Average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Shoreline Healthcare Center during CMS and state inspections, most recent first.
Residents Not Treated With Dignity and Respect: Two residents were found to have dignity concerns. One resident, who had decision-making capacity and needed assistance with ADLs, was observed in a hospital gown and said she had worn the same gown since admission, did not have her own clothes, and felt ashamed to socialize with others. Another resident reported that a CNA spoke to her rudely during toileting assistance, telling her to clean herself and making an insulting comment about her toileting needs. Facility leaders acknowledged the clothing and communication concerns, and policy required residents to be appropriately dressed and treated with respect.
Failure to Measure and Maintain ROM for Two Residents: Two residents with significant mobility and ROM limitations did not receive fully documented OT ROM measurements, and one resident also missed PROM and splinting after PT/OT discharge. One resident with hemiplegia, contractures, and severe cognitive impairment had OT evals that noted impaired ROM in both arms but did not objectively measure the joints, and RNA services for PROM and splint use were not provided as ordered for a period after therapy ended. Another resident with muscle weakness, CABG history, atrial fibrillation, and a healed fracture had an OT eval that noted right shoulder ROM impairment but did not include goniometer measurements.
A facility failed to administer polyethylene glycol correctly to one resident and failed to give pregabalin as ordered to another resident, with no physician notification or clarification on multiple occasions. One resident with metabolic encephalopathy, COPD, and heart failure received only part of a PEG dose when it was mixed into orange juice, while another resident with hemiplegia, DM with neuropathy, and generalized weakness did not receive ordered pregabalin for pain.
A facility failed to follow standardized recipes and prescribed diet textures during lunch service. Pureed corn served to residents on a pureed diet was dry, lumpy, and contained corn pieces that required chewing, and staff confirmed it did not meet IDDSI Level 4 expectations. In addition, residents on a soft and bite size diet were served minced/ground meat and pureed potato instead of the ordered Salisbury steak and chopped boiled potatoes, despite facility recipes and the cook's spreadsheet calling for the correct soft and bite size textures.
Food was not consistently served at safe, appetizing temperatures and was described as unpalatable. Kitchen and tray observations showed hot items such as Salisbury steak, corn, and potatoes were only lukewarm, milk was warm, and ice cream had melted; staff also noted the tray line took too long and pans were not always held on the steam table. Two residents complained that food was cold or had poor texture and flavor, including one resident with CVA-related weakness, DM, and neuropathy and another with DM and ESRD.
Failure to Honor Food Preferences and Ordered Diets: Two residents were served foods that did not match their tray card preferences or ordered diets. One resident received corn despite corn being listed as a dislike, and another resident with severe cognitive impairment and a vegan diet order was served whole milk, ice cream, melted butter, and meat-containing pureed food. The DS, RD, and DON all acknowledged the diet mismatches and that the vegan order had not been clarified before the meal was served.
Kitchen sanitation was deficient when a juice dispenser nozzle had dried residue, a reach-in freezer shelf had food debris, a food processor bowl was stored wet with a dirty lid, and a blender jar had a torn, glued seal. The DS and dietary staff acknowledged the cleaning and storage issues, and the facility’s cleaning schedule and sanitation practices did not consistently address the equipment involved.
A facility failed to keep accurate and complete medical records for two residents with significant mobility limitations. One resident’s records repeatedly showed sit-to-stand transfers and walking 10 feet as dependent even though staff and rehab leadership stated the resident was unable to stand or walk, and PT documentation also lacked support for a discharge statement that the resident tolerated sitting in a wheelchair for two hours. A second resident’s records similarly showed dependent mobility entries despite staff stating the resident was unable to stand or walk. The ADM also stated there was no policy for medical record documentation.
Failure to Provide Written Bed Hold Notice Upon Transfer: A resident with leukemia, fractures, severe cognitive impairment, and no capacity to make decisions was transferred to a GACH, but the Bed Hold Notification was not completed in writing upon transfer. The RN Supervisor stated the transfer section was blank and the record did not show the responsible party was notified in writing of the 7-day bed hold, despite facility policy requiring written notice and a copy in the chart.
Licensed nursing staff failed to clarify conflicting Norco directions for a resident with knee pain and osteoarthritis. The chart showed Norco 5-325 mg ordered PRN every 6 hours, while a PM&R note said to continue it every 4 hours. The resident said the medication helped only a little and wore off quickly, and the RNS and DON stated the orders should have been clarified to ensure proper pain management.
Failure to Monitor Foley Output and Follow Care Plan for Edema and Urine Output: A resident with CHF, generalized edema, and an indwelling foley catheter was receiving Lasix for fluid overload, but staff did not monitor or document urine output and did not implement care plan interventions for edema and urinary output. The RD, RNS, and DON all stated the resident’s care plans required monitoring of fluid status, edema, and output, and that no fluid output was documented in the CNA task section.
A resident with a G-tube was observed lying supine and below 30 degrees while enteral feeding was running. A CNA said the resident was lower than she should have been during the feeding and that the tube feeding should be turned off when repositioning is needed. An LVN later confirmed the resident should not be lying flat during feeding, paused the tube feeding, and said the resident needed assistance to be safely elevated; the DON stated the head should be elevated above 30 to 45 degrees and never flat during feeding.
Failure to Document Non-Pharmacological Pain Interventions: A resident’s June MAR and Progress Notes showed no documented non-pharmacological interventions before pain medication was given throughout the month. An LVN and the DON confirmed that non-pharmacological interventions should be used and documented first, but the record did not show that this occurred.
Uncovered Dialysis Port: A resident with dialysis, dementia, and cognitive communication deficit had a right subclavical dialysis port observed exposed with tape residue present and not covered. The DSD stated the port should be covered to prevent infection and that the site should be routinely checked for redness, swelling, or other issues. RNS and DON also stated the dialysis port should be covered, and the facility policy required dialysis access to be assessed upon return to the facility and any access problems addressed immediately.
Failure to maintain sterile technique during a dialysis port dressing change occurred when an RN Supervisor wore non-sterile gloves, handled the resident’s shirt and port area, and then placed sterile gloves over the contaminated gloves without removing them or performing hand hygiene first. The resident had dialysis, dementia, and cognitive communication deficit, with moderate cognitive impairment and dependence on staff for several ADLs. The DON stated this was not acceptable because it breaks the sterile field and increases the risk of infection.
A resident with acute respiratory failure, COPD, muscle weakness, and type 2 DM was transferred to the GACH after chest pain and later cleared to return, but the facility did not readmit the resident when the GACH first called to confirm acceptance. The CL told the GACH the resident could return when ready and the DON reviewed the records and found readmission appropriate, yet the resident was not brought back until several days later. The DON stated the admission criteria policy was not followed.
A resident with COPD, cellulitis, muscle weakness, and moderately impaired cognition was admitted with several personal items, including a backpack, documented on an inventory form that did not list the backpack’s contents or any refusal to have it opened. The resident later reported that an envelope with an unknown amount of cash in $20 bills was missing from the backpack, and family confirmed the resident had a significant amount of money in the backpack when they later counted it. The CNA who completed the admission inventory stated the resident refused to allow inspection of the backpack, that the resident said it contained only important documents and no money, and that the CNA reported this verbally to a charge nurse but did not document the refusal or date the inventory form. Review of nursing notes showed no record of the refusal or of education about inventorying valuables, despite facility policies requiring a written admission inventory and cautioning residents about keeping valuables in their rooms, leaving the facility unable to determine what was in the backpack or how much money the resident had.
Surveyors found that a bed was positioned so that it partially blocked a door marked as an emergency exit in a room shared by four residents, all with impaired cognition and needing assistance with ADLs. One resident with a right patella fracture reported that during heavy rain, water entered from under this exit door, flooding the floor and soaking her clothing, which she then hung to dry. The facility’s Disaster and Evacuation Plan identified this door as an exit to a back patio, and the Fire and Disaster policy required exits to remain clear at all times. The Maintenance Supervisor confirmed the door was unlocked, operable via a push bar, and that flooding occurred from rainwater entering under the door, with no modifications made to prevent recurrence. The DON and Administrator stated that, although the door was marked as an exit on the floor map, it was not included in the emergency exit plan and staff were not trained to use it during emergencies.
A resident with a right patella fracture and moderately impaired cognition, requiring supervision or touch assistance for ADLs, was placed in a bed positioned so that the head of the bed partially blocked an emergency exit door. During heavy rain, water entered under this exit door, flooding the floor near the bed and soaking the resident’s clothing, which had been kept on the floor and was later observed hanging to dry on a chair. The exit door was found unlocked and operable via a push bar to a back patio, and the Maintenance Supervisor reported that while housekeeping had mopped and used towels after the incident, no changes were made to the door to prevent future flooding. The DON acknowledged that having an exit door by the bed could affect resident safety, and the ADM stated the belongings would not have been wet if the bed had not been placed by the exit door.
A resident with a history of pressure ulcer, neuromuscular bladder dysfunction, and moderate cognitive impairment did not receive documented toileting hygiene after a bowel movement. Staff interviews and record reviews revealed unclear and inconsistent documentation practices, with no specific record of hygiene care being provided after the resident's last bowel movement, despite the resident's total dependence on staff for such care.
A resident admitted with a left heel blister and right heel SDTI did not receive timely or adequate wound assessments, consistent offloading interventions, or prompt referrals to a wound care practitioner. The care plan was not updated when the wound status changed, and the physician was not notified of significant changes, including infection and wound deterioration. As a result, both heel wounds progressed to unstageable pressure injuries, causing pain and requiring hospital transfer for advanced treatment.
Three residents with ROM and mobility concerns did not receive required therapy evaluations, interventions, or restorative nursing services as ordered, including sit-to-stand transfers, AAROM, PROM, and splinting. One resident lost the ability to stand, and others were at risk for further ROM decline due to the facility's failure to follow physician orders, accurately assess joint mobility, and implement care plan reviews.
A resident with a history of physical and emotional abuse was not protected from further mental abuse when a family member, against whom there was an open APS case, was able to enter the facility twice, including once during personal care, causing the resident significant emotional distress and requiring medication for anxiety. The facility did not follow its abuse prevention policy, failed to offer a room change, and did not thoroughly investigate or report the incident as required.
A resident with significant physical and cognitive impairments was left with his genital area exposed during personal care, while the privacy curtain between him and his awake roommate remained open. Two CNAs acknowledged that they should have covered the resident and closed the curtain to maintain privacy, in accordance with facility policy and expectations stated by the DON.
Two residents did not have required Interdisciplinary Team (IDT) meetings to discuss their care plans and discharge goals. One resident's IDT meeting was not documented in the medical record, while the other did not have an IDT meeting at all, despite facility policy requiring these meetings within 72 hours of admission. Both the Social Service Director and DON confirmed the deficiency.
Two residents did not have required Interdisciplinary Team (IDT) meetings to discuss their person-centered care plans and discharge goals. One resident's IDT meeting was not documented in the medical record, while another did not have an IDT meeting at all, despite facility policy requiring these meetings within 72 hours of admission. Both residents had significant medical needs and required assistance with daily activities.
A resident with moderate cognitive impairment and significant medical conditions was admitted without the facility obtaining a copy of their Advance Directive, despite documentation indicating one existed and facility policy requiring it. Staff interviews confirmed the omission, resulting in a deficiency related to resident rights and documentation.
Two residents experienced significant changes in skin integrity, including the development and worsening of pressure injuries, but the facility failed to promptly notify the physician and responsible family members as required. One resident's left heel wound deteriorated to an unstageable pressure injury with pain and odor before the physician was informed, while another resident's right buttock wound progressed to a stage four pressure injury without timely family notification. Facility staff did not follow established protocols for communication and documentation of changes in condition.
Three residents did not receive timely, individualized care planning: one with a heel wound did not have updated interventions after the wound worsened; another was not weighed for months due to unaddressed equipment-related pain, resulting in unmonitored significant weight loss; and a third developed a severe pressure injury without timely care plan updates or risk reassessment. Staff interviews confirmed delays and omissions in care plan development and implementation.
Two residents did not receive required care as ordered: one was not seen by neurology despite physician orders, and another did not have decision-making capacity determined or documented, even though assessments indicated severe cognitive impairment. Facility staff interviews and record reviews confirmed missed appointments and lack of follow-up, with policies requiring these actions not being followed.
Nursing staff failed to demonstrate competency in wound care and documentation for two residents with pressure injuries. One resident's left heel wound progressed from a suspected deep tissue injury to an unstageable pressure injury without proper assessment, documentation, or physician notification. Another resident developed a right buttock pressure injury that advanced to stage four without timely clinical oversight or escalation to the DON. These deficiencies resulted in a lack of accurate wound documentation and delayed care.
Two residents did not receive required psychosocial and trauma assessments upon admission, despite having significant medical and trauma histories. Staff interviews revealed that assessments were either not completed or delayed, and facility policy requiring timely social services and behavioral health evaluations was not followed.
The facility did not keep required records for emergency drug usage from the Cubex system, failed to obtain proper witness signatures for non-controlled drug destruction, and did not ensure nurses verified medications against orders upon receipt, resulting in two residents receiving incorrect medications. Additionally, a nurse crushed medications for a resident without a physician order, and the facility lacked a policy on medication administration guidance.
Surveyors observed that the facility's medication error rate exceeded 5%, with three errors out of 31 opportunities. In two cases, residents received incorrect medications or dosages, including administration of the wrong strength of benazepril, giving vitamin C instead of calcium, and providing morphine IR instead of the prescribed ER formulation. These errors were confirmed through direct observation, interviews with nursing staff, and review of physician orders and medication packaging.
Two residents experienced significant medication errors when one was given immediate release morphine instead of the prescribed extended release formulation, leading to inadequate pain control and increased use of Norco, while another received double the ordered dose of benazepril due to a pharmacy dispensing error and failure to verify the correct dose during administration.
Staff did not follow standardized recipes and portion sizes for residents on ground, mechanical soft, and pureed diets during a lunch meal. A cook used the wrong scoop, resulting in under-portioning BBQ chicken for residents on ground diets, and served mechanical soft chicken in inconsistent, unground pieces. For pureed diets, chicken was not blended with BBQ sauce as required. Dietary supervisors, RDs, and a speech therapist confirmed that menus and recipes were not followed, leading to improper food texture and portioning.
Staff failed to consistently use required PPE for a resident on contact isolation for C. diff and did not ensure a family member wore PPE, while another resident with an indwelling catheter under EBP had their catheter bag on the floor and was handled without PPE. Additionally, an outbreak of C. diff was not reported to public health authorities as required by facility policy.
The facility did not consistently monitor or document the immunization status for influenza and pneumococcal vaccines for two residents, resulting in incomplete medical records. For both residents, there were discrepancies and lack of verification regarding whether the vaccines were received or refused, and the required documentation was not maintained as per facility policy.
The facility did not maintain documentation of COVID-19 vaccination status for all required staff, including on-call, part-time employees, and licensed professionals entering the facility. Interviews with the IPN and DON confirmed gaps in tracking and documentation, despite facility policy requiring comprehensive vaccination records for all staff categories.
A resident with severe cognitive impairment and a history of multiple falls was not identified as a fall risk due to the absence of a falling star sticker on their door, as required by facility policy. Staff were unaware of the resident's fall risk status, resulting in inadequate supervision and failure to implement necessary fall prevention measures.
A resident with respiratory failure and COPD, requiring continuous oxygen, was found to have a nasal cannula in use beyond the facility's seven-day replacement policy. Staff and nursing leadership confirmed the equipment had not been changed as ordered, resulting in a failure to follow infection control procedures.
A resident with multiple chronic conditions and severe cognitive impairment did not receive a required face-to-face physician visit within the mandated 60-day interval. Review of records and staff interviews confirmed the absence of physician documentation and visits, contrary to facility policy.
A resident with a documented strawberry allergy and dislike was served strawberry flavored gelatin, despite this information being clearly listed on their meal ticket and care records. Dietary staff and the supervisor were aware of the allergy, but the resident still received the inappropriate dessert and did not consume it.
A resident with mobility and ROM concerns did not have accurate medical record documentation for restorative nursing services, as staff were found to have initialed records for dates they did not work and for services they did not provide. Facility records and payroll data confirmed these discrepancies, and interviews revealed that staff sometimes signed for each other, resulting in incomplete and inaccurate documentation of care.
The QAA committee did not provide effective oversight or timely implementation of the QAPI plan, as evidenced by delayed action on skin and pressure injury issues. Although a pressure injury was identified in a resident, the administrator did not consider it widespread and did not initiate a QAPI project until later, contrary to facility policy requiring proactive and data-driven quality improvement.
A resident with a history of physical and emotional abuse was subjected to repeated, unwanted visits by a family member who was the subject of an open APS case. Despite staff and police intervention during incidents where the family member was verbally and emotionally abusive, the facility's abuse coordinator did not report the incidents to the state agency or conduct a thorough investigation, as required by policy. The resident experienced significant distress and required anti-anxiety medication following the events.
A resident with a history of physical and emotional abuse was subjected to two unauthorized visits by a family member, during which the individual forced entry into the resident's room, shouted at the resident, and caused significant emotional distress. Despite staff awareness of the resident's wishes and visible signs of trauma, the facility did not conduct a thorough investigation or report the incident as required by its abuse prevention policy.
Two multi-bed rooms and two single-bed rooms were found to be below the required minimum square footage per resident, as confirmed by facility records and direct measurement. The MS was unaware of the regulatory requirements, and the DON stated that inadequate space could impact residents' ability to store belongings and receive care.
An LVN failed to administer 9 a.m. medications on time for five residents, as observed during a survey. The residents had various medical conditions requiring timely medication, such as hypertension and depression. The facility's policy mandates that medications be administered as prescribed and documented on the MAR. The DON acknowledged the potential risks of missing routine medications.
A facility failed to label a multi-dose vial of Humulin N insulin with an open date, risking the administration of potentially expired medication. An LVN found the vial in a medication cart without the necessary labeling, and the DON confirmed the requirement for labeling to ensure medication safety.
Residents Not Treated With Dignity and Respect
Penalty
Summary
The facility failed to ensure two residents were treated with dignity and respect. One resident, admitted with morbid obesity, gout, and osteoarthritis of the hips, had decision-making capacity and was assessed as needing assistance with multiple activities of daily living. During observation, the resident was found in bed wearing a hospital gown and stated she did not want to wear a gown, did not have her clothes with her, and had been wearing the same gown since admission. She also stated she had not been told the facility offered donated clothing and felt ashamed to leave her room and socialize because other residents wore their own clothing. Record review showed the resident had only one purple sweater listed among her possessions, and staff acknowledged that residents were expected to wear their own clothes unless they preferred a gown. The RNS stated the facility promoted a home-like environment and encouraged residents to wear regular clothing to honor dignity and respect. The SSD stated staff should have offered donated clothing or contacted family to bring clothing from home, and the DON stated staff should have contacted the family as soon as they realized the resident did not have proper clothing at admission. Facility policy required residents to be appropriately dressed in clean clothes and well groomed. A second resident, admitted with diagnoses including a lumbar compression fracture, dysphagia, cognitive communication deficit, and other conditions, was also assessed as capable of making decisions but needing extensive assistance with personal care and mobility. The resident stated a CNA told her to clean herself and turn off the light and was rude when she requested toileting assistance, including saying, 'first you are using the bathroom on the toilet, then in the bedside and now in the bed, what's wrong with you!' The resident reported the incident to RNA 1, who notified the DSD. The DSD confirmed awareness of the complaint and stated the resident reported feeling rushed while receiving restroom assistance. Facility policy stated staff shall display respect for residents when speaking, caring for, or talking about them.
Failure to Measure and Maintain ROM for Two Residents
Penalty
Summary
The facility failed to provide appropriate care to maintain or improve ROM and mobility for two residents with limited ROM. One resident had a history of traumatic subarachnoid hemorrhage, left-sided hemiplegia, aphasia, dysphagia, contractures, and severely impaired cognition. The resident’s MDS indicated ROM limitation in both arms and legs and dependence for multiple ADLs. OT evaluations dated 5/6/2025 and 11/11/2025 documented impaired ROM in both shoulders, elbows/forearms, wrists, and hands, but neither evaluation included objective measurements of the impairments. The DOR stated that therapy staff are trained to measure joints with a goniometer and that the absence of measurements prevented monitoring for changes in ROM. For the same resident, PT and OT services ended on 8/19/2025, and physician orders dated 9/3/2025 directed RNA staff to provide PROM to both arms and legs five times per week as tolerated and to apply resting hand splints, elbow extension splints, knee extension splints, and ankle splints five times per week for four to six hours as tolerated. The OT discharge summary recommended 24-hour care, and the PT discharge summary recommended a restorative nursing program. However, the DOR stated the OT discharge summary did not include RNA services, and the resident did not receive ROM exercises and splint application from 8/10/2025 to 9/3/2025. During observation, the resident was lying in bed, unable to speak, with elbow and hand splints in place; PROM was later provided to both shoulders, elbows, wrists, and hands, and the resident’s elbows could not be fully straightened, with fixed bent positions noted in some fingers and knuckles. A second resident had diagnoses including muscle weakness, atherosclerosis of CABG grafts, atrial fibrillation, and a healed traumatic fracture. The resident’s MDS indicated unclear speech, severely impaired cognition, and dependence for toileting, showering, dressing, rolling, transfers, and sit-to-stand transfers. The OT evaluation dated 4/16/2026 documented a history of CABG, right humeral fracture, and right shoulder anterior dislocation with closed reduction, and noted right shoulder ROM impairment, but did not include objective ROM measurements. The DOR and the evaluating OT both stated that goniometer measurements are part of OT training and are used to establish baseline ROM and monitor improvement or decline, and the OT stated the resident’s right shoulder ROM should have been measured because it could affect ADLs.
Medication Administration Errors and Missed Doses
Penalty
Summary
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was deficient because the facility did not administer polyethylene glycol correctly to one resident and did not administer pregabalin as ordered to another resident. Resident 30 was admitted and readmitted with diagnoses including metabolic encephalopathy, COPD, and heart failure. The H&P stated the resident had the capacity to understand and make decisions, while the MDS indicated moderate cognitive impairment and dependence for several activities of daily living. The physician ordered polyethylene glycol 3350 powder 17 grams by mouth twice daily for bowel management, mixed with 8 ounces of fluid and held for loose stool. During observation, an LVN prepared the polyethylene glycol in orange juice and handed it to Resident 30, who drank only half and returned the cup. The LVN discarded the remaining medication, and the resident stated they did not finish the orange juice and did not know medication had been mixed into it. The LVN stated the resident did not receive the full dose and that not taking the full dose could increase the risk for constipation. Resident 6 was admitted and readmitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction, DM with diabetic neuropathy, and generalized muscle weakness. The H&P stated the resident had the capacity to understand and make decisions, while the MDS indicated moderate cognitive impairment and significant assistance needs. The physician ordered pregabalin 25 mg, 2 capsules orally three times a day for pain, but the facility did not administer the medication and did not notify the physician or clarify administration on multiple specified dates.
Failure to Follow Prescribed Diet Textures and Standardized Recipes
Penalty
Summary
The facility failed to follow standardized recipes and diet textures for lunch service on 6/22/2026. During tray line observation, the pureed corn for nine residents on a pureed diet was observed to be dry, lumpy, and not smooth, with small pieces of corn kernels present. In a concurrent interview and taste test with the Dietary Supervisor, Cook 1, and the Registered Dietitian, the corn was confirmed to have a lumpy texture and to require chewing before swallowing. The spoon tilt test showed the food sticking to the spoon. Staff stated the corn had been prepared from regular corn and peppers, blended with water, and then became thicker and dry on the steam table. The facility recipe for corn with green peppers directed that creamed corn be pureed and tested to confirm IDDSI Level 4 specifications. The facility also served the wrong texture for eight residents on a soft and bite size diet. During kitchen observation, minced/ground meat and pureed potato were served instead of Salisbury steak and boiled potato chopped into 1/2 inch pieces. In interviews, the Regional Dietitian and Dietary Supervisor stated the Salisbury steak should have been tender chopped and not ground, and the cook's spreadsheet indicated tender chopped Salisbury steak rather than ground. Facility recipes for Salisbury steak and diced potatoes specified soft and bite size textures with 1.5 cm by 1.5 cm pieces. The facility policy required menus to meet residents' nutritional needs and standardized recipes to be used in food preparation, and the cook job description required meals to be prepared according to planned menus, special diet orders, and standardized recipes.
Food Served at Improper Temperatures and Poor Palatability
Penalty
Summary
The facility failed to ensure food was prepared and served at palatable, attractive, and safe temperatures for 64 of 67 residents who received food from the kitchen, including Resident 4 and Resident 6, who both complained about the quality of the food. During the initial tour, complaints about food temperature and texture were identified, and similar concerns were discussed at the resident council meeting. The facility policy stated that meals should be served at appropriate temperatures and that the goal was to serve cold food cold and hot food hot. During kitchen observation, the dietary supervisor was warming a bowl of oatmeal for a resident and stated that residents' families or nurses bring in food to be warmed in the microwave and that the facility often warms food for residents. At lunch preparation, the cook checked temperatures of multiple items, including Salisbury steak, corn with bell peppers, fried potatoes, pureed potato, pureed corn, pureed meat, brown rice, milk, and water. Later, several pans of food were observed sitting on top of other pans rather than directly on a heat source, and the dietary supervisor stated there was not enough space in the steam table to keep extra pans of food there. The registered dietitian stated smaller pans should be used to fit the steam table wells. During the test tray observation, food temperatures ranged from warm to lukewarm, with Salisbury steak at 120 degrees F, corn with peppers at 112 degrees F, fried potatoes at 115 degrees F, milk at 53 degrees F, and ice cream melted at 30 degrees F. The registered dietitian stated the tray line took a long time and the food was not warm. Resident 6, who had diagnoses including hemiplegia/hemiparesis following cerebral infarction, diabetes mellitus with diabetic neuropathy, and generalized muscle weakness, stated the chicken tasted like rubber and the fish was raw. Resident 4, who had diagnoses including wedge compression fracture of the lumbar vertebra, diabetes mellitus, and end stage renal disease, stated the food was cold most of the time and that staff reheated it almost every day.
Failure to Honor Food Preferences and Ordered Diets
Penalty
Summary
The facility failed to ensure resident food preferences and ordered diets were followed for two sampled residents during lunch service. One resident had corn listed as a dislike on the lunch tray card, but corn with peppers was served anyway. During the kitchen observation, the Dietary Supervisor checked tray cards and read diet orders to the cook, but did not read the dislikes on this resident’s tray card. The resident later stated the food could not be eaten, pointed to the tray card, and said corn had been placed on the tray despite being listed as a dislike. The same meal service also showed a failure to follow another resident’s ordered vegan diet. That resident had diagnoses including dysphagia, dementia, CHF, and scoliosis, and was documented as having no capacity to make medical decisions and severe cognitive impairment. During lunch observation, the resident was fed pureed food along with whole milk and ice cream. The meal ticket identified the resident as ordered for a pureed, fortified vegan diet, yet the tray contained dairy items and the pureed food was mixed with melted butter and included meat. The resident could not express food preferences and stated she did not know what foods she was being served. Interviews and record review showed the resident’s responsible party had reported a long-standing vegan diet and did not want meat or dairy products if it could be avoided. The Dietary Supervisor stated the resident should have received vegan food items and acknowledged the tray contained dairy products and meat. The Registered Dietitian stated vegan substitutes were available and that staff should have followed the vegan diet order until it was clarified with the physician. The DON stated staff must assess, document, and honor residents’ food preferences, and that if the diet order indicated vegan, ice cream, whole milk, melted butter, and meat should not have been provided.
Kitchen Equipment Not Kept Clean or in Sanitary Condition
Penalty
Summary
Safe and sanitary food storage and food preparation practices were not maintained in the kitchen when a juice machine dispenser nozzle was observed with dried red residue inside it. During the observation, a clean paper towel swipe inside the nozzle produced dark red stains, and the Dietary Supervisor confirmed the residue appeared to be dried grape juice. The Dietary Supervisor and a dietary aide stated the nozzle was removable, but the aide said it had only been cleaned on the outside and had not been soaked as described by the supervisor. The facility’s daily cleaning schedule did not include cleaning the juice machine dispenser holder and nozzle. A reach-in freezer was also observed with dried food debris on the bottom shelf. The Dietary Supervisor stated the facility had a cleaning schedule for deep cleaning refrigeration units, but there was no cleaning log for refrigerators and freezers. The facility’s daily cleaning schedule for the week did not include cleaning the refrigerators and freezers, although a separate Thursday cleaning schedule listed deep cleaning of the refrigerator during one week and other equipment during other weeks. The facility policy stated refrigerators and freezers should be on a weekly cleaning schedule and that spills should be wiped up immediately. The food processor bowl was observed stored wet rather than air dried, and the lid had dried food stains. The cook stated the bowl had just been washed and should be allowed to drain and air dry before storage, while the Dietary Supervisor returned the lid to be washed again because it was not clean. The blender jar was also observed with a gap at the base covered by a gel-like seal, and the seal was torn and not smooth. The Dietary Supervisor stated the blender jar was a temporary fix until a replacement could be purchased and agreed the surface could not be properly washed and sanitized because of the glue. The facility sanitation policy stated utensils and equipment must be kept clean, maintained in good repair, and free from breaks, cracks, and chipped areas.
Inaccurate Mobility Documentation and Missing Medical Record Policy
Penalty
Summary
The facility failed to maintain accurate and complete medical records for two residents with mobility and range of motion concerns and did not have a policy and procedure for medical record documentation. Resident 3 was re-admitted with diagnoses including cellulitis of both lower limbs, heart failure, COPD, muscle weakness, and morbid obesity. The resident’s MDS indicated dependence for several activities of daily living and stated sit-to-stand transfers and walking 10 feet were not applicable because the resident did not perform those activities prior to the current illness, exacerbation, or injury. Despite that assessment, the Documentation Survey Reports for April through June 2026 repeatedly documented Resident 3 as dependent for sit-to-stand transfers and walking 10 feet on multiple dates. CNA 2, the DSD, and the DON stated the resident was unable to stand and walk, and the DSD stated the records should have indicated the activities were not attempted or not performed. PT records also showed inconsistency: the PT Evaluation stated Resident 3 was unable to sit supported in a wheelchair and included a goal to sit supported for two hours, while PT Treatment Encounter Notes did not document sitting tolerance. The PT Discharge Summary stated the resident tolerated sitting supported in a wheelchair for two hours, but PTA 1 stated this was verbally communicated and not supported by documented evidence in the medical record. Resident 5 was admitted with diagnoses including traumatic subarachnoid hemorrhage, left-sided hemiplegia, aphasia, dysphagia, and muscle contractures. The resident’s MDS indicated no speech, severely impaired cognition, ROM limitations in both arms and legs, dependence for multiple care activities, and that sit-to-stand transfers and walking 10 feet were not attempted because the resident did not perform those activities. However, the Documentation Survey Reports for April through June 2026 repeatedly recorded Resident 5 as dependent for sit-to-stand transfers and walking 10 feet on multiple dates. CNA 1, the DSD, and the DON stated the resident was unable to stand and walk and that the documentation should have reflected that the activities were not attempted or not performed. The Administrator stated the facility expected accurate documentation in residents’ medical records but acknowledged that this expectation was not included in a policy because the facility did not have a policy for medical record documentation.
Failure to Provide Written Bed Hold Notice Upon Transfer
Penalty
Summary
The facility failed to provide a written bed hold notice upon transfer for one sampled resident. Resident 68 was initially admitted with diagnoses including leukemia and fractures of the left humerus, maxilla, and ribs. The admission record showed the resident was transferred to a general acute care hospital on 4/10/2026. The history and physical dated 4/10/2026 indicated the resident did not have the capacity to understand and make decisions, and the MDS dated 4/10/2026 indicated severe cognitive impairment and dependence for eating, oral hygiene, toileting hygiene, bathing, and dressing. During a concurrent interview and record review on 6/25/2026, the RN Supervisor reviewed Resident 68's Bed Hold Notification dated 4/10/2026 and stated the notification should be signed by the resident or responsible party on admission and upon transfer. The RN Supervisor stated the section to be completed upon transfer was blank and that the medical record did not indicate the responsible party was notified in writing of the seven-day bed hold. The DON stated staff should explain the bed hold process to the resident and/or responsible party on admission and upon transfer. The facility policy required written notice of the right to exercise the seven-day bed hold provision and a second notice before transfer to a GACH or therapeutic leave, with a copy placed in the resident's health record at the time of transfer.
Failure to Clarify Conflicting Pain Medication Orders
Penalty
Summary
Licensed nursing staff failed to meet professional standards by not clarifying conflicting pain medication directions for a resident with left knee pain, right knee osteoarthritis, and SIRS. The resident’s record showed an order for Norco 5-325 mg, 1 tablet by mouth every 6 hours as needed for pain with a start date of 4/2/2026, while a PM&R note dated 6/14/2026 stated to continue Norco 5-325 mg every 4 hours. The resident was mildly cognitively impaired on the MDS, but the H&P stated he had the capacity to understand and make decisions. During interview, the resident stated he received Norco 1 tablet and that it helped a little but did not do any good because it wore off quickly. The RNS reviewed the conflicting order summary and PM&R note and stated the orders should have been clarified with the doctor if the medication was intended every 4 hours or every 6 hours, noting that confusion could arise and the resident’s pain level would be uncontrolled without clarification. The DON also stated licensed staff must clarify whether the pain medication should be given every four or six hours to ensure proper pain management. The facility’s pain management policy stated pain care should be consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident’s goals and preferences, while the physician orders policy did not include a procedure for clarifying discrepancies between orders and the doctor’s notes.
Failure to Monitor Foley Output and Follow Care Plan for Edema and Urine Output
Penalty
Summary
Failed to ensure Resident 3’s foley catheter urine output was monitored and documented, and failed to implement the resident’s care plan for monitoring edema and urine output. Resident 3 was admitted and later readmitted with diagnoses including CHF, cellulitis of both lower limbs, and generalized edema. The history and physical dated 4/30/2026 indicated the resident had capacity to make medical decisions. Resident 3’s care plans included interventions to observe catheter function, urine output, and signs and symptoms of complications for the indwelling foley catheter, and to monitor and document edema and urinary output. Additional care plans directed staff to inspect the feet, ankles, and calves for changes such as weeping, edema, and tenderness, and to monitor for signs and symptoms of dehydration, including decreased or no urine output. The order summary showed the resident was receiving Furosemide 40 mg by mouth twice daily for fluid overload. During interview and record review, the RD stated the Lasix dose had been increased from once daily to twice daily and that weights should be monitored to assess fluid overload and whether the medication dosage needed to be changed. RNS 2 stated staff are required to follow care plans, that the care plans were not being implemented, and that there was no fluid output documented in the CNA task section. The DON stated that when a resident has CHF and is taking Lasix, staff should monitor for fluid overload, weight gain, edema, and urine output, and that care plans need to be followed to determine whether interventions are effective.
Resident with G-tube was fed while lying flat
Penalty
Summary
A deficiency was cited after a resident with a G-tube was observed lying in bed supine and halfway down the bed while enteral feeding was running. The resident’s head was against the back rest of the bed with the neck bent forward, and the resident was positioned at less than 30 degrees during the feeding. A CNA stated the resident was lying lower than she should have been while the tube feeding was running and said the feeding should be turned off when the resident needs repositioning. During the same observation, an LVN assessed the resident and stated the resident should not be lying supine while enteral feeding was being delivered. The LVN paused the tube feeding and said additional assistance was needed to safely elevate the resident from the supine position, adding that the feeding should not be on when the resident was lying flat because it can lead to aspiration and choking. The DON later stated the resident’s head should be elevated above 30 to 45 degrees to prevent aspiration and that the resident should never be lying flat. The facility policy titled Gastrostomy Tube Care and Management stated that before every feeding the tube position should be verified and, if feeding is continuous, the position should be checked every shift and as needed.
Failure to Document Non-Pharmacological Pain Interventions
Penalty
Summary
The facility failed to implement non-pharmacological interventions for Resident 26 before administering pain medication. During review of the June MAR with an LVN, no non-pharmacological interventions were documented for the entire month of June. The LVN stated there should be documentation of non-pharmacological interventions before giving the medication because the resident should not receive unnecessary medications. A later review of the June MAR and Progress Notes with another LVN also showed no documented non-pharmacological interventions for Resident 26 during the month. The LVN stated non-pharmacological interventions should be implemented first because they can minimize the amount of medication given. During review with the DON, the MAR and Progress Notes again showed no documentation of non-pharmacological interventions, and the DON stated that providing non-pharmacological interventions before giving pain medications should be implemented first and that the nurses were not accurately assessing the resident's pain by not checking non-pharmacological interventions first.
Uncovered Dialysis Port
Penalty
Summary
Provide safe, appropriate dialysis care/services for a resident who requires such services was not met for one of 24 sampled residents, Resident 9. During an observation on 6/23/2026 at 8:34 a.m., Resident 9's right dialysis port, located beneath the collarbone, was noted to be exposed with tape residue present. During a concurrent observation and interview at 8:46 a.m., the DSD stated the dialysis port had a lot of tape residue on it and was not covered, and stated that any licensed personnel could apply the dressing. The DSD also stated the dialysis port should be covered to prevent infection and that the site should be routinely checked for redness, swelling, or other issues.
Failure to Maintain Sterile Technique During Dialysis Port Dressing Change
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when facility staff failed to follow the facility’s policy and procedure for infection prevention related to Foley catheters and central lines. During an observation, a Registered Nurse Supervisor donned non-sterile gloves, unbuttoned the resident’s shirt to view the dialysis port, and then put sterile gloves over the same non-sterile gloves without removing them or performing hand hygiene first. The resident involved was admitted and later readmitted to the facility with diagnoses including dialysis, dementia, and cognitive communication deficit, and the history and physical noted fluctuating capacity to understand and make decisions. The resident’s Minimum Data Set indicated moderate cognitive impairment and dependence on staff for multiple activities of daily living, including bathing, toileting hygiene, and lower body dressing, with partial assistance needed for several other tasks. During interview, the RN Supervisor stated she should have removed the non-sterile gloves and performed hand hygiene before putting on sterile gloves to change the dialysis port dressing, and stated sterile gloves were worn to keep the field sterile because breaking sterile field could cause cross contamination and infection of the dialysis port. The DON stated that changing a dressing for a dialysis port must be performed using a sterile procedure and that it was not acceptable to put sterile gloves over contaminated non-sterile gloves because it breaks the sterile field and increases the risk of infection.
Delayed Readmission After Hospital Clearance
Penalty
Summary
The facility failed to ensure a resident was readmitted back to the facility after the resident was evaluated and cleared by the GACH to return. Resident 1 had diagnoses including acute respiratory failure, COPD, muscle weakness, and type 2 DM. The resident’s MDS indicated the resident could express wants and ideas, understand others, and was dependent on nursing staff for toileting, showering, dressing, sitting up, lying down, and rolling from left to right. On 5/13/2026, Resident 1 complained of chest pain radiating to the back with a pain score of 7/10 and was transferred to the GACH for further evaluation. The Community Liaison stated she received a call from the GACH on 6/5/2026 asking whether the facility would accept Resident 1 back and told them the resident could return when ready. She requested the resident’s medical records for DON review, and the DON determined it was appropriate to accept the resident back. However, the resident was not readmitted until 6/12/2026. The Community Liaison stated she did not speak with the resident or GACH staff on 6/5/2026 and later explained there had been a misunderstanding about the facility not readmitting the resident. The DON stated the facility’s admission criteria policy was not followed when determining whether to accept the resident back.
Failure to Document Resident Refusal and Inventory Contents of Personal Belongings
Penalty
Summary
The deficiency involves the facility’s failure to properly document a resident’s refusal to have the contents of her backpack inventoried at admission, resulting in the facility being unable to determine what was inside the backpack, including the amount of cash the resident later reported missing. The resident was admitted with COPD with acute exacerbation, left lower limb cellulitis, and muscle weakness, and her H&P indicated she could make her own medical decisions. Her MDS showed moderately impaired cognition and that she required varying levels of assistance with ADLs, and also documented that it was somewhat important to her to take care of her personal belongings. Upon admission, an undated Resident Clothing and Possessions Form listed several items, including a backpack and “important documents,” but did not list the contents of the backpack or any documentation that the resident refused to have the backpack inventoried. The resident later reported to a complainant and family that a white envelope containing an unknown amount of cash in $20 bills was missing from her backpack. The complainant stated the resident recalled withdrawing approximately $200 before hospitalization and that the resident did not know when or where the money went missing and did not remember having the money while at the acute care hospital. In a separate interview, the resident stated she had withdrawn approximately $600 before hospitalization, combined it with other funds to pay rent, and had leftover money in several $20 bills, but she was unsure of the remaining amount. She stated she had the backpack at the hospital, kept it on her bedside table at the facility, did not put it away when sleeping or leaving the room, did not remember telling the facility she had money in the backpack, and did not report the missing money to the facility. Staff interviews and record reviews showed that the facility’s admission inventory process was not fully followed or documented for this resident. The Social Services Director and Director of Staff Development explained that facility practice and training required completion of an inventory list upon admission, including contents of items such as backpacks, and that refusals to allow inventory should be reported to a nurse and documented on the inventory form and in nursing progress notes, along with education about the importance of inventorying belongings. CNA 1, who completed the inventory, acknowledged she did not date the inventory list and stated she checked that the resident had a backpack but did not look inside because the resident refused, reporting that the resident said the backpack contained only important documents and no money or wallet. CNA 1 stated she reported the refusal to a charge nurse but did not document the refusal on the inventory list and admitted this was her mistake. Review of nursing progress notes showed no documentation of the resident’s refusal or of any education about inventorying the backpack’s contents. The DON stated it was important to document the contents of the backpack or the resident’s refusal and related education, and that without such documentation the facility was unable to determine how much money the resident had. Facility policies on admission documentation and theft and loss required that all personal belongings be accounted for and that a written personal property inventory be completed on admission, with residents and/or families cautioned about keeping valuables in rooms. The combination of the incomplete inventory list, lack of dating of the form, absence of documentation of the resident’s refusal to allow inspection of the backpack’s contents, and lack of documented education about the risks of keeping valuables in an uninventoried backpack at bedside led to the deficiency. Because the contents of the backpack were never itemized and the resident’s refusal and related education were not recorded in the medical record, the facility could not verify or determine the amount of cash or other valuables that may have been present when the resident was admitted, after she later reported missing money.
Blocked Exit Door and Water Intrusion Create Unsafe Egress Route
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe and unobstructed exit and to prevent water intrusion that created an unsafe exit route in a shared resident room. Surveyors observed that one resident’s bed was positioned so that the head of the bed partially blocked a door marked with signage as an emergency exit, stating “Exit WARNING!! ALARM WILL SOUND EMERGENCY EXIT ONLY!” This door was identified in the facility’s Disaster and Evacuation Plan as an exit leading to a back patio. The facility’s Fire and Disaster Policy/Procedure required that exit ways be kept clear at all times and that exit doors never be blocked, but this requirement was not followed in the room occupied by four residents. Resident 1, who had a displaced transverse fracture of the right patella, moderately impaired cognition, and required supervision or touch assistance with ADLs, had been assigned to the current bed for several days. During observation, her bed was found positioned halfway blocking the exit door. Resident 1 reported that on a recent day of heavy rain, water flooded the floor near her bed, and her clothing became wet. She believed the water came in from under the exit door and stated that she hung her wet clothes on a chair to dry because she was concerned they could develop mildew and odors. Residents 3, 6, and 7 also occupied the same room and all had severely impaired cognition and required substantial to total assistance with ADLs. The Maintenance Supervisor confirmed that the exit door was unlocked, operable via the push bar, and led to a back patio, and acknowledged that Resident 1’s bed was partially blocking the exit and would need to be moved for full access in an emergency. He stated that flooding had been reported to him after it occurred, that housekeeping had already mopped and placed towels, and that the flooding was caused by heavy rain entering under the exit door, wetting some of Resident 1’s clothing that was kept on the floor. He also stated that no changes were made to the door to prevent future flooding. The DON and Administrator both stated that, despite the door being marked as an exit on the floor map, it was not considered part of the emergency exit plan and staff were not trained to use it during emergencies, while also acknowledging that having an exit door by the bed could impact resident safety.
Resident Bed Placement by Flood-Prone Exit Door Compromises Living Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment when a resident’s bed was positioned so that the head of the bed partially blocked an exit door that was marked as an emergency exit. The resident, who had been admitted with a displaced transverse fracture of the right patella and had moderately impaired cognition, required supervision or touch assistance for ADLs. During observation, the resident was seen hanging a pair of pants and two shirts over a towel on a chair next to the bed. The resident reported that she had been in that bed for about six to seven days and that on the previous day water had flooded the floor near her bed during rain, causing her clothing to become wet, which led her to hang the clothes on the chair to dry. The Maintenance Supervisor stated that the flooding incident was reported to him after it had already occurred and that when he arrived, housekeeping had already mopped and towels had been placed to absorb remaining water. He attributed the flooding to heavy rainwater entering under the exit door and acknowledged that some of the resident’s clothing became wet because she kept belongings on the floor. The exit door in the resident’s room was observed to be unlocked and operable via a push bar leading to a back patio area. The Maintenance Supervisor confirmed that no changes were made to the door to prevent future water intrusion. The DON stated that the flooding near the resident’s bed was reported to her later and acknowledged that having an exit door by the bed could impact the resident’s safety. The Administrator stated that the resident’s belongings would not have been wet if the bed had not been positioned by the exit door.
Failure to Provide Toileting Hygiene for Dependent Resident
Penalty
Summary
The facility failed to provide toileting hygiene care after a bowel movement for a resident who was dependent on staff for all activities of daily living, including toileting hygiene. The resident had a history of acute respiratory failure, a Stage 3 pressure ulcer on the right buttock, and neuromuscular dysfunction of the bladder, and was assessed as having moderate cognitive impairment and requiring maximal to total assistance for personal care. Emergency personnel reported that the resident was found with soiled incontinence briefs and had not been changed or showered in some time when transported from the facility. Interviews with staff and review of documentation revealed inconsistencies and lack of clarity in how toileting hygiene was recorded. The CNA task flowsheet did not have a specific section to document whether toileting hygiene was provided after a bowel movement, and staff relied on assumptions that care was given if a bowel movement was recorded. Documentation showed a gap between the last recorded bowel movement and the last documented toileting hygiene, with no clear evidence that hygiene care was provided after the resident's last bowel movement. The facility's policy required assistance with activities of daily living for residents unable to perform them, but this was not consistently documented or verified in practice.
Failure to Prevent and Manage Pressure Ulcers Resulting in Wound Deterioration
Penalty
Summary
A resident with a history of left femur fracture, joint replacement surgery, and type 2 diabetes was admitted to the facility with existing wounds, including a left heel blister and a right heel suspected deep tissue injury (SDTI). Upon admission, the facility failed to document comprehensive wound assessments, including descriptions and measurements of the wounds. The initial skin integrity check did not provide adequate baseline information, and subsequent weekly wound assessments were not documented as required by facility policy. The left heel blister was reclassified as an SDTI three days after admission, but this change was not communicated to the physician, and the care plan was not updated in a timely manner to reflect the new wound status or necessary interventions. The facility did not implement or consistently provide essential interventions to prevent the progression of the resident's wounds. The resident did not consistently receive offloading measures such as heel protector boots or a low air loss mattress, and nutritional supplements to promote wound healing were not initiated until much later. The interdisciplinary team, including the DON, treatment nurse, and registered dietician, did not meet to discuss or coordinate care for the resident's wounds. The resident was not referred to a wound care practitioner despite the presence of worsening wounds, and the physician was not notified when the left heel blister was reclassified as an SDTI or when the wound developed signs of infection, including foul odor, eschar, and slough. As a result of these failures, the resident's left heel blister and right heel SDTI progressed to unstageable pressure injuries, causing significant pain and requiring transfer to an acute care hospital for further management. The resident received intravenous antibiotics, pain management, and hydration in the emergency department. Interviews with staff and family members confirmed lapses in wound care, documentation, communication, and timely intervention, all of which contributed to the decline in the resident's condition.
Failure to Maintain or Improve Range of Motion and Mobility
Penalty
Summary
The facility failed to provide appropriate care and services to maintain or improve range of motion (ROM) and mobility for three residents with identified ROM and mobility concerns. For one resident with a history of muscle weakness, diabetes, peripheral vascular disease, and difficulty walking, the facility did not provide a physical therapy screening or evaluation after a decline in the ability to perform sit-to-stand transfers was identified. The resident's restorative nursing aide (RNA) program for sit-to-stand transfers was discontinued without a therapy evaluation, and no interventions were implemented to address the decline, despite facility policy requiring such actions. The resident did not receive a right-hand splint to prevent further ROM decline, even though significant limitations and contractures were observed and confirmed by occupational therapy. Additionally, the facility did not provide active assistive range of motion (AAROM) exercises to both arms and legs as ordered by the physician on a specified date. The report also documents that the facility did not accurately assess another resident's right hand during a joint mobility evaluation and failed to provide passive range of motion (PROM) exercises to both wrists during an RNA session, as ordered by the physician. For a third resident, the facility did not provide ROM exercises to both wrists, hands, and ankles during an RNA session, again failing to follow physician orders. These failures were identified through record reviews, staff and resident interviews, and direct observations of care sessions, which revealed inconsistencies between ordered care and care provided. As a result of these failures, one resident lost the ability to stand and experienced frustration and feelings of debilitation. The lack of appropriate interventions and assessments also created the potential for further ROM decline in the affected residents. The facility did not complete required interdisciplinary team (IDT) care plan reviews or document discussions regarding the residents' declines in mobility, and there was no evidence that therapy evaluations were requested or conducted when declines were identified.
Failure to Protect Resident from Mental Abuse by Family Member
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident with a history of physical and emotional abuse from further mental abuse by a family member. The resident, who had diagnoses including confirmed physical abuse, major depressive disorder, and anxiety disorder, had an open Adult Protective Services (APS) case against a specific family member. The resident had clearly expressed to the facility's interdisciplinary team and case manager that she did not want any contact, calls, or visits from this family member, citing a long history of various forms of abuse. The care plan and medical record documented these wishes, and staff were notified accordingly. Despite these documented restrictions, the family member was able to enter the facility on two separate occasions. On the second occasion, the family member bypassed safety checks, pushed past staff, and attempted to enter the resident's room while she was receiving perineal care, trying to pull back the privacy curtain and shouting at the resident. The resident was visibly distressed, shaking her head no, tearful, and later required medication for anxiety. Staff intervened and called the police to remove the family member from the premises. The resident's emotional distress was documented, and a new order for Ativan was issued to manage her anxiety following the incident. The facility failed to implement its own abuse prevention policy, which required protecting residents from all forms of abuse, including mental abuse, and ensuring the health and safety of residents regarding visitors. The policy also indicated that room changes should be considered for resident safety, but there was no evidence that a room change was offered after either incident. Additionally, the administrator did not conduct a thorough investigation or report the incident to the state agency, as required by policy, due to incomplete information from staff. The resident's name remained posted outside her room, which may have facilitated the family member's access.
Failure to Maintain Resident Privacy and Dignity During Personal Care
Penalty
Summary
Facility staff failed to protect and promote the rights of a resident by not maintaining privacy and dignity during personal care. During an observation, a resident with hemiplegia, hemiparesis, and a cognitive communication deficit was found lying in bed with his genital area exposed. While two CNAs assisted the resident in turning and repositioning, his back and buttocks were also exposed. The genital area remained uncovered even after repositioning, and the privacy curtain between the resident and his roommate was left open throughout the care. The roommate was awake and positioned to potentially observe the care being provided. Both CNAs acknowledged that the resident should have been covered and the curtain closed to protect privacy. The resident's medical records indicated significant physical and cognitive impairments, requiring maximal to total assistance for personal hygiene and showering. The facility's policy required that residents be treated in a manner that maintains privacy, including the use of closed doors or drawn curtains during personal care. The Director of Nursing confirmed that residents should be covered when not actively receiving care and that privacy curtains should be closed if a resident's genital area is exposed during care.
Failure to Conduct and Document Required IDT Care Plan Meetings
Penalty
Summary
The facility failed to ensure that two of four sampled residents had Interdisciplinary Team (IDT) meetings to discuss their plan of care and discharge goals. For one resident, the admission record indicated diagnoses of dementia, bipolar disorder, and Type II Diabetes Mellitus, with mild cognitive impairment and significant assistance required for daily activities. Although an IDT meeting was reportedly conducted with the resident's representative over the phone, the Social Service Director stated that the meeting documentation was not included in the medical record, as it was kept exclusively by her and not entered into the chart. For another resident, admitted with dementia, a fracture, and traumatic subarachnoid hemorrhage, the record review and staff interviews confirmed that no IDT meeting was conducted, despite the resident being able to make her own medical decisions and having intact cognitive skills. The facility's policy requires that IDT meetings be held within 72 hours of admission to address the plan of care, concerns, medications, dietary preferences, and discharge plans. Both the Social Service Director and Director of Nursing acknowledged that the required IDT meetings were not completed or documented as per policy.
Failure to Conduct and Document Required IDT Care Plan Meetings
Penalty
Summary
The facility failed to ensure that two of four sampled residents were provided with Interdisciplinary Team (IDT) meetings to discuss their person-centered plan of care and discharge goals. For one resident, the admission record indicated diagnoses including dementia, bipolar disorder, and Type II Diabetes Mellitus, with mild cognitive impairment and significant assistance required for daily activities. Although an IDT meeting was reportedly conducted with the resident's representative over the phone, the Social Service Director (SSD) stated that the documentation of this meeting was not included in the medical record, as it was kept exclusively by her and not entered into the chart. For another resident, who had diagnoses including dementia, a fracture, and traumatic subarachnoid hemorrhage, and was cognitively intact, the SSD confirmed that an IDT meeting was not conducted, despite facility policy requiring such meetings within 72 hours of admission. The Director of Nursing (DON) also confirmed that IDT meetings are necessary to address the resident's plan of care and that failure to conduct these meetings could result in residents' problems not being addressed. The facility's policy specifies that the IDT should include various professionals and, to the extent practicable, the resident or their representative.
Failure to Obtain Advance Directive Upon Admission
Penalty
Summary
The facility failed to obtain a copy of a resident's Advance Directive (AD) upon admission, as required by facility policy. The resident was admitted with diagnoses including cerebral infarction and metabolic encephalopathy, and their cognitive skills were noted to be moderately impaired. Documentation indicated that the resident had an AD and needed to bring a copy, but the facility did not secure this document at the time of admission. Both the Social Service Director and the Director of Nursing confirmed during interviews that the AD was not obtained, despite acknowledging the importance of having this information available in the resident's health record. A review of the facility's policy revealed that staff are required to provide written information about advance directives to residents or their representatives and to obtain and file a copy of the AD in the resident's health record when available. In this case, the required documentation was not collected or placed in the record, resulting in a deficiency related to honoring the resident's right to have their healthcare wishes known and respected.
Failure to Notify Physician and Family of Change in Condition for Two Residents
Penalty
Summary
The facility failed to notify responsible parties and physicians of significant changes in condition for two residents, resulting in delayed care and treatment. For one resident with a history of left femur fracture, diabetes, and recent hip surgery, a left heel wound initially identified as a blister progressed to a suspected deep tissue injury (SDTI) and later to an unstageable pressure injury with eschar, slough, and foul odor. Despite clear changes in the wound's appearance and the resident's increasing pain, the physician was not notified of the deterioration on the day it was observed. Documentation did not reflect timely communication or comprehensive wound assessments, and the resident was ultimately transferred to an acute care hospital for further evaluation and treatment after the wound worsened. Another resident, who lacked decision-making capacity and had a family member as the responsible party, developed right buttock redness that progressed to moisture-associated dermatitis (MASD), then to an unstageable pressure injury requiring debridement, and eventually to a stage four pressure injury. The family member was not informed of the initial skin changes or subsequent wound progression until the injury had reached stage four. Facility staff acknowledged that the family should have been notified at each stage of the wound's development, and the DON confirmed that both herself and the family member were not informed in a timely manner as required. Facility policies required prompt notification of physicians and responsible parties for changes in resident condition, as well as thorough documentation and escalation of wound care concerns. However, interviews and record reviews revealed that these protocols were not followed for either resident, resulting in a lack of timely intervention and communication regarding significant changes in their health status.
Failure to Develop and Implement Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for three residents, resulting in unmet needs and inadequate care. For one resident with a left heel blister, the care plan was not updated in a timely manner to reflect the progression to a suspected deep tissue injury (SDTI). Although clinical documentation and wound care consults identified the need for specific interventions such as offloading the heel and using specialized mattresses, these interventions were not incorporated into the care plan until several days after the wound was reclassified. Interviews with nursing staff and the DON confirmed that the care plan update and implementation of person-centered interventions were delayed, despite the recognized importance of immediate action for wound healing and prevention of further decline. Another resident experienced a prolonged period of not being weighed, with no weight recorded for five months. The care plan only generically noted the resident's preference not to be weighed, without documenting the underlying reason or providing interventions to address the refusal. Interviews and observations revealed that the resident's refusal was due to pain caused by the lift equipment used for weighing, not a lack of willingness. The facility did not assess or accommodate this need, nor did they document efforts to resolve the issue. When the resident was finally weighed with proper support, a significant weight loss was discovered, which had gone unmonitored due to the lack of a comprehensive and individualized care plan. A third resident's care plan was not adequately personalized upon admission or when new skin issues developed. The resident, who had multiple risk factors including cognitive impairment and immobility, developed a right buttock pressure injury that progressed from redness to an unstageable wound and eventually to a stage four pressure injury. The care plan did not reflect timely updates or specific interventions in response to changes in the resident's condition. Staff interviews indicated that risk assessments were not reassessed when the resident's condition changed, and necessary interventions such as increased repositioning and nutritional support were not promptly implemented or documented in the care plan.
Failure to Complete Neurology Consults and Determine Decision-Making Capacity
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders and residents' needs for two of three sampled residents. For one resident with diagnoses including metabolic encephalopathy, cerebral infarction, and a lower spinal cord compression fracture, there were physician orders for a neurology consult within 2-4 weeks and a subsequent neuro consult for dementia. However, the resident was not seen by a neurologist as ordered. The resident's family member confirmed that the neurology appointment was missed, and facility staff interviews revealed that there was no documentation of appointment confirmation or follow-up in the resident's chart. The case manager was responsible for arranging and documenting such appointments, but this process was not completed, resulting in the missed consult. For another resident admitted with encephalopathy and a cognitive communication deficit, the medical record and assessments indicated severe cognitive impairment. The resident's history and physical noted that decision-making capacity should be deferred to psychiatry or neurology, but there was no clear documentation in the record regarding the resident's capacity to make decisions. Although the resident was seen by psychiatry, the visit summary did not address decision-making capacity, and the resident was not seen by neurology. Facility staff acknowledged that the determination of capacity was not completed or documented as required. Facility policies reviewed indicated that social services are responsible for ensuring medically related social services, including scheduling and transportation for appointments, and that informed consent procedures require documentation of a resident's capacity or surrogate decision maker. In both cases, the facility did not follow through with required consults and documentation, resulting in failures to meet physician orders and to determine and document decision-making capacity.
Failure to Ensure Competency in Wound Care and Documentation
Penalty
Summary
The facility failed to ensure that nurses and nurse aides demonstrated appropriate competencies in caring for residents with pressure injuries, as evidenced by the care provided to two residents. For one resident with a history of left femur fracture, diabetes, and recent hip surgery, the treatment nurse did not perform or document weekly wound assessments as required by the facility's Wound Management and Prevention Policy. The nurse also failed to complete a change of condition assessment or notify the physician when the resident's left heel wound changed from a suspected deep tissue injury to an unstageable pressure injury. The medical record lacked accurate and timely documentation of the wound's progress, and the physician was not informed of the wound's decline, despite the presence of eschar, slough, and signs of infection. The resident's wound worsened, requiring further medical intervention and wound care consultation. Another resident, admitted with multiple diagnoses including metabolic encephalopathy and a history of stroke, developed a right buttock pressure injury that progressed from redness to moisture-associated skin damage, then to an unstageable injury, and ultimately to a stage four pressure injury. The Director of Nursing was not aware of this resident's pressure injury until it had reached stage four, and there was no evidence of clinical oversight or timely escalation of the wound's status. The care plan and treatment administration records indicated ongoing changes in the wound's condition, but the DON was not informed of these changes, and interventions such as increased repositioning and offloading were not implemented in a timely manner. Interviews with staff, including the treatment nurse and DON, confirmed that required wound assessments, documentation, and physician notifications were not completed according to facility policy. The DON acknowledged that wounds should be assessed upon admission, for any changes, and weekly, with all findings recorded in the resident's chart. The treatment nurse admitted to not documenting wound progress or notifying the physician of significant changes, and the DON confirmed a lack of oversight and monitoring for residents with pressure injuries. These failures resulted in a lack of accurate documentation and delayed care for both residents.
Failure to Complete Psychosocial and Trauma Assessments on Admission
Penalty
Summary
The facility failed to provide medically-related social services to two out of four sampled residents by not completing required psychosocial and trauma assessments upon admission. For one resident with diagnoses including influenza, PTSD, and anxiety disorders, there was no trauma assessment or social services assessment completed at the time of admission. The Social Services Director confirmed that all residents should be screened for trauma on admission to ensure appropriate treatment and resources, but this was not done for the resident in question. Another resident, admitted with dementia, a fracture, a history of assault, and traumatic subarachnoid hemorrhage, also did not receive a trauma assessment or social services assessment upon admission. The Social Services staff indicated that trauma assessments were only performed if a resident had a diagnosis of PTSD, despite the resident's history of assault. The staff also stated that the social services assessment, which includes trauma-related questions, was not completed at the time of admission, as they believed they had up to a week to do so. Interviews with the Director of Nursing confirmed that trauma and psychosocial assessments should be initiated upon admission for all residents, regardless of diagnosis, to identify any needs or triggers that may require additional support. Facility policies reviewed indicated that social services and behavioral health assessments are to be completed for all new admissions to ensure the highest practicable well-being, but these were not followed in the cases identified.
Failure to Maintain Pharmaceutical Services and Medication Administration Standards
Penalty
Summary
The facility failed to maintain proper pharmaceutical services in several key areas. There was no separate record kept for emergency drug usage from the Cubex automated dispensing system, as required by state regulations. The discrepancy summary reports provided by the pharmacy did not include resident names or other necessary details, and the facility did not maintain records for emergency drug usage retrieved from the Cubex. The emergency kit logbook was only used for intravenous kits, and the oral emergency kits had been replaced by Cubex without an appropriate record-keeping system in place. Additionally, the facility did not ensure that two licensed nurses signed off on the disposition of non-controlled drugs, as evidenced by a missing witness signature on the Medication Disposition Log for a drug destruction event. The facility's policy required signatures of both the nurse performing the destruction and a witness, but this was not followed. This lapse was confirmed during interviews and a review of the facility's policy and procedure documents. There were also failures in medication administration and verification processes. Nurses did not consistently check medications received from the pharmacy against physician orders and medication administration records. This resulted in one resident receiving the wrong dose of benazepril and another receiving the wrong formulation of morphine. Furthermore, a nurse crushed medications for a resident without a physician order to do so, despite the resident being on a puree diet for non-medical reasons. The facility lacked a policy on medication administration guidance, and nurses were expected to follow standard nursing practice.
Medication Error Rate Exceeds 5% Due to Incorrect Drug Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by three medication errors out of 31 observed opportunities, resulting in a 9.68% error rate. In one instance, a resident with hypertension and heart failure was administered benazepril 40 mg instead of the ordered 20 mg, and was also given vitamin C 500 mg, which was not prescribed, instead of the ordered calcium 500 mg. The nurse involved acknowledged the errors after reviewing the resident's physician orders and medication packaging, confirming that the medications administered did not match the orders. In another case, a resident with a history of surgical aftercare and chronic lymphocytic leukemia was prescribed morphine sulfate ER 15 mg every 12 hours for pain management. During medication administration, the nurse gave the resident morphine IR 15 mg instead of the prescribed extended-release formulation. The nurse confirmed the discrepancy after reviewing the medication packaging and physician orders. These errors were directly observed during medication passes and confirmed through interviews and record reviews.
Significant Medication Errors Due to Incorrect Drug and Dose Administration
Penalty
Summary
The facility failed to ensure that two residents were free from significant medication errors. In the first instance, a resident with a history of surgical aftercare and chronic lymphocytic leukemia was ordered to receive morphine sulfate extended release (ER) 15 mg every 12 hours for pain management. Instead, the resident was administered morphine sulfate immediate release (IR) 15 mg, which did not match the physician's order. The error was identified when the nurse reviewed the medication bubble pack and the order, noting the discrepancy. The resident reported inadequate pain relief and required additional doses of Norco for breakthrough pain, as documented in the electronic medication administration record (eMAR) and confirmed by the resident and nursing staff interviews. In the second instance, another resident with hypertension and heart failure was ordered benazepril 20 mg once daily. However, the resident was administered benazepril 40 mg, which was dispensed by the pharmacy in error. The nurse failed to identify the incorrect dose during medication administration, despite facility policy requiring verification of the correct drug and dose against the order and eMAR. The director of nursing confirmed that the pharmacy sent the wrong medication and acknowledged the risk associated with the higher dose. Both incidents were observed during medication pass observations and were corroborated by interviews with nursing staff and review of medical records. The facility's policy on the six rights of medication administration was not followed, resulting in significant medication errors for both residents.
Failure to Follow Standardized Recipes and Portion Sizes for Modified Diets
Penalty
Summary
The facility failed to ensure that standardized recipes and portion sizes were followed for residents on modified diets during a lunch service. Specifically, the cook used a smaller scoop than required, resulting in residents on ground texture diets receiving 2 2/3 ounces of BBQ chicken instead of the 3 ounces specified in the menu. The cook admitted to not consulting the food portion and serving guide, leading to the incorrect portion being served. The dietary supervisor confirmed that the wrong scoop was used and that residents on ground diets received less food than those on regular diets. Additionally, residents on mechanical soft diets received BBQ chicken that was cut into inconsistent sizes rather than being ground as required by the menu and recipe. The mechanical soft and regular chicken were served from the same tray, and the mechanical soft chicken was not prepared to the correct texture. Both the cook and the dietary supervisor acknowledged that the menu and spreadsheet were not followed, and the registered dietitian verified that the recipe called for ground chicken, not cut pieces. The speech therapist emphasized the importance of following the correct texture for residents with chewing or swallowing difficulties. For residents on pureed diets, the facility did not follow the recipe for pureed BBQ chicken. Instead of blending the BBQ sauce with the chicken, the cook served plain pureed chicken with BBQ sauce poured on top. The dietary supervisor stated that this did not meet the recipe requirements and could lead to meal dissatisfaction. Review of facility policies and job descriptions confirmed that staff are required to follow standardized recipes and portion control procedures for all therapeutic diets.
Failure to Follow Infection Control Protocols and Report Outbreaks
Penalty
Summary
The facility failed to follow proper infection prevention and control protocols in several instances involving residents with infectious conditions and indwelling medical devices. For one resident on contact isolation for Clostridium difficile (C. diff), staff were observed delivering a lunch tray without wearing required personal protective equipment (PPE) such as gown and gloves, despite signage indicating transmission-based precautions. Additionally, a family member was present in the room without PPE and reported never being instructed to use it. Interviews with staff confirmed that all individuals entering a transmission-based precautions room should wear PPE, and that visitors should be educated and reminded to comply, but this was not consistently enforced. Another resident with an indwelling urinary catheter and under enhanced barrier precautions (EBP) was observed with their catheter bag resting on the floor, and a certified nurse assistant handled the bag without wearing gown or gloves. The CNA acknowledged the bag should not be on the floor and that it was missing a hook, but still failed to use appropriate PPE. The infection preventionist confirmed that EBP requires staff to wear gown and gloves during high-contact care activities, such as handling a catheter bag, to reduce infection risk. The facility also failed to report an outbreak of C. diff to local and state health departments, as required by policy. Infection surveillance data showed multiple positive cases over several months, meeting the facility's definition of an outbreak. The infection preventionist and director of nursing both acknowledged that the outbreak should have been reported to ensure proper guidance and resources for infection control, but this was not done. Facility policies reviewed confirmed the requirements for PPE use, catheter care, and outbreak reporting, which were not followed in these instances.
Failure to Monitor and Document Immunization Status for Flu and Pneumococcal Vaccines
Penalty
Summary
The facility failed to adequately monitor and document the immunization status for influenza and pneumococcal vaccinations for two residents. For one resident with chronic obstructive pulmonary disease, atrial fibrillation, and hypertension, there were inconsistencies in the records regarding vaccination status. The admission record and a spreadsheet indicated refusal or unknown status for the vaccines, while a consent form stated the resident had already received them. The Infection Preventionist Nurse (IPN) was unable to verify vaccination status through the California Immunization Registry and relied on resident or family reports, but no definitive documentation was available in the medical record. For another resident with Type II diabetes mellitus, heart failure, and hypertension, the records also showed refusal or unknown status for the vaccines. The consent form indicated a verbal refusal, but the IPN could not confirm vaccination history through the registry or other documentation. The facility's policy required screening and documentation of immunization status upon admission, but this was not consistently followed, resulting in incomplete medical records for both residents.
Failure to Document and Track COVID-19 Vaccination Status for All Staff
Penalty
Summary
The facility failed to provide documented evidence of COVID-19 vaccination screening, education, offering, and current vaccination status for all employees, including on-call and part-time staff, as well as medical doctors and other licensed professionals who enter the facility. During interviews, the Infection Prevention Nurse (IPN) acknowledged not having the COVID-19 vaccination status for these groups and stated that such information is important to prevent staff from being exposed to and acquiring the infection. The Director of Nursing (DON) confirmed that all employees, including the Director of Staff Development, nurses, CNAs, MDs, and NPs, are considered staff and that vaccination status is important to prevent outbreaks. A review of the facility's policy and procedure on staff immunizations indicated that staff includes anyone providing care, treatment, or services for the facility or its residents, including those under contract or other arrangements, and that documentation of vaccination should be maintained. The policy also requires the Infection Preventionist to maintain surveillance data on vaccine coverage and reported rates among residents and staff. The lack of documentation and tracking for all required staff groups led to the deficiency.
Failure to Implement Fall Risk Communication Protocol
Penalty
Summary
The facility failed to follow its own Falling Star Program policy, which requires a star sticker to be placed on the door tag of any resident who has fallen within the last 30 days. Despite having fallen four times in the past four months and being assessed as high risk for falls, a resident did not have the required falling star sticker on their door post. Multiple observations confirmed the absence of the sticker, and staff interviews revealed that the lack of this indicator led to staff being unaware of the resident's fall risk status. As a result, staff did not provide the level of supervision or precautions that would have been indicated for a high fall risk resident. The resident involved had significant cognitive impairment, a history of dementia, and was dependent on staff for most activities of daily living. Documentation showed that the resident had experienced multiple falls and was consistently assessed as high risk for falls. However, the communication tool intended to alert staff to this risk—the falling star sticker—was not utilized as required by facility policy, leading to a lack of appropriate supervision and interventions.
Failure to Replace Oxygen Cannula as Required by Policy
Penalty
Summary
The facility failed to follow its own policy and procedure regarding the timely replacement of oxygen delivery equipment for a resident with significant respiratory needs. Specifically, the policy required that the oxygen cannula or mask and the disposable humidifier be changed at least every seven days. However, for one resident with diagnoses including acute respiratory failure with hypoxia and chronic obstructive pulmonary disease (COPD), the nasal cannula in use was observed to be dated more than seven days prior, indicating it had not been replaced as required. This was confirmed during observations and interviews with facility staff, including the Director of Staff Development and the Director of Nursing, who both acknowledged the cannula should have been changed weekly to prevent infection. The resident in question had moderate cognitive impairment and required varying levels of assistance with daily activities, including being dependent for personal hygiene and toileting. The resident had a continuous oxygen order via nasal cannula, with specific orders to change the cannula and humidifier every Sunday. Despite these orders and the facility's policy, the cannula remained in use beyond the prescribed timeframe, as verified by the date marked on the equipment and staff interviews. The failure to replace the nasal cannula as scheduled constituted a breach of the facility's infection control practices.
Failure to Ensure Timely Physician Face-to-Face Visits
Penalty
Summary
The facility failed to ensure that a physician conducted a face-to-face visit with a resident at least once every 60 days, as required by facility policy. Review of the resident's records showed that the last physician note was dated 1/28/2025, and there were no subsequent notes or documentation of a physician visit in the electronic medical record or the resident's chart. The Assistant Director of Nursing (ADON) confirmed that the resident, who was classified as custodial, had not been seen by a physician since that date, despite the expectation that such residents are to be seen every two months. The resident involved had a history of Type II Diabetes Mellitus, heart failure, and hypertension, and was assessed as having severely impaired cognitive skills and being dependent on all activities of daily living. The facility's policy required physician visits at least every 30 days for the first 90 days after admission and at least every 60 days thereafter. The deficiency was identified through interviews and record reviews, which confirmed the absence of required physician visits and documentation.
Failure to Honor Resident Food Allergy and Preference
Penalty
Summary
A deficiency occurred when a resident with a documented allergy and dislike to strawberries was served strawberry flavored gelatin during lunch. The resident's Nutrition-Quarterly Evaluation listed a strawberry allergy, and the meal ticket on the lunch tray also indicated this allergy. Despite this, dietary staff placed strawberry gelatin on the resident's tray, and the resident reported receiving and not consuming the dessert due to the allergy. The dietary supervisor confirmed awareness of the resident's allergy and acknowledged that an alternative dessert should have been provided, regardless of the gelatin containing only artificial flavorings. Observations during meal service and interviews with both the resident and dietary staff confirmed that the resident's food preferences and allergies were not honored as required by facility policy. The policy states that food preferences are to be adhered to and updated as resident needs change. The failure to provide an appropriate dessert option resulted in the resident not receiving a meal that accommodated their documented allergy and preference.
Inaccurate Documentation of Restorative Nursing Services
Penalty
Summary
The facility failed to ensure accurate and complete medical record documentation for a resident with range of motion (ROM) and mobility concerns. Specifically, the Restorative Nursing Aide (RNA) services provided to the resident were not properly documented, as the records did not accurately indicate which RNA performed active assistive range of motion (AAROM) exercises and sit-to-stand transfers on multiple dates. Review of the facility's sign-in sheets and payroll records revealed that the RNAs who initialed the records for providing services were not present or did not work on those dates. Additionally, there were inconsistencies between different versions of the resident's restorative nursing records, including future discontinue dates and discrepancies in which staff were documented as providing care. The resident in question had a medical history including muscle weakness, diabetes mellitus, peripheral vascular disease, and difficulty walking. Physician orders required the RNA to provide AAROM to both arms and legs and to assist with sit-to-stand transfers using a front wheeled walker, with changes to the orders over time as the resident's condition evolved. Observations and interviews confirmed that the resident received ROM exercises and that the resident was aware of some changes in their care, but was not always informed about discontinuation of certain services. During direct observation, the resident demonstrated limited ROM in the right hand and more active movement in the left, and described a history of using assistive devices for mobility. Interviews with RNAs and facility leadership confirmed that staff sometimes initialed records for each other or for dates they did not work, and that there was no policy or procedure in place for accurate medical record documentation. The Director of Nursing acknowledged that the medical record is a legal document and that only the staff providing the treatment should sign the record. The lack of accurate documentation resulted in incomplete and inaccurate medical records for the resident's restorative nursing services.
Failure to Ensure Effective QAPI Oversight and Timely Implementation
Penalty
Summary
The facility's Quality Assessment and Assurance Committee (QAA) failed to provide effective oversight and implementation of the Quality Assurance and Performance Improvement (QAPI) plan. The administrator indicated that QAPI projects are initiated for areas of concern that require improvement, such as negative trends, but stated that skin issues were not considered a main focus because they had not previously been widespread. Despite a pressure injury occurring in a resident in February or March, the administrator did not believe the issue was widespread enough to warrant a QAPI project at that time. The QAA minutes from March indicated that weights and pressure ulcers were discussed, but the QAPI plan for skin was not initiated until April. The facility's policy requires the QAA committee to establish and implement a QAPI plan, identify and prioritize performance improvement projects, and monitor corrective actions. However, the delay in addressing skin issues and the lack of timely implementation of a QAPI project for pressure injuries demonstrated a failure to follow these procedures. This deficiency had the potential to allow recurring issues that could impact the quality of care for residents.
Failure to Timely Report Alleged Abuse and Protect Resident from Family Member
Penalty
Summary
The facility failed to immediately report an allegation of abuse to the state agency as required by its own policy and federal regulations. A resident with a history of confirmed physical abuse, major depressive disorder, and anxiety disorder was admitted to the facility after being abused by a family member. Despite clear documentation that the resident did not want contact with the alleged abuser and that the abuser was the subject of an open Adult Protective Services (APS) case, the facility did not report subsequent incidents of potential mental and verbal abuse by the same family member to the state agency within the required timeframe. On two separate occasions, the family member entered the facility and attempted to visit the resident against her wishes. During the second incident, the family member became hostile, pushed past staff, and attempted to enter the resident's room while she was receiving personal care, causing the resident visible distress, fear, and anxiety. Staff and police intervention were required to remove the family member from the premises. Documentation from staff, including the case manager and LVN, described the family member's actions as verbally and emotionally abusive, and noted the resident's significant emotional response, including the need for anti-anxiety medication. Despite these events, the facility's abuse coordinator (administrator) did not conduct a thorough investigation or report the incident to the state agency, citing a lack of complete information from staff and a belief that the incident was a family dynamic rather than abuse. The administrator acknowledged that, according to facility policy, such incidents should be reported and investigated as potential abuse, but this was not done. The resident was not offered a room change for her safety after either incident, and the administrator did not speak directly with the resident about the events.
Failure to Investigate and Report Alleged Abuse by Family Member
Penalty
Summary
The facility failed to investigate an allegation of abuse in accordance with its own policy and procedure for one resident. The resident, who had a documented history of physical abuse, major depressive disorder, and anxiety disorder, was admitted following an incident of confirmed physical abuse by a family member. Upon admission, the care plan and interdisciplinary team notes clearly indicated that the resident did not want any contact with the alleged abuser, and staff were made aware of these wishes. Despite this, the family member was able to enter the facility on two separate occasions, with the second incident involving the family member forcing entry into the resident's room, shouting at the resident, and causing visible emotional distress. During the second incident, staff attempted to prevent the family member from entering the resident's room, but he pushed past them and tried to pull open the privacy curtain while the resident was receiving personal care. The resident was observed to be visibly upset, tearful, and shaking her head in refusal, and required administration of anti-anxiety medication following the event. Staff interviews confirmed that the resident was traumatized by the encounter and that the family member's behavior was verbally and emotionally abusive. The incident was not thoroughly investigated or reported to the state agency as required by the facility's abuse prevention policy. The administrator, who served as the abuse coordinator, acknowledged that she was not fully informed of the details of the incident and did not conduct an interview with the resident regarding the situation. The facility's policy required prompt and thorough investigation of abuse allegations, including interviews with the resident and witnesses, documentation of findings, and protection of the resident from further abuse, such as offering a room change. However, there was no evidence that these steps were taken following either incident involving the family member.
Resident Rooms Below Required Square Footage
Penalty
Summary
The facility failed to ensure that two of its resident rooms met the required minimum square footage per resident, as specified by regulations. Specifically, two multi-bed rooms were found to provide less than 80 square feet per resident, and two single-bed rooms provided less than 100 square feet per resident, based on measurements from the Client Accommodations Analysis form and direct observation. During interviews, the Maintenance Supervisor was unaware of the required square footage standards and believed the rooms were adequate, while the DON acknowledged that insufficient space could hinder residents' ability to store belongings and receive care. These findings were based on direct measurement, staff interviews, and review of facility records.
Medication Administration Delay
Penalty
Summary
Licensed Vocational Nurse (LVN) 1 failed to administer medications on time for five residents, as observed during a survey on March 3, 2025. The medications were scheduled for 9 a.m., but LVN 1 did not administer them as per the physician's orders. This was confirmed through observation, interviews, and a review of the Medication Administration Record (MAR), which was not signed to indicate that the medications had been given. LVN 1 acknowledged the oversight and stated that she would notify the residents' physicians about the missed doses. The residents involved had various medical conditions requiring timely medication administration. Resident 1 had essential hypertension, chronic pain syndrome, and major depressive disorder, with orders for medications such as Amitriptyline and Furosemide. Resident 2 had essential hypertension, hyperlipidemia, and type 2 diabetes mellitus, with orders for medications like Aspirin and Bisoprolol Fumarate. Resident 3 had essential hypertension and cardiomegaly, with an order for Metoprolol ER. Resident 5 had essential hypertension, major depressive disorder, and seizures, with multiple medication orders including Amlodipine Besylate and Keppra. Resident 6 had essential hypertension, muscle weakness, and cardiomegaly, with orders for medications such as Valsartan-Hydrochlorothiazide and Metoprolol ER. The facility's policy and procedures require that medications be administered as prescribed by the attending physician and documented on the MAR before administering the next resident's medication. The Director of Nursing (DON) acknowledged the potential risks of missing daily routine medications, which could lead to adverse reactions and complications. The failure to administer medications as ordered increased the risk of adverse outcomes for the residents involved.
Failure to Label Insulin Vial with Open Date
Penalty
Summary
The facility failed to label a multi-dose vial of Humulin N insulin with an open date, which is necessary to ensure the medication's efficacy and safety. During an observation and interview, a Licensed Vocational Nurse (LVN) found an opened vial of Humulin R insulin in medication cart #2 without an open date label. The LVN acknowledged that whoever opened the vial should have labeled it with the open date but was unaware of when it was opened. The Director of Nurses (DON) confirmed that the insulin should have been labeled with both an open and expiration date to prevent the administration of potentially expired medication.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 5,741 citations issued within 25 miles in the last 12 months — including the 16 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Long Beach
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bel Vista Healthcare Center | 0 mi | ★★★★★ | 0 | 0 |
| Marlora Post Acute Rehab Hosp | 0.6 mi | ★★★★★ | 29 | 1 |
| Pacific Palms Healthcare | 0.6 mi | ★★★★★ | 41 | 0 |
| Coral Cove Post Acute | 0.7 mi | ★★★★★ | 8 | 0 |
| Ocean Ridge Post Acute | 0.7 mi | ★★★★★ | 23 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.