was in effect. During interviews, an RN acknowledged that administering Eliquis after the physician ordered it to be held was a medication error with the potential to cause bleeding, and the DON stated the Eliquis was to be held until the cause of the discoloration was identified. The facility’s medication administration policy required that medications be administered safely, timely, and as prescribed, in accordance with prescriber orders, which was not followed in this instance.
Lack of Formally Appointed and Consistently Present Administrator
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a licensed Administrator (ADM) was formally appointed and serving in the capacity of a Nursing Home Administrator (NHA), and that an ADM was present for sufficient hours to provide adequate oversight and management of operations. During observation and interview, the DON’s license was posted in the lobby identifying the DON as the Abuse Coordinator, but there was no indication of an appointed ADM. The facility’s Department Head Directory did not list an ADM, and staff interviews confirmed that the previous ADM had left on January 10, 2026. Staff reported that since the prior ADM’s departure, an interim or regional ADM had been coming to the facility only approximately three times per week for a few hours per visit, either in the morning or afternoon. The receptionist stated that the temporary ADM had been absent from the facility for the past three days due to attending a corporate conference. The DON confirmed that the regional ADM providing oversight did not have a formal appointment letter designating them as the Administrator and had been assigned by the corporate office. As a result, the facility was operating without a consistently present, formally appointed, and properly licensed ADM responsible for managing and overseeing facility operations.
Failure to Implement Person-Centered Activity Care Plan
Penalty
Summary
The facility failed to implement a person-centered care plan for one resident by not following documented interventions related to the resident's preference for not attending group activities. The resident, who had diagnoses including diabetes mellitus with neuropathy, an amputation below the right knee, and left shoulder pain, was admitted with intact cognitive skills and required some assistance with daily activities. The care plan specified that staff should encourage self-directed activities and conduct rounds to monitor and offer appropriate interventions for activity needs. Despite these documented interventions, interviews and record reviews revealed that activity staff did not conduct room visits or offer in-room activities unless specifically requested by the resident. The resident reported that activity staff had not inquired about his preferences for in-room activities and that he enjoyed making a ball from rubber elastic bands, but this interest was not addressed. Activity staff confirmed that the resident only attended group activities when his room was being deep cleaned and that no group or in-room activity visits occurred for a one-month period. The Director of Nursing acknowledged that the care plan interventions were not followed, emphasizing that staff should have encouraged self-directed activities and monitored the resident's activity needs as outlined in the care plan. Facility policies required comprehensive, person-centered care plans with measurable objectives and timetables, and specified that activity plans should be developed with resident participation and included in the total care plan. However, these requirements were not met for this resident, resulting in a failure to deliver necessary care and services as planned.
Failure to Provide Resident-Centered Activity Program
Penalty
Summary
The facility failed to provide an ongoing, resident-centered activity program for one resident with diabetes, diabetic neuropathy, an amputation below the right knee, and left shoulder pain. The resident was cognitively intact and required staff setup assistance for certain activities of daily living. Documentation showed that the resident's care plan included participation in group and independent activities, as well as room visits. However, interviews and record reviews revealed that the resident did not receive activity room visits and was not asked about preferences for in-room activities. The resident reported that activity staff had not inquired about his needs for in-room activities and that he enjoyed making a ball from rubber elastic bands, but this interest was not addressed. Activity staff confirmed that the resident only attended group activities when his room was being deep cleaned and that no room visits or group activities were provided from 11/1/2025 to 12/1/2025 unless specifically requested by the resident. The activity staff did not proactively visit the resident or offer activities unless the resident asked. The Director of Nursing acknowledged that daily activities should be provided and documented, including refusals, and that lack of daily activity could negatively impact the resident's self-esteem. Facility policy required assessment of resident interests and the development of individualized activity plans, but these procedures were not followed for this resident.
Failure to Hold Antihypertensive Medication per Physician Order
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with physician orders for one resident by not holding amlodipine when the resident's systolic blood pressure (SBP) was below the prescribed threshold. Specifically, the physician order directed that amlodipine be held if the SBP was less than 110 mmHg. Despite this, the medication was administered when the resident's SBP was recorded at 105/76 mmHg. This action was confirmed through review of the Medication Administration Record and interviews with the Assistant Director of Nursing and the Director of Nursing, both of whom acknowledged that the medication should have been withheld according to the order. The resident involved had multiple diagnoses, including sepsis, lobar pneumonia, and essential hypertension, and was dependent on staff for all activities of daily living with severely impaired cognitive skills. The facility's policy required that medications be administered as prescribed and that vital signs be checked and verified prior to administration when necessary. The failure to follow the physician's order and facility policy resulted in the administration of a blood pressure-lowering medication despite a low SBP reading.
Failure to Accurately Document Held Medications in Medical Record
Penalty
Summary
The facility failed to maintain accurate and complete medical records for one resident by not properly documenting medications that were held according to physician orders. Specifically, the physician had ordered that certain blood pressure and heart failure medications be held if the resident's systolic blood pressure was below 110 mmHg. Despite this, the Medication Administration Record (MAR) indicated that these medications were administered on dates when the resident's blood pressure was below the specified threshold. However, the nurse involved stated during interview that she did not actually administer the medications on those dates, but instead must have documented them as given in error. She also failed to document that the medications were held, as required by facility policy. The resident involved had multiple diagnoses, including sepsis, pneumonia, and hypertension, and was dependent on staff for all activities of daily living with severely impaired cognitive skills. The Assistant Director of Nursing and Director of Nursing both confirmed that the nurse should have held the medications and documented this action accurately in the MAR, using the appropriate code for held medications. The facility's policy required that all services provided, including medications administered or held, be documented objectively and completely in the resident's medical record.
Failure to Follow Enhanced Barrier Precautions During G Tube Care
Penalty
Summary
The facility failed to implement its infection prevention and control program for a resident who was on enhanced barrier precautions (EBP) due to the presence of a wound and a gastrostomy (G) tube. According to the resident's medical records, the resident was dependent on staff for all activities of daily living and had severe cognitive impairment. Physician orders and facility policy required staff to wear both gloves and a gown when providing direct care, including G tube care, to prevent the spread of multi-drug-resistant organisms (MDROs). During an observation, a Licensed Vocational Nurse (LVN) entered the resident's room, which had EBP signage posted, and provided G tube care while wearing gloves but without donning a gown. The LVN stated she intended to loosen the G tube before putting on the gown but acknowledged she should have worn the gown before providing care. Both the Director of Nursing (DON) and the Infection Preventionist (IP) confirmed that the LVN should have worn a gown during the procedure, as required by facility policy and the resident's care plan.
Incomplete Documentation of Change of Condition and Oxygen Administration
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident by not documenting essential information during a change of condition event. Specifically, the Change of Condition (COC) form for the resident did not include documentation of oxygen administration details or comprehensive monitoring of vital signs, such as the amount and timing of oxygen provided. This omission was confirmed during interviews with both the registered nurse involved and the Director of Nursing, who acknowledged that the documentation was incomplete and did not accurately reflect the care and treatment provided. The resident in question had a history of anemia, chronic kidney disease, and urinary tract infection, and was assessed as having moderately impaired cognitive skills, requiring varying levels of assistance with daily activities. On the day of the incident, the resident experienced tachycardia, hypertension, and episodes of oxygen desaturation, ultimately requiring transfer to an acute care hospital. Despite these significant changes in condition, the medical record lacked detailed documentation of the resident's vital signs and the specifics of oxygen therapy administered during the event. Facility policies reviewed indicated that all services, treatments, and changes in a resident's condition should be thoroughly documented in the medical record to facilitate communication among the care team. However, the COC form for this resident did not meet these standards, as it failed to include care-specific details about the treatments performed and the resident's response to those interventions.
Failure to Provide Adequate Supervision and Monitoring Leads to Resident Elopement and Injury
Penalty
Summary
A resident with a history of cognitive impairment, dysphagia, and previous elopement was not provided with adequate supervision and monitoring as required by their care plan and physician orders. The resident was identified as being at risk for aspiration, falls, and elopement, with care plans and physician orders specifying interventions such as supervision during meals, frequent visual checks, and placement near the nursing station. Despite these documented risks and interventions, staff failed to consistently implement and document the required supervision and monitoring. For example, the resident was left unsupervised during mealtimes, and staff were unaware of the supervision order. Documentation of meal intake and visual checks was inaccurate or completed without direct observation of the resident. On the day of the incident, the resident was last seen in their room before lunch, but was not visually confirmed to be present by the assigned CNA, who assumed the resident was in the bathroom and documented meal intake without verifying the resident's presence or consumption. The nurse assigned to the resident did not perform the required blood pressure checks or visual monitoring as ordered, and used earlier readings to fill documentation. During shift change, handoff procedures were insufficient, with staff not being informed of the resident's elopement risk or previous incidents. As a result, the resident's absence went unnoticed for several hours, and staff only became aware the resident was missing during the evening meal service. The resident was later found in the community after having eloped from the facility, suffering a fall and requiring hospital evaluation for trauma and aspiration precautions. Interviews with staff revealed a lack of awareness regarding the resident's elopement risk, required supervision, and the need for individualized care plan interventions. The care plan for elopement was not person-centered and did not include specific interventions such as visual checks or supervision. The failure to implement and communicate required safety interventions, combined with inadequate handoff and documentation practices, directly contributed to the resident's elopement and subsequent injury.
Failure to Ensure Call Lights and Specialty Call Lights Were Within Reach of Residents
Penalty
Summary
The facility failed to provide reasonable accommodation of resident needs and preferences by not ensuring that call lights and specialty pad call lights were within reach for several residents. In multiple instances, surveyors observed that call lights were either tied to bed rails, dangling toward the floor, or placed on the side of the resident's body that was paralyzed or immobile, making them inaccessible to the residents. Staff interviews confirmed that the call lights were not positioned according to facility policy and the residents' care plans, which required call lights to be within easy reach to allow residents to summon assistance when needed. For example, one resident with acute and chronic respiratory failure, tracheostomy, ventilator dependence, and total dependence on staff for activities of daily living was found with the call light tied to the side rail and out of reach. Another resident with hemiplegia and hemiparesis affecting the left side had the call light clipped to the left side, which was not accessible due to paralysis, despite being able to use the right arm. In both cases, staff acknowledged the error and repositioned the call lights after being prompted by surveyors. Additionally, two residents with severe contractures and total dependence on staff, who were provided with specialty pad call lights due to their limited mobility, were found with these devices placed out of reach—either hanging over the side rail or near the floor. Staff and nursing leadership confirmed that the pad call lights should have been placed on the chest or near the face to allow the residents to alert staff for assistance. Facility policies and care plans reviewed by surveyors consistently required that call lights be within reach of all residents, including those with limited mobility or cognitive impairment.
Failure to Ensure Residents' Rights and Proper Use of Physical Restraints
Penalty
Summary
Surveyors identified multiple deficiencies related to the improper use of physical restraints and failure to ensure residents' rights to dignity and freedom of movement. In several cases, side rails were raised on both the upper and lower sides of beds without proper assessment, physician orders, or informed consent. For example, one resident was found with all four side rails raised, despite only having an order and assessment for bilateral upper side rails. Staff interviews confirmed that the lower side rails were raised without authorization, and there was no documentation of an assessment for their safety or need. The facility's own policies require assessment, informed consent, and physician orders prior to the use of restraints, which were not followed in these instances. Another deficiency involved the use of pillows and blankets as physical barriers under a resident's fitted sheet, which was not ordered or care planned. Staff acknowledged that this practice was not standard and could restrict the resident's movement, effectively acting as a restraint. Additionally, for another resident, required entrapment risk assessments and quarterly restraint assessments for the use of side rails were not completed as mandated by facility policy. Staff interviews confirmed that these assessments were missing for multiple review periods, and the use of both upper and lower side rails was not properly evaluated for safety or necessity. Further deficiencies were found in the use of tab alarms for two residents. These alarms, which are considered restraints, were applied without obtaining informed consent or completing initial and quarterly restraint assessments. Staff confirmed that the alarms were in use to prevent falls, but the required documentation and evaluation for their appropriateness and safety were not completed. Facility policies reviewed by surveyors clearly state that restraints, including alarms, require a physician's order, informed consent, and ongoing assessment, none of which were consistently documented or performed in these cases.
Deficient Psychotropic Medication Management and Documentation
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary psychotropic medication use and chemical restraints, as evidenced by multiple deficiencies in the management of psychotropic medications for two residents. For one resident with a history of traumatic brain injury, depression, and anxiety disorder, the facility did not provide ongoing re-evaluation of the need for PRN lorazepam, as the medication was ordered without an end date and continued indefinitely. The orders for lorazepam also lacked specific, measurable behavioral manifestations to guide administration, and there was no consistent monitoring for adverse effects following administration. Additionally, there was no documented evidence of informed consent being obtained prior to the administration of the psychotropic medication, as required by facility policy. Interviews with facility staff, including the MDS nurse, RN, and ADON, confirmed that the facility's process for psychotropic medication management was not followed. Staff acknowledged that PRN psychotropic medications should be ordered with a stop date, monitored for specific behaviors, and that informed consent must be obtained and documented. Review of the medication administration record revealed multiple instances where lorazepam was administered without documentation of side effect monitoring, and the informed consent form did not indicate who provided consent or when it was obtained. For another resident with dementia and a history of alcohol abuse, the facility failed to ensure that the antipsychotic medication risperidone was used only with a clear, documented indication. The resident's clinical record did not contain a confirmed diagnosis of schizophrenia, which was listed as the reason for the risperidone prescription. The diagnosis was questioned in psychiatric notes, and neither the care plan nor the MDS included schizophrenia as an active diagnosis. The resident and her representative were not aware of a schizophrenia diagnosis, and the DON confirmed that the use of risperidone without a clear, confirmed diagnosis was not appropriate. Facility policies required a comprehensive assessment and documentation of a specific condition for psychotropic medication use, which was not met in this case.
Failure to Ensure Proper Use and Timely Replacement of Low Air Loss Mattresses
Penalty
Summary
The facility failed to provide pressure ulcer care consistent with professional standards of practice for four residents who were at risk for or being treated for pressure injuries. For two residents, the low air loss mattresses (LALM) were not set according to the residents' current weight or comfort as indicated by both the facility's policy and the manufacturer's guidelines. In one case, a resident weighing 123 lbs was found lying on a LALM set at 240 lbs, despite a sticker on the pump indicating the correct setting should be 120 lbs. Staff confirmed that the mattress should have been set to match the resident's weight, and that failure to do so could affect comfort and increase the risk of pressure injury. Another resident's LALM was set at 160 when the correct setting, based on the resident's weight of 185 lbs, should have been 200, as confirmed by both nursing staff and the assistant director of nursing. For two additional residents, the LALMs were observed to be malfunctioning, with the pump units emitting a beeping sound and a flashing "low pressure" indicator light. Both residents appeared sunk into their beds, and staff confirmed that the mattresses had been in this state for over two hours. The staff and DON acknowledged that the mattresses were deflating or had leaks, and that the residents' buttocks were nearly touching the bed frame, which could lead to skin breakdown. The facility did not have extra LALMs readily available to replace the malfunctioning units, resulting in the residents remaining on inadequately functioning support surfaces for an extended period. All four residents involved had significant medical histories and were at moderate to very high risk for developing pressure injuries, as indicated by their Braden Scale assessments and physician orders for LALM use. The facility's own policies and the manufacturer's guidelines required that LALMs be set according to resident weight and that malfunctioning mattresses be promptly replaced to ensure proper pressure redistribution. The failure to follow these procedures resulted in residents being exposed to improper support surfaces, increasing their risk for the development or worsening of pressure injuries.
Failure to Label Urinals and Secure Catheters Leads to Infection Control Deficiency
Penalty
Summary
The facility failed to provide appropriate care and services to residents who were incontinent of urine, specifically in the areas of urinal labeling and catheter care, as observed and documented by surveyors. Multiple residents, including those with significant medical needs such as respiratory failure, tracheostomy, ventilator dependence, neuromuscular dysfunction of the bladder, and severe cognitive impairment, were affected by these deficiencies. In several instances, urinals used by residents were not labeled with resident identifiers, despite facility policy and staff interviews confirming that labeling is required to prevent cross-contamination and infection. For example, in a shared restroom, an unlabeled urinal was found hanging from a mobility assistance bar, and staff acknowledged that this could result in urinals being used for the wrong resident. Additionally, a resident with an indwelling catheter was observed to have the catheter tubing unsecured, not anchored in the stat lock as required by physician order and facility policy. Staff interviews confirmed that the catheter should have been anchored to prevent accidental tugging or dislodgement, which could cause trauma and increase the risk of infection. The facility's policies on infection prevention, urinal use, and catheter care all specify the need for proper labeling and securement, but these procedures were not followed in the observed cases. Staff, including CNAs, RNs, the Infection Preventionist, and the Assistant Director of Nursing, all confirmed during interviews that the observed practices did not align with facility policy and could lead to cross-contamination and urinary tract infections. The documentation and interviews consistently indicated that the lack of urinal labeling and failure to secure catheter tubing represented a failure to implement established infection control measures for residents who are incontinent or require catheterization.
Failure to Properly Label and Administer Enteral Feedings and Water Flushes
Penalty
Summary
Surveyors identified multiple deficiencies related to the administration and labeling of enteral feeding and water flush bags for residents with feeding tubes. In several cases, staff failed to label water flush bags and formula bottles with essential information such as the resident's name, room number, administration rate, date and time hung, and the initials of the licensed nurse. For example, one resident's water flush bag lacked the resident's name, room number, and infusion rate, and the staff confirmed that both the tube feeding bottles and water flush bags should be labeled with this information to ensure correct administration. Another resident's formula bottle was labeled with an incorrect administration rate that did not match the rate set on the feeding pump, and the water flush bag was also missing required identifying information. The report details that these labeling failures were observed across multiple residents, all of whom had significant cognitive impairments and required total assistance with activities of daily living. The residents had complex medical histories, including tracheostomies, ventilator dependence, gastrostomies, dysphagia, and protein-calorie malnutrition. Staff interviews confirmed that the facility's policy required specific labeling to prevent errors in administration and to ensure that residents received the correct formula and hydration as ordered by physicians. However, observations and record reviews revealed that these protocols were not consistently followed. Additionally, the facility's own policies and procedures, which were reviewed by surveyors, clearly outlined the steps necessary to ensure safe administration of enteral nutrition, including checking the label against the order and documenting all required information. Despite this, staff did not consistently adhere to these protocols, as evidenced by the lack of proper labeling and mismatched administration rates. These deficiencies were confirmed through direct observation, staff interviews, and review of facility policies.
Failure to Assess and Document Safe Use of Bed Rails and Side Rails
Penalty
Summary
The facility failed to ensure proper assessment and documentation for the use of bed rails and side rails for multiple residents. For one resident with severe cognitive impairment and total dependence on staff for activities of daily living, the facility did not complete required entrapment risk assessments and quarterly restraint assessments for both upper and lower side rails, despite physician orders and care plan interventions indicating their use. Observations confirmed that both upper and lower side rails were up, and staff interviews revealed that this was not in accordance with the resident's care plan and could restrict freedom of movement. For two other residents, both of whom had significant physical impairments but were cognitively intact, the facility failed to assess the risk of entrapment from bed rails prior to installation. Although physician orders and informed consent were documented, there was no evidence of an entrapment risk assessment before the use of side rails. Staff interviews confirmed that such assessments were not completed, and the use of side rails was primarily for safety, balance, and as an enabler for bed mobility and transfers. Additionally, another resident was found with all four side rails raised without an assessment for the need, safety, or informed consent for the lower side rails. Staff interviews indicated that the use of all four side rails was not ordered or assessed, and that this practice could restrict the resident's movement and be considered a restraint. The facility's policies required alternatives to be tried, interdisciplinary evaluation, and informed consent before the use of bed rails, as well as regular reassessment, but these procedures were not consistently followed for the residents involved.
Failure to Rotate Insulin Injection Sites Results in Medication Errors
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors by not rotating subcutaneous insulin injection sites as required by physician orders, manufacturer guidelines, and professional standards. For three residents with diabetes, review of medical records and interviews with nursing staff revealed repeated administration of insulin in the same anatomical locations, despite clear orders and policies mandating site rotation. The electronic medication administration record system had the capability to track previous injection sites, yet staff did not utilize this feature to prevent repeated use of the same sites. One resident with type 2 diabetes and diabetic neuropathy received multiple insulin injections in the same abdominal quadrants over several weeks, as documented in the Location of Administration Report. Both the registered nurse and assistant director of nursing confirmed that this practice did not follow the physician's orders or facility policy, and acknowledged that it constituted a medication error. Similar findings were observed for two other residents, one with end-stage renal disease and metabolic encephalopathy, and another with severe cognitive impairment and total dependence for activities of daily living. In each case, insulin was administered repeatedly in the same areas, and staff interviews confirmed that site rotation was not performed as required. Facility policies and procedures, as well as manufacturer guidelines for both insulin aspart and insulin glargine, were reviewed and all specified the necessity of rotating injection sites to prevent adverse effects. The failure to rotate sites was consistently identified by nursing leadership and staff as a medication error, as it did not comply with physician orders, manufacturer instructions, or accepted professional standards. Documentation requirements for injection site assessment were also outlined in facility policy, but the records reviewed indicated non-compliance with these standards.
Deficiency in Drug Labeling and Secure Storage
Penalty
Summary
Drugs and biologicals in the facility were not labeled in accordance with currently accepted professional principles. Additionally, all drugs and biologicals were not stored in locked compartments, and controlled drugs were not kept in separately locked compartments as required. These actions and inactions resulted in a deficiency related to the proper labeling and secure storage of medications and biologicals within the facility.
Failure to Follow Food Procurement and Handling Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Failure to Inform of Arbitration Agreement Rights
Penalty
Summary
The facility failed to inform residents or their representatives of their choice to enter into a binding arbitration agreement and their right to refuse such an agreement. This deficiency occurred when the required information regarding the arbitration process and the option to decline participation was not communicated to the resident or their representative at the appropriate time.
Arbitration Agreements Missing Required Neutral Arbitrator and Venue Language
Penalty
Summary
The facility failed to ensure that the binding arbitration agreements for three sampled residents included the selection of a neutral arbitrator agreed upon by both parties and the selection of a venue that is convenient to both parties. During interview and record review, the Admission Coordinator stated she could not find that required verbiage in the arbitration agreements signed by Residents 23, 33, and 51. The Assistant Director of Nursing also stated the contracts should include that information so residents are properly informed and their rights are not violated when entering into a binding agreement. Resident 23 was admitted on 12/27/2024 with diagnoses including cerebral infarction, depression, and anxiety disorder. The History and Physical dated 12/27/2024 indicated the resident had the capacity to understand and make decisions. The MDS indicated the resident could make self understood, understand others, had intact cognition, and the resident and family participated in assessment and goal setting. The arbitration agreement signed by the resident on 12/27/2024 was reviewed with the Admission Coordinator, who stated the required neutral arbitrator and venue language was not present. Resident 33 was admitted on 6/28/2024 with diagnoses including psychosis, generalized anxiety disorder, and need for assistance with personal care. The H&P dated 7/2/2025 indicated the resident had the capacity to understand and make decisions, and the MDS indicated intact cognition and participation by the resident and family in care planning. Resident 51 was admitted on 12/14/2024 and readmitted on 4/12/2025 with diagnoses including visual loss in the right eye and need for assistance with personal care; the MDS indicated intact cognition and ability to communicate and understand others. For both residents, the Admission Coordinator reviewed the signed arbitration agreements and stated the required language regarding a neutral arbitrator and convenient venue could not be found.
Multiple Lapses in Infection Control and Environmental Cleanliness
Penalty
Summary
The facility failed to implement appropriate infection control practices in several key areas, as observed and documented by surveyors. In one instance, a shower room was found to be unclean, with feces, wound dressings, and a band-aid left on the floor and behind the curtain. Despite policies requiring daily cleaning and frequent visual checks, staff interviews revealed that the cleanliness of the shower room was not maintained, and this lapse was acknowledged by both the Housekeeping Director and the Assistant Director of Nursing as a risk for contamination and infection spread among residents. In the laundry area, two out of three dryer tumblers had torn door seal gaskets that were covered with tape, compromising the dryers' ability to reach and maintain proper temperatures. This issue was not reported to the Housekeeping Director until it was discovered during the survey, despite daily checks being part of the facility's maintenance protocol. The lack of timely reporting and repair of the equipment was recognized by staff as potentially leading to improperly dried linens, which could result in mold growth and increased infection risk. Additional deficiencies were observed in the use of personal protective equipment (PPE) and environmental cleanliness. One LPN failed to don gown and gloves when entering a resident's room under contact isolation for a multidrug-resistant organism, contrary to facility policy and posted signage. Another LPN did not wear a gown while repositioning a resident on Enhanced Barrier Precautions, despite clear orders and care plans requiring this for direct patient care. Furthermore, a shared bathroom trash can used by two residents was found to be dirty, stained, and possibly contaminated with feces, yet was not reported or replaced promptly by staff. These lapses in infection control practices were confirmed through interviews, observations, and review of facility policies.
Failure to Develop and Implement Comprehensive Care Plans for Multiple Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for multiple residents, resulting in deficiencies related to medication management, use of medical devices, and environmental safety. For one resident prescribed PRN lorazepam for anxiety, there was no care plan addressing monitoring for side effects or behaviors associated with the medication, despite facility policy requiring such plans for psychotropic medications. Staff interviews confirmed that the absence of a care plan for monitoring could result in the resident not being properly observed for adverse effects or behavioral changes. Another resident using lower side rails per family request did not have a timely care plan developed to reflect this intervention. The care plan was created several days after the intervention was implemented, contrary to facility expectations that care plans be developed on the day of intervention. Observations and staff interviews revealed that the use of both upper and lower side rails was not always in accordance with orders, and the lack of a timely care plan could lead to staff not being aware of the correct interventions, potentially restricting the resident's movement or causing injury. Additional deficiencies included the failure to include the use of low air loss mattresses in the care plans of two residents at risk for pressure sores, despite physician orders and the presence of these devices in their rooms. Another resident prescribed Eliquis, an anticoagulant, did not have a care plan developed for its use after a medication change, leaving staff without guidance on monitoring for side effects. The facility also failed to implement a care plan intervention for a resident at risk of falls, resulting in a cluttered environment that impeded safe access to the restroom. Lastly, a resident with a history of elopement did not have an effective care plan in place, which resulted in the resident eloping from the facility. Staff interviews indicated a lack of awareness regarding the resident's elopement risk, and handoff communication did not consistently include this information.
Failure to Rotate Insulin Injection Sites and Inadequate Resident Supervision
Penalty
Summary
Licensed nursing staff failed to provide care in accordance with professional standards for multiple residents, specifically in the administration of insulin and the management of resident safety. For three residents with diabetes, staff did not rotate subcutaneous insulin injection sites as required by physician orders, facility policy, and manufacturer guidelines. Documentation and interviews confirmed repeated use of the same injection sites, despite the availability of electronic medication administration records that could track previous injection locations. Both the RN and ADON acknowledged that this practice was inconsistent with professional standards and could lead to complications such as skin irritation and poor insulin absorption. In addition to the insulin administration deficiencies, staff failed to adequately address the safety and supervision needs of a resident at risk for elopement, aspiration, and falls. The care plan for this resident did not include comprehensive, person-centered interventions for elopement risk, and staff did not provide the ordered supervision during meals. The resident was able to leave the facility unsupervised and experienced a fall upon return. There were also failures to monitor the resident's blood pressure as ordered, to implement the facility's monitoring policy requiring checks every two hours, and to conduct shift change endorsements at the bedside as required by facility policy. The report provides detailed evidence from record reviews, interviews with nursing staff, and policy documents, all confirming that the facility did not meet professional standards of quality in these areas. The deficiencies were observed across multiple residents and involved both medication administration and resident safety protocols, with staff and leadership acknowledging the lapses during interviews.
Failure to Follow Treatment Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident's preferences and goals. This deficiency was identified through surveyor observation and review of care practices, which revealed that care provided did not align with the established orders or the expressed wishes and objectives of the resident. Specific details regarding the resident's medical history or condition at the time of the deficiency are not provided in the report.
Nursing Staff Lacked Required Competencies
Penalty
Summary
Nurses and nurse aides did not demonstrate the necessary competencies to provide care that maximizes each resident's well-being. The deficiency was identified due to a lack of appropriate skills and knowledge among nursing staff, which impacted the quality of care provided to residents. There were no specific details provided about individual residents, their medical history, or their condition at the time of the deficiency. The report focuses on the general failure of staff to meet competency requirements necessary for resident care.
Failure to Maintain Accurate and Complete Clinical Records
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for multiple residents, as required by professional standards and facility policy. In one instance, a registered nurse did not document the physician's reply on the change of condition/SBAR form after a resident experienced an unwitnessed fall. Although the physician was notified and gave an order to hold the resident's anticoagulant for three days, this information was not recorded on the form. Both the nurse and the Director of Nursing confirmed that the physician's response should have been documented, regardless of whether new orders were given, to ensure all staff were aware of the interventions provided. In another case, a resident with a tracheostomy and dependence on a ventilator had missing documentation in the respiratory therapy electronic Medication Administration Record (eMAR) for two scheduled treatments. Both the registered nurse and the respiratory therapist acknowledged that the required documentation was not completed after the treatments, as mandated by physician orders and facility policy. The Director of Nursing also confirmed that all documentation should be completed prior to staff leaving the facility to ensure accuracy and continuity of care. Additionally, a certified nursing assistant inaccurately documented the amount of food a resident consumed during lunch, recording that the resident ate 50% of the meal without verifying the tray, when in fact the food was untouched. The same resident's blood pressure was not measured as ordered every six hours; instead, a licensed vocational nurse used a previous reading for a later time slot. Furthermore, the nurse documented zero crying spells for the resident, despite reports and observations that the resident had been crying throughout the day. These actions resulted in incomplete and inaccurate information in the residents' medical records.
Failure to Obtain Proper Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents were fully informed and able to understand their health status, care, and treatments, specifically regarding the use of psychotropic medications. For one resident with diagnoses including Alzheimer's disease, dementia, and mood disorder, the informed consent documented was for Depakene Oral Solution, while the actual physician's order and administration were for Depakote Oral Tablet Delayed Release. Staff interviews confirmed that the consent form did not match the medication preparation being administered, and a new consent was not obtained when the medication form was changed. This discrepancy was acknowledged by nursing staff, who stated that a new consent should have been obtained from the resident's representative to honor the resident's right to informed consent. For another resident with insomnia and depression, the facility failed to obtain informed consent from the resident or their responsible party prior to the administration of psychotropic medications, specifically citalopram and trazodone. The resident's responsible party reported not being contacted by the facility to discuss the risks, benefits, or alternatives to these medications before they were started. Facility documentation and staff interviews confirmed that there was no record of education or consent being provided prior to the initiation of these medications. Facility policies reviewed indicated that it is the responsibility of the attending healthcare practitioner to inform the resident or their representative about the initiation, reason for use, and risks associated with psychotropic medications, and that informed consent must be obtained prior to starting such medications. The failure to follow these policies resulted in residents or their representatives not being given the opportunity to make informed decisions regarding the use of psychotropic medications.
Failure to Provide Accessible and Accurate State Survey Agency Contact Information
Penalty
Summary
The facility failed to ensure that residents were properly informed of their right to file a complaint with the State Survey Agency, and did not provide visible, readable, and accurate contact information for the agency. During a Resident Council meeting, four out of five residents stated they did not know where the State Survey Agency contact information was posted and had not been made aware of where to find it. Observations confirmed that the required contact information was either missing or posted in a manner that was not easily readable, with incorrect address and telephone number details. The Activity Director acknowledged that the information was not accessible or accurate, and that it should have been provided during monthly council meetings. Further observation with the DON confirmed that the posted contact information was not visible, easily readable, or up to date, and that the residents' right to file a complaint with the State was not honored. Review of the facility's policy and procedure indicated that residents are to be informed about their rights, including the right to communicate with outside agencies. The deficiency was identified through direct observation, resident interviews, and review of facility policy.
Failure to Ensure Safe and Homelike Environment
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a safe, clean, comfortable, and homelike environment. The report notes that the facility did not ensure residents received treatment and supports for daily living in a manner that maintained their safety and comfort. Specific details about the actions or inactions leading to this deficiency, as well as information about the residents involved, are not provided in the report.
Failure to Timely Develop and Review Care Plan
Penalty
Summary
The facility failed to develop the complete care plan within 7 days of the comprehensive assessment. The care plan was not prepared, reviewed, and revised by a team of health professionals as required. This deficiency was identified based on the review of facility records and documentation, which showed that the care planning process did not meet the specified timeline and team involvement requirements.
Failure to Prevent Unjustified Decline in ADL Abilities
Penalty
Summary
Residents experienced a loss in their ability to perform activities of daily living (ADLs) without a documented medical reason. The facility failed to ensure that residents maintained their highest practicable level of functioning in ADLs, as required, unless a decline was clinically unavoidable due to a medical condition. This deficiency was identified through surveyor observation and review of resident records, which did not provide evidence of a medical justification for the decline in ADL performance.
Failure to Provide Adequate Food and Fluids
Penalty
Summary
The facility failed to provide sufficient food and fluids to maintain a resident's health. This deficiency was identified by surveyors based on observations and records indicating that the nutritional and hydration needs of at least one resident were not adequately met. The report specifically notes the lack of provision of adequate food and fluids necessary for the resident's health maintenance.
Failure to Maintain Safe Oxygen Tubing Practices
Penalty
Summary
Facility staff failed to provide safe and appropriate respiratory care to a resident who required continuous oxygen therapy. During an observation, the resident's oxygen tubing via nasal cannula was found touching the floor, and the date on the tubing was illegible. Interviews with a CNA, RN, and the Assistant Director of Nursing confirmed that the tubing should not have been in contact with the floor due to infection control concerns, and that all staff were responsible for ensuring proper handling and labeling of the tubing. The facility's policy required oxygen tubing to be labeled with the date it was last changed, and for infection control practices to be followed to prevent the spread of infection. The resident involved had a history of sepsis, pneumonitis, and COPD, and was cognitively intact and able to make decisions regarding activities of daily living. Medical records indicated an order for oxygen administration via nasal cannula, with instructions to change the tubing as needed when soiled. Despite these orders and facility policies, the tubing was not properly maintained, leading to a deficiency in respiratory care and infection control practices.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Accurately Account for and Timely Administer Medications
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not ensuring accurate accounting and administration of medications for two residents. In one instance, a discrepancy was found during an inspection of a medication cart, where the controlled drug record for oxycodone 10 mg indicated two doses remaining, but only one dose was present in the medication card for a resident. The registered nurse on duty admitted to administering the missing dose earlier in the day but failed to document it immediately on the controlled drug record, citing divided attention due to supervisory responsibilities. In another case, a resident with multiple diagnoses, including aphasia, dysphagia, hypertension, anxiety, depression, and a history of seizures, did not receive several scheduled medications on time. The medication administration audit revealed that five different medications, including atenolol, docusate sodium, Zoloft, Keppra, and clonazepam, were administered nearly four hours late. The licensed vocational nurse responsible for administering these medications confirmed the delay and acknowledged that such late administration could impact the resident's health, especially for medications related to blood pressure, seizures, and mental health. Interviews with both the nurse and the director of nursing confirmed that facility policy requires timely administration and documentation of medications, as well as necessary pre-administration monitoring such as checking vital signs. The director of nursing reviewed the medication administration record and confirmed the delay, noting that staff are required to document medication administration immediately after giving the medication, in accordance with facility policy.
Late Submission of Quarterly MDS Assessment
Penalty
Summary
The facility failed to complete and submit a Quarterly Minimum Data Set (MDS) assessment within the required timeframe for one resident. The resident was originally admitted with diagnoses including urinary tract infection, generalized muscle weakness, and dysphagia, and was later readmitted. Review of the resident's records showed that the Quarterly MDS assessment had an Assessment Reference Date (ARD) of 4/24/2025 but was not submitted until 5/8/2025, which was the 93rd day, exceeding the 92-day requirement. The Director of MDS confirmed that the assessment was completed late and acknowledged the use of an MDS Scheduler to track due dates, which provides warnings for overdue assessments. Interviews with the Director of MDS and the Director of Nursing confirmed that timely completion and submission of MDS assessments are necessary for accurate quarterly reviews, care planning, and billing. Both staff members stated that late completion or submission of MDS assessments could result in delays in care, especially if there are significant changes in a resident's condition. Review of facility policy and the CMS Resident Assessment Instrument Manual confirmed the requirement for quarterly MDS assessments to be completed within 92 days of the previous assessment.
Late Submission of MDS Assessment Data
Penalty
Summary
The facility failed to ensure timely transmission of the Minimum Data Set (MDS) assessment data to the Centers for Medicare and Medicaid Services (CMS) for one resident. Specifically, the admission MDS for a resident with diagnoses including type 2 diabetes mellitus with foot ulcer, encephalopathy, and generalized muscle weakness was completed with an Assessment Reference Date (ARD) of 2/12/2025 but was not submitted to CMS until 2/26/2025, which was beyond the required 14-day timeframe. The Director of MDS confirmed that the assessment was submitted late and acknowledged that the MDS Scheduler is used to track due dates, and that the system provides warnings for overdue assessments. Interviews with the Director of MDS and the Director of Nursing confirmed that timely completion and submission of MDS assessments are necessary for accurate quarterly reviews, care planning, and billing. The facility's policy and procedures, as well as the CMS Resident Assessment Instrument Manual, require assessments to be completed and submitted within specific timeframes. The late submission of the MDS assessment was verified through review of the CMS Final Validation Reports and facility records.
Failure to Secure and Cover Feeding Tube Tip After Disconnection
Penalty
Summary
A deficiency occurred when staff failed to secure and cover the feeding tube tip with a cap after disconnecting it from a resident who was receiving enteral feeding. During an observation, the disconnected feeding tube tip was found lying on the floor, uncovered and exposed to the environment. The registered nurse present confirmed that the tube should have been covered with a cap and secured on the pump when not in use, in accordance with facility policy and best practices to prevent infection. The resident involved had a history of gastrostomy, dysphagia, tracheostomy, and traumatic brain injury, and was assessed as having severely impaired cognitive functioning, requiring total assistance with all activities of daily living. The care plan identified risks including infection at the gastrostomy tube site, and the physician's orders specified the use of tube feeding. Facility policy required that enteral feeding safety precautions be followed, including keeping the tube covered when not in use, but this was not done in this instance.
Failure to Implement Infection Prevention Policy Due to Mice Infestation
Penalty
Summary
The facility failed to implement its infection prevention policy by not preventing the presence of mice in residential rooms occupied by four residents. The deficiency was identified through interviews and record reviews, revealing that mice were found in rooms occupied by residents with various medical conditions, including hypertension, anxiety disorder, major depressive disorder, heart failure, and mobility issues. The presence of mice was reported by visitors and confirmed by the Maintenance Supervisor, who captured mice in the affected rooms. The facility's policies on pest control and infection prevention, last revised in 2008 and 2023 respectively, were not effectively implemented, as evidenced by the presence of mice. The Infection Control Nurse acknowledged that pests should not be inside the facility due to the potential for disease transmission. The facility's pest control policy states that the building should be kept free of insects and rodents, and the infection prevention program aims to maintain a safe and sanitary environment to prevent communicable diseases. However, the presence of mice indicates a failure to adhere to these policies.
Facility Fails to Prevent Mice Infestation in Resident Rooms
Penalty
Summary
The facility failed to maintain a safe, sanitary, and comfortable environment by allowing the presence of mice in residential rooms occupied by four residents. The deficiency was identified through interviews and record reviews, revealing that mice were found in rooms occupied by residents with various medical conditions, including hypertension, anxiety disorder, major depressive disorder, and heart failure. The presence of mice was confirmed by both staff and visitors, indicating a breach in maintaining a homelike environment. Interviews with facility staff, including a Certified Nurse Assistant and the Maintenance Supervisor, confirmed the presence of mice in the residents' rooms. The Maintenance Supervisor provided photographic evidence of mice captured in the rooms, further substantiating the issue. The Infection Control Nurse acknowledged that pests should not be present in the facility due to the potential health risks they pose, including the transmission of diseases. The facility's policies and procedures, including those related to pest control, maintenance, and infection prevention, were reviewed. These policies emphasize the importance of maintaining a pest-free environment to ensure the safety and well-being of residents, staff, and visitors. Despite these policies, the facility failed to prevent the infestation, leading to unsanitary and uncomfortable living conditions for the affected residents.
Deficient Pest Control Program Leads to Mice Infestation
Penalty
Summary
The facility failed to implement an effective pest control program, resulting in the presence of mice in residential rooms occupied by four residents. The deficiency was identified through interviews and record reviews, revealing that mice were found in rooms occupied by residents with various medical conditions, including hypertension, anxiety disorder, major depressive disorder, heart failure, and mobility issues. The presence of mice was confirmed by both staff and visitors, with photographic evidence provided by the Maintenance Supervisor. Interviews with facility staff, including a Certified Nurse Assistant, the Maintenance Supervisor, and the Infection Control Nurse, highlighted the issue of mice being caught in the facility. The Maintenance Supervisor confirmed the capture of multiple mice in the affected rooms, and the Infection Control Nurse emphasized the potential health risks posed by mice, such as disease transmission and property damage. The facility's pest control policy, last revised in 2008, stated the importance of maintaining a pest-free environment, but the presence of mice indicated a failure to adhere to this policy.
Failure to Ensure Call Lights Within Reach
Penalty
Summary
The facility failed to ensure that pad call lights were within reach for three out of five sampled residents during random observations. Resident 3, who was non-verbal, non-communicative, and had severely impaired cognition, was observed with the pad call light placed on the left uppermost part of the bed, out of reach. The resident required total assistance with all activities of daily living and was at high risk for falls. The facility's policy indicated that call lights should be within reach, but this was not adhered to, as confirmed by the Registered Nurse and the Director of Nursing. Similarly, Resident 40, who had severely impaired cognition and required total assistance, was observed with the call light not within reach. The resident was unable to move, and the call light was placed on the left side of the bed, not touching any part of the resident's body. The facility's policy and care plan for Resident 40 also required the call light to be within reach, but this was not followed, as noted by the Registered Nurse and the Director of Nursing. Resident 89, who had severely impaired cognition and required total assistance, was also observed with the call light not within reach. The resident's call light was placed on the left side of the bed, and the resident could not move to reach it. The facility's policy and care plan for Resident 89 required the call light to be within reach, but this was not implemented. Additionally, Resident 19, who required substantial assistance and had mild cognitive impairment, was found with the call light attached to the far side of the bed, out of reach. The Certified Nursing Assistant confirmed that the call light should have been placed within reach, as per the facility's policy.
Deficiencies in Homelike Environment and Resident Care
Penalty
Summary
The facility failed to provide a homelike environment for several residents, leading to deficiencies in their care. For one resident, the bathroom flooring under the shower chair was in disrepair, causing instability and potential risk of injury. Despite the resident and a Licensed Vocational Nurse (LVN) identifying the issue, it was not reported to the Maintenance Supervisor in a timely manner, resulting in the flooring remaining broken and unsafe for use. Another deficiency involved two residents who were not provided with flat sheets on their pressure-reducing mattresses, leading to direct contact with the plastic mattress covers. This was against the facility's policy, which required a flat sheet to be placed over the mattress. The lack of a sheet was attributed to a misunderstanding of the facility's policy on layering, which limited the number of layers on the mattress to two, including incontinence briefs and pads. This oversight resulted in an uncomfortable and non-homelike environment for the residents. Additionally, the facility failed to maintain the cleanliness of a resident's desk fan, which was observed to be dusty. The housekeeping department was responsible for cleaning such equipment, but the fan had not been cleaned as part of the monthly deep cleaning schedule. This lack of cleanliness was noted to potentially affect the resident's dignity and quality of life, as well as pose an infection control risk.
Failure to Obtain Proper Authorization for Restraint Use
Penalty
Summary
The facility failed to ensure that residents were free from the use of physical restraints unless needed for medical treatment, as evidenced by the lack of physician's orders, assessments, and informed consents for the use of restraints on five residents. For Resident 37, pillows were placed under the mattress and bed rails were used without proper authorization or assessment, despite the resident's inability to make decisions and a history of attempting to jump out of bed. The facility's staff and family members were involved in placing these restraints, but no formal consent or assessment was documented. Resident 46, who was diagnosed with quadriplegia and other conditions, had all four side rails raised without a physician's order, consent, or assessment for bed entrapment. This was contrary to the facility's policy, which requires such documentation to ensure the safety and rights of the resident. Similarly, Resident 79 had all side rails raised without the necessary orders and consents, despite having a history of falls and expressing discomfort with the restraints. Resident 63 was found with bilateral hand mittens applied too tightly, contrary to the physician's order for a right hand mitten only. This improper application posed risks of poor circulation and skin breakdown. Lastly, Resident 73 had all four side rails raised, which was not in accordance with the physician's order for only bilateral upper half side rails. These deficiencies highlight the facility's failure to adhere to its own policies and procedures regarding the use of physical restraints, potentially compromising resident safety and dignity.
Failure to Rotate Injection Sites for Insulin and Anticoagulant Administration
Penalty
Summary
The facility failed to adhere to professional standards of care by not rotating subcutaneous injection sites for insulin and anticoagulant administration for several residents. This deficiency was identified during interviews and record reviews, revealing that insulin and anticoagulant injections were repeatedly administered in the same areas, contrary to the facility's policy and manufacturer guidelines. The failure to rotate injection sites was observed in four residents receiving insulin and one resident receiving anticoagulant therapy, increasing the risk of adverse effects such as lipodystrophy and bruising. Resident 61, who was admitted with type 2 diabetes mellitus and other conditions, had multiple instances where insulin was administered without site rotation, as confirmed by a review of the Location of Administration Report. Similarly, Resident 60, who was on insulin and anticoagulant therapy, also had instances of non-rotated injection sites. Interviews with the RN and DON confirmed that the licensed nurses did not follow the expected practice of rotating injection sites, which is crucial to prevent skin complications. Further review of the facility's policies and manufacturer guidelines emphasized the importance of rotating injection sites to prevent skin abnormalities. Despite these guidelines, the MARs for Residents 24, 43, and 85 showed multiple instances of non-rotated insulin administration sites. The DON acknowledged that the failure to rotate injection sites could lead to skin abnormalities, such as lumps or thickened skin, and confirmed that several licensed nurses did not adhere to the standard practice, placing the residents at risk of harm.
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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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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near North Hollywood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Four Seasons Healthcare & Wellness Center, Lp | 0.9 mi | ★★★★★ | 21 | 0 |
| Valley Village Care Center | 2.1 mi | ★★★★★ | 27 | 0 |
| Studio City Rehabilitation Center | 2.1 mi | ★★★★★ | 45 | 0 |
| Imperial Care Center | 2.1 mi | ★★★★★ | 4 | 0 |
| Sherman Oaks Health & Rehab | 2.3 mi | ★★★★★ | 3 | 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.