Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Shoreline Care Center during CMS and state inspections, most recent first.
Staff failed to knock and announce before entering a resident's room, as a MA entered the room while the resident was lying in bed without obtaining permission to enter. The MA said he usually enters if the door is open and does not always knock when he is there to do something quickly. The DON and DSD stated that all staff are expected to knock before entering residents' rooms, and the facility policy requires staff to knock before entering a resident's room.
A resident’s PASRR-IDR recommended specialized services for psychotherapy/counseling, but the service was not being provided. During record review and interview with the DON, it was confirmed that facility social services staff are not licensed mental health professionals and that the recommended mental health service had not been implemented.
Care plans for two residents did not address psychosocial needs appropriately. One resident was observed anxious, tearful, and repeatedly stating, "I don't want to die," while the CP included a psych consult that was not completed and an antidepressant monitoring intervention that did not apply. Another resident with schizophrenia had a PASRR recommendation for psychotherapy/counseling, but the CP did not incorporate that service and used vague interventions that did not specify the medication, behaviors, or documentation frequency.
Failure to revise smoking care plan after reassessment: A resident’s care plan was not reviewed and updated by the IDT after a smoking policy assessment. Staff observed a lighter on the resident’s bedside table, and when an LPN addressed it, the resident became belligerent and yelled at staff. Records showed social services reviewed the smoking policy with the resident, who refused to sign it, but the smoking care plan was not reviewed at the last IDT meeting.
Failure to complete hearing referral for a resident with hearing impairment. A resident with a physician order for hearing consultation reported difficulty hearing and needing a hearing aid, but staff had not completed follow-up or documented a referral. SS stated it was responsible for following up on hearing consultations, and the DON confirmed no referral had been completed; the facility also did not provide hearing amplifiers for new residents with hearing loss.
A resident who refused to sign the smoking policy was found with a lighter on his bedside table, even though the facility policy required smoking materials to be secured when a resident could not safely store them or comply with the policy. An LPN observed the lighter in the room and said it should not have been there. Review of the care plan, IDT care plan review, and SS notes showed the resident's smoking safety evaluation was not marked, the smoking care plan was not reviewed at the last IDT meeting, and the resident had refused to sign the smoking policy.
Infection Control Lapses With Foley Bag Contact and Outdated Refrigerated Food: A resident with a Foley catheter was observed with the urine collection bag inside a dignity bag whose bottom was touching the floor, and the WCN and DON agreed it should not have been in contact with the floor. In the kitchen, multiple food and liquid items were found in refrigerators past their use-by dates, and the DAS acknowledged they should have been discarded.
Medication refrigerators in the North Station med room were not maintained in safe working condition: the fridge read 40 degrees Fahrenheit, the freezer had no thermometer, and the freezer was defrosting with water dripping onto damp medication packaging, a rusted metal box, and pooled water in an insulin container. An LN confirmed the findings, while the ESD said he was unaware the unit was defective and the DON stated the refrigerator was the facility's property. The kitchen ice machine also showed yellowish residue and black speckles in the ice; the DAS and ES staff validated the findings, and ES stated the machine was cleaned monthly with Nugon.
The facility failed to consistently enforce its own English‑only communication policy intended to protect resident dignity and ensure clear communication. Several CNAs and a hospitality aide reported that some staff were told not to speak their native language and complied, while others continued to do so in front of staff and residents without corrective action, and that staff of certain backgrounds appeared to receive preferential treatment in scheduling and assignments. Some residents stated they were not bothered by staff speaking other languages, but a resident reported feeling extremely bothered and anxious when staff spoke in a language they could not understand, believing staff might be speaking negatively about others, and stated that this concern had persisted for years despite repeated requests that staff speak English.
A resident with dementia and other comorbidities fell while attempting an unassisted transfer, after which an RN obtained a verbal physician order for a hip and sacrum x‑ray and PRN Tylenol. The nurse documented the fall and family notification but did not transcribe the x‑ray order into the EHR, complete a requisition, or contact the diagnostic company, and no other staff implemented the order. Record review confirmed no x‑ray order or results, and leadership later identified the omission when the resident began complaining of hip pain during transfers. The resident was then sent to the ED, where an intertrochanteric right hip fracture was diagnosed, demonstrating a failure to follow physician orders and facility policies for post‑fall diagnostics.
A resident on hospice with severe cognitive impairment and multiple comorbidities had an unwitnessed fall with subsequent complaints of left hip pain. Although initial documentation noted no swelling, slight swelling of the left hip was observed several days later and reported to nursing, and an x‑ray was obtained after a physician order. However, nursing staff did not initiate a new electronic COC, did not document the responsible party’s refusal for hospital transfer, and did not complete the required 72‑hour follow‑up assessments and documentation in PCC, resulting in a lack of documented monitoring of the resident’s swollen hip as required by facility policy and professional standards.
A resident on hospice care with vascular dementia, anemia, physical debility, and COPD had multiple physician orders for morphine sulfate oral solution for severe pain, each specifying that the dose be held if the respiratory rate (RR) was less than 12. Medication Administration Records showed that morphine was given on numerous occasions under both PRN and scheduled orders, but there was no documentation that RR was obtained prior to administration. During interviews, an LN, the ADON, and the DON all confirmed that RR should have been checked and documented before giving morphine and acknowledged that this documentation was missing.
A resident with Alzheimer's disease, psychosis, and depression had multiple documented episodes of hallucinations and was prescribed antipsychotic medication for these symptoms. However, the MDS assessment did not reflect the presence of hallucinations, despite supporting evidence in the resident's records and acknowledgment by the Health Information Manager that the assessment was inaccurate.
A resident was not readmitted after a hospital transfer for medication adjustment, despite being told a bed would be held. Facility staff did not document which needs could not be met or what attempts were made to meet those needs, and key sections of the discharge notice were left blank. The administrator later cited behavioral issues as the reason for declining readmission, but this was not reflected in the official records or physician summary.
Two residents and their representatives were not provided with required written bed-hold notifications upon transfer to hospitals, and one responsible person was not given information about private pay or reserve bed-payment requirements. Staff interviews and record reviews confirmed that the necessary documentation was incomplete or missing at the time of transfer, contrary to facility policy.
A resident with multiple medical and psychiatric conditions was physically abused by another resident with a history of aggressive outbursts, resulting in bruising. Despite a psychiatrist's recommendation for 1:1 staffing, both residents were observed together without supervision, and the facility failed to implement protective measures as outlined in its abuse prevention policy.
A resident with a history of schizophrenia and psychosis began refusing psychiatric medications, leading to escalating psychosis, aggression, and multiple incidents of harm and fire-setting. Despite these significant changes, the IDT did not initiate a Significant Change in Status Assessment or conduct required interdisciplinary reviews, as confirmed by staff interviews and record review.
A resident's admission MDS was completed with inaccurate information, including incorrect responses regarding fall history and the inclusion of schizophrenia as an active diagnosis without supporting documentation. The MDS Coordinator and DON confirmed that the documentation did not support these entries, and the errors were identified through interviews and record review.
A resident with psychosis, schizophrenia, and bilateral heel fractures did not receive care in accordance with their person-centered care plan, as male staff were assigned for 1:1 ADL assistance despite a directive for female staff only. Additionally, after the resident's left foot was placed in a non-weight bearing immobilizer cast, the care plan was not updated to include protocols for cast care or circulatory monitoring.
A resident with multiple respiratory and mental health diagnoses had a nebulizer and oxygen tubing that were not dated or properly stored, contrary to facility policy. A nurse confirmed the equipment should have been dated and stored in a plastic bag, but it was left on the bedside table without proper labeling or containment.
Surveyors found the South Side dining room in unsanitary and unsafe condition, including a dirty container with fruit flies under a nonfunctional sink, a trash can surrounded by flies, dirty walls with food particles, exposed plumbing, cracked floor tiles, and stained floors. Staff confirmed these issues, and there was no documentation of regular floor cleaning or maintenance, in violation of facility policies and infection control standards.
A resident with dementia and a history of falls experienced an unwitnessed fall resulting in a left hip fracture. The incident was reported internally to nursing staff and the DON, but not to the Department within the required 48-hour period, delaying external investigation.
A resident's hearing aid filter was not changed as scheduled according to instructions from an outside clinic. The filter change was delayed because staff were unaware of the care instructions until the resident's responsible party requested the change, and the facility could not provide documentation of when the instructions were received.
A resident suspected of having scabies was not placed on required isolation precautions upon return from a dermatology visit, and there was no documentation of enhanced barrier precautions. The Infection Preventionist did not develop a contact identification list, and nursing staff had not received training on recognizing or reporting scabies symptoms, in violation of the facility's infection control protocol.
A resident with diabetes mellitus received incorrect doses of insulin on two occasions, as nursing staff failed to follow physician orders for insulin administration. The resident's care plan required specific doses of Novolog insulin based on blood sugar levels, but the staff administered lower doses than prescribed. The facility's DON and HIM confirmed the discrepancies and lacked documentation of physician notification or response.
A resident with end-stage renal disease and diabetes missed multiple doses of prescribed medications due to being offsite for dialysis, without the facility notifying the physician or adjusting administration times. The resident also did not receive the full schedule of ordered physical therapy sessions, and there was a delay in implementing a physician's order for weight-bearing therapy due to an order discrepancy.
A facility failed to maintain complete medical records for a resident during an IDT admission assessment. The assessment form was incomplete, missing critical sections such as diagnosis, high-risk medications, and functional status. The DON acknowledged the oversight. The facility's policy requires comprehensive assessments within 72 hours of admission, which was not met in this case.
A resident with dementia and anxiety was not properly assessed for elopement risk and did not receive adequate supervision or medication management, leading to their unsupervised exit from the facility and subsequent fatal accident on a busy street.
A facility failed to accurately complete an MDS Assessment for a resident with dementia, resulting in an incorrect elopement risk assessment. The resident had an incident of following a visitor outside, but the Nurse Supervisor did not review the resident's history or other staff input before concluding the resident was not at risk. Additionally, the Social Services Assistant did not check the MAR for behavior monitoring, missing documented episodes of anxiety and paranoia.
A facility failed to implement a behavioral care plan for a resident with dementia, resulting in increased aggression, anxiety, and paranoia. Despite multiple episodes, staff did not document non-pharmacological interventions or administer prescribed anti-anxiety medication. Interviews revealed a lack of communication with the physician or psychiatrist about the resident's behavior, contrary to the facility's care coordination policy.
The facility failed to maintain a clean and homelike environment in two shower rooms, where clean razors were improperly stored on dirty sharps containers, and broken floor tiles were observed. The Health Information Manager confirmed these issues, which were contrary to the facility's policy on maintaining a safe and comfortable environment.
The facility failed to maintain food safety and sanitation standards, with issues including unclean food preparation equipment, undated and unlabeled leftovers, improper thawing of raw meat, and inadequate use of gloves and hair restraints. The Manager of Dietary cited short staffing as a challenge in maintaining cleanliness, while the Registered Dietitian and Executive Director emphasized the importance of adhering to food safety protocols.
The facility failed to properly dispose of garbage and refuse, with dumpster lids left open and trash overflowing, affecting all 171 residents. Despite staff acknowledging the issue and daily cleaning efforts, the problem persisted, posing potential infection control and rodent infestation risks.
A resident with severe cognitive impairment and a history of aggressive behavior was involved in multiple incidents of physical abuse against other residents. Despite the facility's policy to monitor and intervene, the resident's care plan interventions were not effectively implemented, leading to altercations. Staff were aware of the resident's behavior but failed to prevent further incidents, highlighting a deficiency in protecting residents from abuse.
The facility failed to ensure accurate Level I PASRR screenings for three residents with mental disorders or intellectual disabilities. One resident was admitted with psychosis and depression, but their screening inaccurately indicated no serious mental illness. Another resident with schizophrenia and anxiety disorder also had an inaccurate screening. A third resident's screening indicated an exempted hospital discharge, but a new screening was not submitted after the 30-day exemption period. The DON acknowledged the inaccuracies and the need for proper screenings.
The facility failed to serve meals according to planned recipes for residents on pureed diets, affecting 22 residents. Staff pureed plain beef instead of beef stew, used breadcrumbs instead of sliced bread, and served applesauce instead of pureed baked apple slices. The Manager of Dietary noted staff felt overwhelmed and opted for easier methods, while the RD confirmed staff training on recipe adherence.
A resident received psychological services without a physician's order, as confirmed by the Health Information Manager and the Director of Nursing. The facility's policy mandates a physician's order for such services, which was not obtained, leading to a deficiency.
A facility failed to follow physician orders for a resident's wound care, missing documentation for Hydrogel application on two occasions. The resident had an unstageable pressure ulcer, Type Two Diabetes, and mobility issues, which could complicate healing. The facility's policy required adherence to physician orders, but the Health Information Manager confirmed the missing entries and lack of records to show compliance.
A resident missed doses of Lacosamide due to the facility's failure to reorder the medication timely, as per policy. The resident, with a seizure diagnosis, was at risk due to missed doses. Staff interviews revealed a lack of clear processes for ordering and tracking medication refills, leading to oversight and delay in pharmacy delivery.
A facility failed to maintain a resident's room and restroom in a clean and homelike manner. The room had walls in disrepair with scrapes and missing paint, and the restroom's hand sanitizing dispenser was missing a front cover. These issues were not reported by staff or logged for maintenance, contrary to the facility's policy requiring immediate reporting of such issues.
Staff Entered Resident Room Without Knocking
Penalty
Summary
The facility failed to ensure staff knocked and announced their presence before entering a resident's room for one of six sampled residents, Resident 5. During an observation on 4/21/26 at 11:02 a.m., the Maintenance Assistant entered room [ROOM NUMBER] without knocking on the door or announcing presence. Resident 5 was observed lying in bed, and the Maintenance Assistant went into the room without obtaining permission to enter. During an interview on 4/21/26 at 11:05 a.m., the Maintenance Assistant stated that he usually enters if the door is open and does not always knock because he is just there to do something quickly. The Director of Nursing stated on 4/22/26 that the facility expectation is for all staff to knock and announce themselves prior to entering residents' rooms to promote resident dignity and privacy. The Director of Staff Development stated on 4/23/26 that all staff should knock before entering residents' rooms. The facility policy stated that all residents be treated with kindness, dignity, and respect, and that staff members shall knock before entering the resident's room.
PASRR Recommended Psychotherapy/Counseling Not Provided
Penalty
Summary
The facility failed to ensure that Resident 26’s PASRR Individualized Determination Report recommended specialized services for psychotherapy/counseling were implemented. During record review and interview with the DON, the resident’s PASRR-IDR dated 1/4/22 was reviewed and showed a recommendation for specialized services of psychotherapy/counseling, defined as individual and/or group and/or family treatment provided by a licensed mental health professional. The DON stated that the facility social services staff is not a licensed mental health professional and further stated that the recommended service was not being provided.
Care plans lacked implemented and measurable interventions for psychosocial needs
Penalty
Summary
Resident 51 had a comprehensive care plan for being at risk for depression related to admission, but the plan included interventions that were not carried out or were not applicable to the resident. During observation, Resident 51 was in bed wearing a hospital gown, anxious, tearful, and repeatedly stated, "I don't want to die." The MDS comprehensive assessment documented little interest or pleasure in doing things nearly every day, feeling down, depressed, or hopeless half or more of the days, trouble falling or staying asleep half or more of the days, and feeling bad about self or being a failure nearly every day. The care plan directed staff to arrange a psychiatric consult and observe for side effects of antidepressant medication, but medical records showed no evidence of a psychiatric consultation and no order for an antidepressant. The Director of Social Services stated the psychiatric consultation intervention was not followed and the antidepressant side-effect intervention did not apply to Resident 51. Resident 26 had a PASRR-IDR that recommended specialized services of psychotherapy/counseling, including individual, group, and/or family treatment by a licensed mental health professional. The resident's care plan for potential behavior problems related to schizophrenia and auditory or visual hallucinations included interventions to administer medications as ordered, monitor and document side effects and effectiveness, and document behaviors. During review, the DON stated social services is not a licensed mental health professional, the PASRR recommended service was not incorporated into the care plan, and the interventions did not identify which medication was to be administered or monitored, what behaviors were to be documented or monitored, or the frequency of documenting.
Failure to Revise Smoking Care Plan After Reassessment
Penalty
Summary
The facility failed to ensure that Resident 133’s care plan was reviewed and revised by the interdisciplinary team after an assessment of the resident’s ability to comply with the facility smoking policy. The facility’s policy stated that if the IDT determined a resident could not safely store smoking materials, the smoking products were to be kept in a secured cabinet accessible only to staff, and smoking residents were to be reassessed quarterly or with any significant change in condition. However, the resident’s care plan still directed staff to conduct a smoking safety evaluation on admission and as needed, and no revisions were made after the smoking policy review. During a concurrent observation, a green lighter was seen on Resident 133’s bedside table, and the resident stated it belonged to him and that he used it when he smoked. A licensed nurse also observed the lighter on the bedside table and stated it should not be there. When the nurse addressed the issue, Resident 133 became belligerent and yelled at the nurse to leave his belongings alone. The record showed social services met with the resident to review the smoking policy, and the resident refused to sign it, but the smoking care plan was not reviewed at the last IDT meeting; the Director of Social Services stated, "I think it fell through the cracks."
Failure to Complete Hearing Referral for Resident with Hearing Impairment
Penalty
Summary
The facility failed to ensure an appropriate audiology referral was implemented for one resident with hearing impairment. Resident 136 was admitted with diagnoses including muscle weakness, gastrostomy tube dependence, and type 2 diabetes mellitus, and the MDS documented a BIMS score of 15, indicating cognitive intactness. The resident stated during interview that he had difficulty hearing and needed a hearing aid, and reported that he had informed facility staff of the problem but no action had been taken. The physician orders included a hearing consultation with follow-up treatments as indicated, and the social services assessment noted that the resident had no hearing aids but was sometimes hard to hear. Social services stated that when a resident reports hearing problems and there is a physician order for a hearing consultation, the department is responsible for following up with the resident regarding the consultation. The DON confirmed that follow-up was required when a resident reported difficulty hearing and stated there was no documentation to support that a follow-up or referral had been completed for Resident 136. The DON also stated that the facility does not provide hearing amplifiers for a new resident experiencing hearing loss.
Smoking Materials Left Accessible Despite Policy Refusal
Penalty
Summary
The facility failed to ensure that one sampled resident was restricted from smoking privileges after refusing to comply with the facility smoking policy requiring the resident to store a cigarette lighter in a secure box. During observation, the resident had a green lighter on the bedside table and stated it belonged to him and that he used it when he smoked. A licensed nurse observed the lighter in the room and stated it should not have been there. The resident became belligerent and yelled at the nurse, "Leave my fucking stuff alone." Review of the facility smoking policy stated that if the IDT determined a resident was unable to safely store smoking materials or required supervision to smoke safely, smoking products were to be kept in a secured cabinet accessible only to staff, with quarterly reassessment of the resident's ability to smoke safely and comply with the policy. The Director of Social Services stated a message had been seen about the resident refusing to sign the last smoking policy review and that the resident's smoking care plan was not reviewed at the last IDT meeting, adding, "I think it fell through the cracks." The resident's care plan identified him as at risk for injury due to smoking and included a smoking safety evaluation on admission and PRN, but no revisions were made. The IDT care plan review indicated the smoking safety evaluation was not marked, and a progress note documented that social services met with the resident to review the smoking policy and that the resident refused to sign it.
Infection Control Lapses With Foley Bag Contact and Outdated Refrigerated Food
Penalty
Summary
Provide and implement an infection prevention and control program was cited after observation, interview, and record review showed two infection control failures. For Resident 140, who had a Foley catheter, the urine collection bag was placed inside a dignity bag with the bottom of the dignity bag in contact with the floor while the resident was lying in bed. During interview, the Wound Care Nurse and the DON both reviewed the picture of the bag touching the floor and agreed that it should not have been in contact with the floor. The facility policy on catheter care stated it was intended to promote hygiene, comfort, and decrease risk of infection for catheterized residents, and the referenced guidance stated the bag should not be permitted to touch the floor to prevent urinary tract infection. In a separate kitchen observation, multiple food and liquid items were found stored in the refrigerators with use-by dates ranging from 4/17/26 through 4/20/26. The Dietary Assistant Supervisor acknowledged the items were past their use-by dates and stated they should not have remained in the refrigerators and should have been discarded. The facility policy on labeling and dating of foods stated the use-by date is the absolute date by which the food must be consumed or discarded by the facility.
Equipment Maintenance and Sanitation Deficiencies
Penalty
Summary
Medication refrigerators in the North Station medication room were not maintained in safe working condition. During observation, the refrigerator thermometer read 40 degrees Fahrenheit, and there was no thermometer in the freezer to record freezer temperature. The freezer compartment at the top of the refrigerator was defrosting, with water dripping down and accumulating on medications stored in the lower section. The medication packaging appeared saturated and damp, a black metal box had rust on its handle hinges, and water was pooled inside the insulin medication container. An LN inspected the unit and confirmed the freezer was defrosting even though the temperature was within range and acknowledged the damp packaging, rust, and pooled water. The ESD stated he was not aware the refrigerator was defective and said he believed it belonged to the pharmacy, while the DON stated the refrigerator was the facility's property and that the ESD had been misinformed. The kitchen ice machine was also not maintained in safe and sanitary working condition. During observation of the ice dispenser in the side room kitchen area, a white tissue test on the lower stainless steel bin showed a moderate amount of yellowish residue, and the ice inside the machine was observed to contain black speckles. The DAS and ES staff were present and validated these findings. ES stated the ice machine was cleaned monthly and sanitized with Nugon by pouring it into the dispenser to flush the system, and said all ice was removed and the interior cleaned during the procedure, but did not know why the dispenser was dirty. The manufacturer's manual stated it was the user's responsibility to keep the ice machine and ice storage bin sanitary and that the machine required occasional cleaning of its water systems with a specifically designed chemical.
Failure to Enforce English‑Only Communication Policy Affecting Resident Dignity and Communication
Penalty
Summary
The deficiency involves the facility’s failure to follow its own “Official Language Designation” policy, which requires all employees on duty to speak English as the official company language in order to respect and protect residents’ dignity and rights to communicate and be communicated with in their own language, and to reduce tension and anxiety among residents and staff. Multiple staff interviews revealed that some employees were instructed not to speak their native language in the presence of others and complied, while other staff continued to speak their native language in front of staff and residents without corrective action. Staff also reported perceptions that employees of certain descent or backgrounds received preferential treatment in areas such as shift assignments, vacation scheduling, and call‑offs, and that residents had voiced discomfort about staff conversations occurring in languages they could not understand. Resident interviews showed differing reactions to staff speaking other languages. One resident stated that staff speaking in other languages did not bother them and that they were accustomed to hearing multiple languages. Another resident reported that it was extremely bothersome when staff spoke in a language they did not understand, expressing anxiety and concern that staff might be speaking negatively about other residents. This resident stated they had repeatedly asked staff to speak in English to ensure understanding and that this concern had persisted over a five‑year stay despite multiple requests. A third resident also reported not being bothered by staff speaking other languages, noting that this had been common throughout their life in California. These observations and interviews demonstrate that the facility did not consistently enforce its English‑only communication policy as written, despite resident reports of discomfort and repeated requests for communication in English.
Failure to Implement Physician-Ordered X-Ray After Resident Fall
Penalty
Summary
The facility failed to ensure that services met professional standards of quality when nursing staff did not transcribe and implement a physician’s x‑ray order following a resident’s fall. The resident, who had anemia, dementia, depression, and anxiety and a BIMS score indicating severe cognitive impairment, experienced a fall onto her bottom while attempting an unassisted transfer from bed to wheelchair. A licensed nurse notified the physician and received verbal orders for a hip and sacrum x‑ray and PRN Tylenol for pain, and documented leaving a message for the resident’s daughter about the fall and the new x‑ray order. However, the x‑ray order was never entered into the electronic health record, no paper requisition was completed, and the diagnostic company was not contacted, contrary to facility policy requiring that personnel receiving verbal or telephone orders transcribe them into the system. Record review confirmed there were no x‑ray orders or results in the resident’s chart following the fall. The licensed nurse later acknowledged she did not transcribe the order or call the diagnostic company and that the x‑ray was never done. The RN supervisor confirmed the absence of x‑ray results in the medical record, and the DON stated that the facility discovered the missed x‑ray only after the resident complained of hip pain during a transfer several days later. The resident was subsequently evaluated in the emergency department, where an intertrochanteric fracture of the right hip was identified. Facility policies on physician orders and fall response, as well as a nursing textbook excerpt on the obligation to follow physician orders, were cited in relation to the failure to carry out the ordered diagnostic testing.
Failure to Document and Monitor Change in Condition After Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure nursing care and services met professional standards of quality through complete and timely documentation and monitoring following a change in condition. A hospice resident with vascular dementia, anemia, physical debility, and COPD experienced an unwitnessed fall, documented on a Change of Condition Evaluation (COC) as occurring without injury or swelling, though the resident complained of pain in the left elbow and left hip. The responsible party and physician were notified and pain medication was ordered. Nursing progress notes indicated that paramedics were called and the responsible party declined hospital transfer and x‑ray at that time. According to the facility’s policy and the ANA guidance on nursing documentation, clear, accurate, and accessible documentation is essential for communication and continuity of care. In the days following the fall, a CNA reported that there was no swelling or discoloration immediately after the fall and that they continued to care for the resident until slight swelling of the left hip was observed several days later, which was reported to the nurse. On that date, nursing notes indicated slight swelling of the left hip and that an x‑ray was taken after an order from the hospice physician. However, there was no documentation of the responsible party’s refusal to send the resident to the hospital, and no follow‑up documentation was found to show that the swollen left hip was monitored. One LVN acknowledged not initiating a new electronic COC when the swelling was observed, and another LVN stated that without a COC, the required 72‑hour follow‑up monitoring and documentation in the electronic system would not occur. The ADON confirmed the observation of mild left hip swelling and acknowledged the missing COC and lack of 72‑hour follow‑up monitoring and documentation, and was unable to provide proof that the swelling was monitored by nurses, contrary to the facility’s Change in Condition Reporting policy requiring assessment and documentation every shift for at least 72 hours after an acute medical change.
Failure to Monitor and Document Respiratory Rate Before Morphine Administration
Penalty
Summary
The deficiency involves the facility’s failure to follow a physician’s order requiring respiratory rate (RR) monitoring prior to administering morphine sulfate to a resident. The facility’s medication administration policy states that medications are to be administered in accordance with written physician orders. The resident was admitted under hospice care with diagnoses including vascular dementia, anemia, physical debility, and COPD. Physician orders for morphine sulfate oral solution were entered on multiple dates with instructions to administer specific doses for severe pain and to hold the medication if the RR was less than 12. These orders applied both when the medication was ordered as needed and when it was ordered routinely every eight hours. Review of the resident’s Order Summary Reports and Medication Administration Records showed that morphine sulfate was administered on multiple days under each of the active orders, but there was no documented evidence that the resident’s RR was obtained prior to any administration. During interviews and concurrent record reviews, a licensed nurse stated that the current order required checking the RR before giving morphine and acknowledged there was no documentation of the RR. The Assistant DON also stated that RR must be documented prior to morphine administration and acknowledged the missing documentation. The DON later confirmed that the RR should have been included and monitored per the physician’s instructions and acknowledged the lack of documentation that this was done.
Inaccurate MDS Assessment of Resident's Behavioral Status
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the behavioral status of a resident with diagnoses including Alzheimer's disease, psychosis, and depression. Despite documented evidence in the resident's records, such as the Medication Administration Record and Order Summary Report, indicating multiple episodes of hallucinations and the use of antipsychotic medication for psychosis manifested by auditory and visual hallucinations, the MDS assessment did not indicate the presence of hallucinations. Additionally, a Change In Condition Evaluation documented an incident involving the resident in a physical altercation, with behavioral symptoms noted. During an interview and record review, the Health Information Manager acknowledged that the MDS assessment was inaccurate and that the section for hallucinations should have been marked. The facility's policy requires that each person completing a section of the MDS attests to its accuracy, referencing the Resident Assessment Instrument User's Manual as guidance. The failure to accurately document the resident's behavioral symptoms on the MDS constitutes a deficiency in the assessment process.
Failure to Readmit Resident After Hospital Transfer and Incomplete Discharge Documentation
Penalty
Summary
The facility failed to readmit a resident after transfer to a VA hospital for medication evaluation and adjustment, despite informing the resident's responsible person that a bed would be held and the resident could return following hospitalization. Documentation for the transfer indicated it was necessary for the resident's welfare and that the resident's needs could not be met at the facility, but did not specify which needs could not be met or what attempts were made to address those needs. Key sections of the transfer/discharge notice were left blank, and there was no documentation supporting the facility's claim that the resident's behavior endangered the safety or health of others. Interviews with facility staff revealed inconsistencies in communication regarding the bed hold policy and the resident's eligibility for readmission. The responsible person was told a bed would be held, but the business office manager later stated that information about bed hold payment was not provided because the resident would not be readmitted. The administrator cited behavioral issues as the reason for declining readmission, but this was not documented in the transfer or discharge records, nor in the physician's discharge summary. The facility's own policy indicated that residents should be allowed to return if eligible and requiring skilled nursing services, but this was not followed in this case.
Failure to Provide Bed-Hold Notifications and Payment Information Upon Resident Transfer
Penalty
Summary
The facility failed to provide required written bed-hold notifications to two residents or their representatives upon transfer to acute care hospitals. In both cases, documentation showed that while an initial bed-hold notification was given at admission, the second notification, which should have been completed and provided at the time of transfer, was left blank and not delivered. Interviews with staff, including the assistant director of nursing and the licensed vocational nurse involved in the transfer, confirmed that the bed-hold notification forms were not completed or provided as required by facility policy. Additionally, the facility did not provide information regarding private pay or reserve bed-payment requirements to the responsible person of one resident prior to the resident's transfer to another facility. The business office manager confirmed that this information was not given. These actions were inconsistent with the facility's own policy, which requires that residents or their representatives be notified of bed-hold duration and payment requirements both at admission and prior to transfer or therapeutic leave.
Failure to Protect Resident from Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from physical and verbal abuse by another resident who exhibited undirected behavioral symptoms and outbursts. The incident involved one resident slapping another, resulting in visible bruising on the left arm, shoulder, and hand. Documentation showed that the resident who was assaulted had multiple medical conditions, including chronic obstructive pulmonary disease, respiratory failure, anxiety disorder, and depression. The assaulted resident reported feeling unsafe and expressed reluctance to change rooms unless another roommate also moved. The facility's records indicated that the aggressor had a history of psychosis, schizophrenia, and repeated aggressive behaviors toward staff and other residents, with interventions from crisis teams and law enforcement documented. A psychiatrist had recommended 1:1 staffing for the resident with behavioral issues. Despite this recommendation, observations revealed that both residents were present together in the smoking patio without visible 1:1 staff supervision. Facility documentation and interviews confirmed that the facility was aware of the behavioral risks and the need for protective measures but failed to consistently implement them. The facility's policy stated that each resident has the right to be free from abuse, including resident-to-resident abuse resulting in physical injury, pain, or mental anguish. The Director of Nurses acknowledged the facility's responsibility to protect residents.
Failure to Initiate Significant Change Assessment After Resident's Behavioral Decline
Penalty
Summary
The facility's Interdisciplinary Team (IDT) failed to initiate a Significant Change in Status Assessment (SCSA) for a resident who experienced a major decline in mental and behavioral health. The resident, admitted with multiple diagnoses including schizophrenia, psychosis, depression, and chronic pain, began refusing critical psychiatric medications such as aripiprazole and sertraline. This refusal persisted over several days, during which the resident exhibited escalating symptoms of psychosis, including delusions, hallucinations, paranoia, and severe behavioral disturbances. Despite these significant changes, there was no evidence in the clinical record of an IDT review or a determination to initiate an SCSA during this period. The resident's behavior became increasingly aggressive and erratic, with documented incidents of physical and verbal aggression towards other residents and staff, refusal to comply with facility rules, and multiple altercations. The resident was involved in several incidents, including slapping another resident, threatening staff, and starting fires within the facility. The crisis team and police were called multiple times, but no effective clinical interventions or comprehensive assessments were implemented by the facility. The resident's actions resulted in harm to other residents, such as bruising, and placed both residents and staff at risk. Throughout the period of behavioral escalation, the facility's records showed no evidence of an SCSA or other required assessments being completed after the resident's admission. Interviews with facility staff, including the DON and MDS RN, confirmed that no additional assessments were performed despite the resident's significant changes in condition. The facility's own policy required the IDT to assess and determine the cause of behavioral symptoms through the MDS/CAA process or team evaluation, but this was not documented or carried out in response to the resident's decline.
Inaccurate MDS Assessment and Documentation
Penalty
Summary
The facility failed to ensure that a resident's health status was accurately documented on the admission Minimum Data Set (MDS). Specifically, the MDS sections regarding active diagnoses and fall history did not accurately reflect the resident's condition. The MDS indicated that the resident had not experienced a fall or sustained a fracture related to a fall in the months prior to admission, despite the admission record showing diagnoses of bilateral calcaneus fractures. Additionally, the MDS listed schizophrenia as an active diagnosis, although the psychiatric discharge note and health and physical did not support this diagnosis, instead documenting psychosis, anxiety disorder, and opiate dependency. Interviews with the MDS Coordinator and review of the resident's Medication Administration Record confirmed that the MDS was completed with incorrect information. The MDS Coordinator acknowledged that the fall history questions were answered incorrectly and that schizophrenia was selected as an active diagnosis based on a history rather than current documentation or treatment. Review of the CMS Resident Assessment Instrument manual with facility staff further confirmed that only active diagnoses with direct relevance to current treatment during the look-back period should be included, and that the documentation did not support the inclusion of schizophrenia as an active diagnosis.
Failure to Implement Person-Centered Care Plan and Update for Orthopedic Changes
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple diagnoses, including psychosis, schizophrenia, and bilateral calcaneus fractures. The care plan specified that only female staff should be assigned to provide 1:1 assistance with activities of daily living due to the resident's psychosocial needs. However, daily assignment sheets showed that male staff were assigned to provide 1:1 care on two occasions, contrary to the care plan and interdisciplinary team notes. The Director of Nursing confirmed that this assignment was not in accordance with the established care plan. Additionally, the resident's care plan was not updated to reflect a change in orthopedic treatment. After the resident's left foot was placed in a non-weight bearing immobilizer cast, there were no new interventions or protocols added to the care plan regarding the care of the cast or monitoring of circulatory function in the affected foot. The Director of Nursing acknowledged that the care plan did not include the necessary updates or interventions related to the immobilizer cast.
Failure to Properly Store and Label Respiratory Equipment
Penalty
Summary
The facility failed to maintain proper infection control practices for one of two sampled residents when respiratory care equipment was not stored or labeled according to policy. Specifically, a nebulizer that was not in use was observed on a bedside table without any dates on the tubing and was not stored in a bag or enclosed container. Additionally, the resident's nasal cannula oxygen tubing had no date indicating when it was last changed. These observations were confirmed during an interview with a licensed nurse, who acknowledged that the equipment should be dated and properly stored to ensure staff know when to change them and to prevent contamination. A review of the resident's admission record showed diagnoses including chronic obstructive pulmonary disease, acute and chronic respiratory failure with hypoxia, anxiety disorder, and depression. Facility policies required that humidifiers be labeled with the date and time opened and that nebulizers be stored in a plastic bag labeled with the resident's name and room number. The observed practices did not comply with these policies, resulting in a deficiency related to infection prevention and control.
Dining Room Environmental Deficiencies and Infection Control Lapses
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment in the South Side dining room, as evidenced by multiple observations of unsanitary and unsafe conditions. Surveyors observed a wet and dirty plastic container surrounded by fruit flies underneath a nonfunctional sink while ten residents were present and eating lunch. The shift coordinator and nursing supervisor confirmed the presence of the fruit flies and the dirty container but did not remove it. Additionally, a trash can next to the sink was also surrounded by flies, and the corner near the sink was visibly dirty, with food particles adhered to the wall and liquid stains running down another wall. The infection preventionist acknowledged these issues and identified them as an infection control problem. Further inspection revealed that the sink in the dining room had been nonfunctional for several weeks, with the cabinet door removed and an open pipe exposed. There was no signage indicating the sink was out of order, and the area was not isolated or covered to prevent resident exposure to possible contaminants. The director of maintenance and housekeeping confirmed the ongoing repairs and lack of notification or barriers. Additionally, the dining room floor had approximately twelve cracked tiles, with some pieces detached and loose, particularly between the sink and the dining table. The director of maintenance was unaware of the damaged tiles and had not been notified by staff. The floor throughout the dining room was noted to have numerous dark stains, especially in the corners, and there was no documentation or logs available to indicate when the floor was last buffed or waxed. The infection preventionist and nursing supervisor confirmed the lack of cleaning records and the visible dirt and stains. These observations were in direct violation of the facility's own policies regarding cleanliness, maintenance, and infection control, as well as CDC guidelines for infection-control measures during repairs.
Failure to Timely Report Resident Fall with Fracture
Penalty
Summary
The facility failed to report a resident's unwitnessed fall that resulted in a left hip fracture to the Department within the required 48-hour timeframe. The incident involved a resident with dementia and a history of falls and fractures prior to admission. The resident was found on the floor in a supine position at the end of the bed and complained of left hip pain. An X-ray confirmed an acute intertrochanteric femoral fracture. The fall was reported internally to the charge nurse and DON, but not to the Department as required by state law. Interviews with staff, including a licensed nurse, the DON, and a CNA, confirmed the details of the fall and the subsequent injury. Review of the medical record and incident reports corroborated the timeline and the nature of the injury. The failure to report the incident to the Department delayed the Department's investigation into the event.
Failure to Timely Change Hearing Aid Filter per Clinic Instructions
Penalty
Summary
The facility failed to change a hearing aid filter for one resident according to instructions provided by an outside clinic. After an outpatient appointment, the resident returned with new hearing aids and instructions from the clinic to change the hearing aid filter monthly. The filter was due to be changed on 3/27/25, but the change did not occur until 4/8/25. Facility staff were unable to provide documentation of when they received the office visit summary with care instructions from the clinic. Progress notes indicated that the facility was not aware of the need to change the hearing aid filter until the resident's responsible party made a request on 4/2/25.
Failure to Implement Scabies Protocol and Isolation Precautions
Penalty
Summary
The facility failed to follow its established protocol for infection prevention and control regarding a resident suspected of having scabies. Upon review of the resident's medical record, it was found that after being seen by a dermatologist and prescribed Permethrin 5% cream for suspected scabies, there was no documentation that the resident was placed on enhanced barrier precautions upon return to the facility. The Assistant Director of Nursing confirmed the absence of such documentation. Further review with the Infection Preventionist revealed that the resident was not placed on isolation precautions as required for suspected scabies cases. Additionally, the Infection Preventionist did not develop a contact identification list for potential exposures, and facility nursing staff had not received training on recognizing and reporting signs and symptoms of scabies infestation. The facility's scabies protocol, which mandates contact isolation and staff training, was not adhered to in this instance.
Failure to Follow Insulin Administration Orders
Penalty
Summary
The facility failed to adhere to physician orders for insulin administration for a resident with diabetes mellitus, leading to potential medication errors. On two separate occasions, the resident's blood sugar levels were significantly high, necessitating specific doses of Novolog insulin as per the sliding scale orders. However, the nursing staff administered incorrect doses of insulin, deviating from the prescribed amounts. On January 25, the resident's blood sugar was 481, and the nurse administered 14 units of insulin instead of the ordered 16 units. Similarly, on February 24, the resident's blood sugar was 485, and the nurse administered 4 units instead of the prescribed 5 units. The Director of Nursing and Health Information Manager confirmed these discrepancies during record reviews and interviews. They acknowledged that the nurses failed to administer the correct insulin doses and could not provide documentation that the resident's physician was notified or responded to the notifications. The resident's care plan, which included administering diabetes medication as ordered by the doctor, was not followed, exposing the resident to potential unsafe insulin doses and preventable medication errors.
Failure to Administer Medications and Provide Ordered Therapy
Penalty
Summary
The facility failed to provide quality care for a resident who was admitted with diagnoses including end-stage renal disease, type two diabetes, and dependence on renal dialysis. The resident missed numerous doses of prescribed medications, including Farxiga, Insulin Glargine, and several others, due to being offsite at a dialysis center. The facility did not inform the resident's physician about the missed medications, nor did they document any attempts to adjust medication administration times or hold orders to ensure the resident received the necessary medications. Additionally, the resident did not receive the full schedule of physical therapy sessions as ordered. The treatment plan required physical therapy services five times a week for four weeks, but the resident only received four sessions per week during two specific weeks. This discrepancy was confirmed by the Rehabilitation Director, indicating a failure to adhere to the prescribed therapy regimen. Furthermore, there was a delay in implementing a physician's order for the resident to begin weight-bearing physical therapy. The order was received on January 31, but due to an order discrepancy, it was not implemented until February 12. This delay in following the physician's order resulted in a postponement of the resident's evaluation by the physical therapy department for weight-bearing therapy, as acknowledged by the Assistant Director of Nursing and the Rehabilitation Director.
Incomplete IDT Admission Assessment for a Resident
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, identified as Resident 1, during an interdisciplinary team (IDT) admission assessment. The assessment form, dated 2/18/25, was found to be incomplete during a review conducted on 2/28/25. Several critical sections of the assessment were left blank, including sections on IDT review date, hospitalizations and procedures, diagnosis, high-risk medications, current functional status, specific functional status and goals, skin and continence, psychoactive medications, medication reconciliation, pain, advanced directive, safety risk, devices, bed rails or positioning/transfer bars, education, and CNA narrative. The Director of Nursing (DON) acknowledged the incompleteness of the IDT Admission Assessment. The facility's policy and procedure titled Interdisciplinary Walking Rounds, dated 2017, requires a comprehensive assessment to be completed within 72 hours of admission or readmission. Each discipline is responsible for collecting pertinent data and documenting it on the IDT WR Assessment within this timeframe. The failure to complete the IDT Admission Assessment for Resident 1, who was admitted with diagnoses including COVID-19 and Alzheimer's Disease, resulted in potentially inaccurate and incomplete medical records, which could affect the care provided to the resident.
Failure to Supervise and Assess Resident Leads to Fatal Elopement
Penalty
Summary
The facility failed to provide adequate supervision and assessment for a resident, leading to a tragic accident. The resident, who had a history of dementia, anxiety, and aggressive behavior, was not accurately assessed for elopement risk. Despite previous incidents of aggression and wandering, the resident was evaluated as not being at risk for elopement without a thorough review of their history and behavior patterns. This oversight contributed to the resident's ability to leave the facility unsupervised. The resident's care plan included interventions for managing anxiety and aggression, such as administering anti-anxiety medication and providing one-to-one supervision. However, these interventions were not consistently followed. Staff failed to administer prescribed medications or document non-pharmacological interventions during episodes of increased anxiety and paranoia. Additionally, the facility did not notify the psychiatric practitioner of the resident's escalating behaviors, missing an opportunity for medication adjustment or other interventions. On the day of the incident, the resident exited the facility through a fire exit door, which was alarmed but not secured, and walked onto a busy street where they were fatally struck by a vehicle. The resident's room was located near this exit, increasing the risk of elopement. The facility's policies on elopement and behavioral health services were not effectively implemented, contributing to the resident's unsupervised departure and subsequent accident.
Inaccurate MDS Assessment Leads to Elopement Risk Misjudgment
Penalty
Summary
The facility failed to accurately complete a Minimum Data Set (MDS) Assessment for a resident, leading to an inaccurate elopement risk assessment. The resident, who was admitted with unspecified dementia, had an incident in January 2025 where they followed a visitor outside the main entrance door, indicating a potential elopement risk. Despite this, the Nurse Supervisor completed an elopement risk assessment on January 10, 2025, without reviewing the resident's history, past evaluations, or other pertinent information from staff, concluding that the resident was not at risk for elopement. Additionally, the Social Services Assistant completed the Quarterly Minimum Data Set Section E-Behavior assessment on January 7, 2025, without checking the Medication Administration Record for January 2025, which documented episodes of anxiety and paranoia. The facility's policy on Behavioral Health Services requires a comprehensive assessment process, including obtaining history from medical records and other sources, which was not followed in this case.
Failure to Implement Behavioral Care Plan for Resident with Dementia
Penalty
Summary
The facility failed to implement the interventions outlined in the behavioral care plan for a resident diagnosed with unspecified dementia, leading to increased episodes of aggression, anxiety, and paranoia. The resident, who had a history of being a danger to self and others, was admitted to the facility with a care plan that included providing reassurance, redirection, administering anti-anxiety medication as needed, and consulting with a psychiatrist for medication adjustments. However, during the review of the Medication Administration Record (MAR) for February 2025, it was found that the resident experienced multiple episodes of anxiety and paranoia over two days, but there was no documented evidence of non-pharmacological interventions being provided or the administration of prescribed anti-anxiety medication. Interviews with facility staff revealed that although the resident's behavior was monitored and documented, the staff did not contact the physician or psychiatrist to report the increased behavioral episodes. Additionally, the staff did not document the non-pharmacological interventions that were reportedly used to calm the resident. The Psychiatry Practitioner confirmed not receiving any communication from the facility regarding the resident's increased behavioral episodes, which could have led to a medication adjustment. The facility's policy and procedure on care plan documentation emphasize the responsibility of nursing services to coordinate care among all disciplines, which was not adhered to in this case.
Improper Storage and Maintenance Issues in Shower Rooms
Penalty
Summary
The facility failed to maintain a clean and homelike environment in two shower rooms, which had the potential to negatively impact residents. During an observation and interview with the Health Information Manager (HIM 1), it was noted that eight clean/unused razors were improperly stored on top of a dirty sharps container in shower room one, located in the south wing of the facility. Similarly, seven clean/unused razors were found on top of a dirty sharps container in shower room two, also located in the south wing. HIM 1 acknowledged that these razors should have been stored at the nurse's station inside a cabinet. Additionally, both shower rooms in the south and central wings had broken floor tiles, which HIM 1 confirmed. The facility's policy on maintaining a safe, clean, and comfortable environment, dated June 2023, requires proper labeling and storage of personal ADL supplies and prompt reporting of maintenance issues, which was not adhered to in this instance.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey. The kitchen staff did not maintain clean food preparation equipment, as evidenced by dried liquid spills, food debris, and trash on the floor of the walk-in freezer. Additionally, clean scoops and serving utensils were stored in a container with spilled food, crumbs, and grime, and the can opener was covered with built-up food debris and grime. The Manager of Dietary acknowledged these issues, attributing them to short staffing, which hindered proper cleaning. The facility also failed to date and label leftover food items, as observed in the walk-in refrigerator, where undated and unlabeled containers of various food items were found. The Manager of Dietary admitted that it was challenging to ensure staff consistently dated and labeled leftover food items. The Registered Dietitian and Executive Director both expressed expectations for proper labeling and dating to maintain food quality and safety. Furthermore, the facility did not follow safe food handling practices. Raw chicken was observed thawing at room temperature, contrary to the policy of thawing under refrigeration or running water. Additionally, a staff member handled ready-to-eat food without gloves and engaged in inappropriate behavior by throwing lettuce. Hair restraint policies were also not followed, as several staff members were observed without proper hairnets or beard nets. The Manager of Dietary and Registered Dietitian acknowledged these lapses, emphasizing the importance of adhering to sanitary standards.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, affecting all 171 residents. Observations revealed that the trash and recycle dumpster lids were open, with trash overflowing and debris scattered around the base of the dumpsters. This was contrary to the facility's policy, which required dumpsters to be kept closed and free of litter. The Manager of Dietary acknowledged the issue and stated that maintenance would be notified to clean the area. However, subsequent observations showed that the problem persisted, with dumpster lids remaining open and trash continuing to overflow. Interviews with facility staff, including the Manager of Dietary, Supervisor of Maintenance, Registered Dietitian, Director of Nursing, and Executive Director, confirmed that the expectation was for dumpsters to be closed and the surrounding area to be clean. The Executive Director noted the challenge of maintaining the area due to the dumpsters being located on the street, where people often opened them to search for food and recyclables. Despite daily cleaning efforts by the maintenance staff, the issue of trash overflow and open dumpster lids remained unresolved, posing potential infection control and rodent infestation risks.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse by another resident, identified as Resident #118, during four separate incidents. Resident #118, who was admitted to the facility with a medical history of dementia, psychosis, and anxiety disorder, exhibited severe cognitive impairment with a BIMS score of 6. Despite the resident's care plan indicating a need for monitoring due to episodes of physical aggression, the facility did not effectively prevent altercations. The incidents involved Resident #118 striking another resident with a coffee cup, smacking a resident, and pushing a resident against a wall. The facility's policy on abuse prevention required monitoring and intervention for residents with behaviors that could lead to conflict. However, Resident #118's care plan interventions, such as keeping residents apart and providing one-to-one supervision, were not adequately implemented. During the incidents, staff failed to prevent Resident #118 from engaging in physical altercations, despite being aware of the resident's aggressive tendencies. The facility's response included contacting law enforcement and revising the care plan, but these measures were reactive rather than preventive. Interviews with staff and residents' responsible parties revealed that the facility was aware of Resident #118's aggressive behavior but did not successfully mitigate the risk of further incidents. Staff interventions were not timely or effective in preventing the altercations, and the facility's efforts to find alternative placement for Resident #118 were unsuccessful. The deficiency highlights a failure in the facility's duty to protect residents from abuse and ensure their safety, as required by their own policies and regulatory standards.
Inaccurate PASRR Screenings for Residents with Mental Disorders
Penalty
Summary
The facility failed to ensure accurate Level I PASRR screenings for residents with mental disorders or intellectual disabilities, affecting three residents. Resident #129 was admitted with diagnoses of unspecified psychosis and depression, but their PASRR Level I screening, completed by a hospital, inaccurately indicated no serious mental illness. The Director of Nursing (DON) acknowledged the error, noting that the screening should have triggered a serious mental illness due to the resident's diagnoses. No additional screenings were conducted for this resident. Resident #26 was admitted with diagnoses of paranoid schizophrenia and anxiety disorder. However, their PASRR Level I screening also inaccurately indicated no serious mental illness. The DON recognized the inaccuracy and stated that schizophrenia should have triggered a serious mental illness. The facility staff, including the DON, were responsible for reviewing the screenings for accuracy, but no new screenings were submitted for this resident. Resident #103 was admitted with diagnoses of psychosis and depression. Their PASRR Level I screening, completed by a hospital, indicated an exempted hospital discharge for a short stay. However, the resident remained in the facility beyond the 30-day exemption period, requiring a new Level I PASRR screening, which was not submitted. The DON confirmed the need for a new screening after the exemption period to determine if the resident triggered for a serious mental illness.
Failure to Follow Pureed Diet Recipes
Penalty
Summary
The facility failed to serve meals according to the recipes for the planned menu for residents prescribed a pureed diet. Specifically, staff pureed plain beef instead of beef stew, mixed breadcrumbs in water in place of sliced bread to make pureed bread, and served applesauce in place of pureed baked apple slices to residents on a pureed diet. This practice had the potential to affect 22 residents who received pureed diets. The facility's policy required that therapeutic diets be prepared and served as planned, with recipes available for use. However, during observations and interviews, it was found that staff did not follow these recipes. For instance, [NAME] #6 pureed plain beef stew meat instead of the scratch-prepared beef stew, citing difficulties in pureeing vegetables. Additionally, breadcrumbs were used instead of sliced bread to make pureed bread, and applesauce was used instead of pureed baked apple slices, as staff believed these substitutions were easier and more consistent. The Manager of Dietary acknowledged the struggle with staff following the menu and recipes, noting that staff felt overwhelmed and opted for easier methods. The Registered Dietitian confirmed that staff had been trained to follow recipes and should consult her before making substitutions. The Executive Director emphasized the importance of following the diet spreadsheet to ensure proper nutrition and flavor for residents on pureed diets.
Failure to Obtain Physician Order for Psychological Services
Penalty
Summary
The facility failed to obtain a physician order before providing psychological services to a resident. During a record review and interview with the Health Information Manager, it was confirmed that the resident received psychological services from November 2023 to July 2024 without a physician's order. The Director of Nursing also confirmed the absence of documentation for a physician's order for these services. The facility's policy requires a medical doctor's order for providing or arranging counseling services, which was not adhered to in this case.
Failure to Follow Physician Orders for Wound Care
Penalty
Summary
The facility failed to adhere to physician orders for wound care treatment for a resident with a pressure ulcer in the sacral region. The resident had multiple diagnoses, including an unstageable pressure ulcer, Type Two Diabetes, and mobility issues, which could complicate wound healing. The physician had ordered the application of Hydrogel to the sacrum every day and evening shift, following cleansing with normal saline and covering with a dry dressing. However, the Treatment Administration Record (TAR) showed missing entries for the evening shifts on two specific dates, indicating that the treatment was not documented as administered. During a review of the facility's policy on wound treatment management, it was noted that the policy required treatments to be provided in accordance with physician orders, including the method of cleansing, type of dressing, and frequency of dressing change. The Health Information Manager confirmed the missing entries and acknowledged that the facility could not provide records to show that the physician's orders were followed on the specified dates. This oversight had the potential to lead to complications for the resident, such as increased pain and wound infections.
Failure to Reorder Medication Timely
Penalty
Summary
The facility failed to reorder medication from the pharmacy according to their policy and procedure for one resident, leading to a potential health risk. Resident 1, who was admitted with a diagnosis of seizures and had an intact cognitive status, missed doses of her antiseizure medication, Lacosamide, for two days. This occurred because the medication was not available, as confirmed by the medication nurse. The facility's policy required medication to be reordered five to seven days in advance, but this was not adhered to, resulting in the missed doses. Interviews with staff revealed a lack of a clear process for ordering and tracking medication refills. The RN mentioned that while refill requests could be sent electronically, there was no alert system to track the order status, and staff relied on verbal endorsements during shift reports. The Licensed Nurse indicated that there were no clear instructions on who was responsible for ordering and tracking medications, which could lead to oversight. The Assistant Director of Nursing confirmed the policy of ordering medications in advance, but this was not followed, as evidenced by the Medication Administration Record and nurse progress notes indicating the missed doses and the delay in pharmacy delivery.
Failure to Maintain Resident Room and Restroom
Penalty
Summary
The facility failed to maintain a resident's room and restroom in a clean and homelike manner, which had the potential to negatively impact residents. During an observation and interview with the Maintenance Director, it was noted that the wall in the resident's room was in disrepair, with large scrapes and missing paint. Additionally, the hand sanitizing dispenser in the resident's restroom was missing a front cover. The Maintenance Director acknowledged that these issues had not been reported by staff nor were they listed on the maintenance log as items needing attention. The facility's policy requires all personnel to report broken or malfunctioning equipment immediately, but this protocol was not followed in this instance.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 90 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Oxnard
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Maywood Acres Healthcare | 0.6 mi | ★★★★★ | 18 | 0 |
| Glenwood Care Center | 2.8 mi | ★★★★★ | 1 | 0 |
| Oxnard Manor Healthcare Center | 3.1 mi | ★★★★★ | 13 | 0 |
| Victoria Care Center | 6.1 mi | ★★★★★ | 0 | 0 |
| Coastal View Healthcare Center | 7.4 mi | ★★★★★ | 11 | 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.