Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Skyline Healthcare Center - La during CMS and state inspections, most recent first.
Failure to care plan cane use and out on pass. A resident with a tibia fracture and walking difficulty left on pass using a cane, but staff had no care plan for cane use and reported he had only been seen using a wheelchair or FWW. Three other residents with DM, HTN, edema, lymphedema, and mobility limitations also had physician-approved out on pass orders and documented sign-outs, yet staff stated no care plans were developed for out on pass interventions or monitoring. The DON stated these care plans communicate care across departments, and staff acknowledged the missing documentation.
Incomplete Out-on-Pass Documentation: The facility failed to keep complete records for several residents who went out on pass. One resident left using a cane and did not have that detail documented, and three other residents had missing documentation for departure and return times, expected return times, and nurse initials on the out-on-pass log and in the medical record. The records also included late entries noting the residents’ returns.
Failure to Assess Safe Use of Cane Before Out on Pass: A resident with a left tibia fracture, difficulty walking, prior falls, and use of a wheelchair/FWW was allowed to leave on pass with a cane. Staff interviews and record review showed the resident had been assessed for wheelchair and FWW use, but there was no documentation of a cane assessment, and the DON stated the resident was not assessed for cane safety before leaving.
A resident with multiple left tibia fractures, gait difficulty, and pain related to internal orthopedic devices experienced an unwitnessed fall documented on a COC evaluation. Despite this event, staff completed fall risk evaluations that recorded low to moderate fall risk scores and incorrectly indicated there had been no falls in the prior three months. During interview and record review, the DON acknowledged the fall should have been reflected on both evaluations with a higher score and that inaccurate fall risk documentation would prevent appropriate fall-prevention interventions, contrary to the facility’s fall management policy.
A resident with fractures of the left tibia and pain related to an internal orthopedic prosthetic device, implants, and grafts had physician orders for acetaminophen for mild pain and hydrocodone-acetaminophen for moderate to severe pain. The facility ran out of the ordered hydrocodone-acetaminophen, and the resident reported severe pain rated 9/10 while only receiving acetaminophen that was ordered for mild pain. An LVN acknowledged administering Tylenol for a pain level of 9 contrary to the pain parameters in the order and stated the medication had run out, while the DON confirmed medications should not run out and recognized the potential for ineffective pain management based on MAR review and the facility’s pain management policy.
A resident with fractures and pain related to orthopedic hardware had PRN orders for acetaminophen for mild pain and hydrocodone-acetaminophen for moderate to severe pain. The facility allowed the hydrocodone-acetaminophen supply to run out, and an LVN administered acetaminophen ordered for mild pain in response to a documented severe pain level of 9. The resident reported not receiving the ordered Norco, described ongoing severe pain and headache, and stated that only Tylenol was given without relief. The LVN acknowledged the medication had run out and that Tylenol was given outside the ordered pain range, while the DON confirmed medications should not run out and noted the potential for ineffective pain management based on the MAR review and facility policies on pain management and medication reordering.
A resident with multiple complex diagnoses exhibited new aggressive behavior, including scratching and injuring staff during care after her requests for different caregivers were not honored. Despite this significant change in condition, the physician was not notified as required by facility policy, and no change of condition documentation was completed.
A resident with multiple complex medical conditions reported being physically handled against her will by two staff members during personal care, despite expressing a desire to wait for the next shift. The incident was communicated to the Administrator, but no immediate investigation or required reporting to authorities was initiated, contrary to facility policy. Staff interviews confirmed the lack of timely action and reporting, resulting in a delayed response to the alleged abuse.
A resident with significant physical and cognitive capacity reported being physically forced into bed by two staff members against her will, describing the incident as traumatizing and abusive. Despite the resident's immediate notification to the administrator and acknowledgment by multiple staff that the event constituted abuse, the facility failed to report the allegation to required authorities within the mandated two-hour timeframe, in violation of its own policy.
A resident with significant physical and neurological conditions alleged that two staff members physically abused her during a transfer, despite her requests to wait for care. The Administrator received the allegation but did not initiate an investigation or report the incident as required by facility policy. Staff interviews confirmed that the incident met the criteria for abuse and should have been reported and investigated, but no action was taken.
A resident with multiple complex medical conditions, who was able to make her own decisions, requested not to receive care from a specific CNA and asked to wait for the next shift for personal care. Despite her repeated refusals, an RN and the CNA proceeded to provide care, physically transferring and changing the resident against her wishes. The resident became distressed and physically resisted, resulting in minor injuries to staff. Facility policy required honoring such refusals, but staff did not follow these procedures, leading to a violation of the resident's rights.
Staff did not promptly inform a resident, the resident's doctor, and a family member about important events such as injury, decline, or room changes that affected the resident, as required by regulation.
Staff did not consistently follow physician orders or honor a resident’s preferences and goals, resulting in care that was not individualized or aligned with the resident’s needs.
A resident with diabetes and hypertension experienced nausea, vomiting, and a critically high blood sugar, but the LVN on duty did not notify the physician, recheck blood sugar, or obtain vital signs as required by orders and facility policy. The LVN also failed to follow infection control procedures by providing a trash can for vomiting. Additionally, the facility did not ensure annual competency assessments and performance evaluations for multiple staff members, with missing documentation and unclear policies regarding assessment frequency.
A resident with limited mobility and a history of falls activated a call light for assistance, but staff did not respond promptly. A respiratory therapist nearby was observed using a cellphone and did not answer the call light, resulting in a delay in meeting the resident's needs for items such as water and oral hygiene supplies. Facility policy requires all staff to answer call lights promptly and restricts personal cellphone use during work hours.
Nursing staff failed to follow a physician's order to hold midodrine for a resident when systolic blood pressure was above 110 mmHg, resulting in the medication being administered on several occasions despite elevated blood pressure readings. The resident had significant cognitive impairment and multiple medical conditions, and the facility's policy requiring adherence to physician orders was not followed.
Two residents experienced incomplete and inaccurate medical record documentation when an LVN failed to correctly record blood sugar checks and medication administration times for a diabetic resident, and staff did not document the time or physician's response after a urine test notification for another resident with severe cognitive impairment. These actions did not follow facility policy for accurate and complete recordkeeping.
A LVN did not follow infection control policy by offering a trash can, rather than a clean basin, to a resident at risk of vomiting. This action was contrary to facility procedures, as confirmed by the Infection Preventionist and an RN, and could have led to cross-contamination.
Failure to complete shift-to-shift endorsement: A resident with anemia and OA had a COC with nausea, vomiting, and feeling sick, but the shift-to-shift report was left incomplete with missing name, signature, date, shift, and cart information. An LVN said the outgoing nurse was responsible for obtaining the incoming nurse’s signature, while another LVN said no proper endorsement was given. The DSD and RN confirmed the facility could not show the LVN was competent to follow the endorsement process.
Several residents were placed in beds with bolsters or concave mattresses, which staff acknowledged could act as physical restraints, without obtaining a physician's order, informed consent, or completing a restraint assessment. Despite residents' high fall risk and complex medical conditions, these devices were used without being incorporated into care plans or documented as required by facility policy. Staff and the DON confirmed that the necessary procedures for restraint use were not followed.
Licensed nursing staff did not rotate subcutaneous insulin injection sites for several residents with diabetes, despite facility policy, physician orders, and manufacturer guidelines requiring site rotation. This practice was confirmed through record review and staff interviews, with repeated injections administered in the same anatomical locations over time.
Surveyors found that several residents at high risk for falls had furniture and medical equipment, such as overbed tables, wheelchairs, and even an unoccupied bed, placed on top of their fall mats, compromising the mats' effectiveness and increasing the risk of injury. Additionally, a resident had medication left at the bedside, contrary to policy, and care plans for fall prevention were not consistently updated or implemented as recommended by the IDT. These deficiencies resulted in an environment that was not free from accident hazards and lacked adequate supervision to prevent accidents.
A resident with a history of kidney infection, BPH, and diabetes had a urinal bottle in their room that was not labeled with their name and room number. Observation and staff interviews confirmed that this failure to label could lead to urinal switching and cross-contamination, which is inconsistent with the facility's infection control policy.
Surveyors found that several residents with diabetes received repeated insulin injections in the same anatomical locations, contrary to professional standards, manufacturer guidelines, and facility policy. Nursing staff and the DON confirmed that injection sites were not rotated as required, constituting a medication error and failing to follow established protocols for safe medication administration.
Three residents with complex medical needs were not served meals according to their meal tickets and the facility's planned menu. Kitchen staff omitted required toppings and substituted menu items without proper approval or documentation, and standardized recipes were not followed. This resulted in residents receiving meals that did not meet their nutritional requirements, as confirmed by staff observations and interviews.
A resident with multiple medical conditions and specific dietary orders was served a lunch that did not match the meal ticket, receiving only one hard quesadilla instead of two soft ones and a cake instead of a sugar cookie. Staff confirmed the meal was not palatable or attractive, and the resident refused to eat it due to poor quality and incorrect preparation.
Surveyors identified multiple deficiencies in food storage, preparation, and sanitation, including unlabeled food containers, soiled kitchen utensils, improper storage of raw meats, missing cleaning and temperature logs, expired enteral feeding formula, and improper hand hygiene by staff. These issues were confirmed through direct observation and staff interviews, revealing lapses in adherence to facility policies and procedures.
Staff failed to properly dispose of garbage, resulting in an overflowing trash bin with the lid left open. The DSS added more trash to the bin, and both the DSS and MS acknowledged that the bin should be closed to prevent pests. The MS stated that garbage is usually collected daily but was unsure why it was not collected, and the DON confirmed the importance of keeping the bin closed to prevent infection.
Staff failed to follow infection control protocols by administering oxygen at a higher rate than ordered and using discolored nasal cannula tubing for a resident with respiratory conditions, improperly storing personal belongings next to clean linen in the laundry area, and not donning a gown when caring for a resident on contact precautions for a multidrug-resistant wound infection. These lapses were confirmed through observation, interviews, and review of facility policies.
The facility did not follow its antibiotic stewardship policy by failing to monitor and document antibiotic use, signs and symptoms, and adverse reactions for two residents receiving antibiotics for serious infections. Additionally, the Infection Prevention and Control Surveillance Log was incomplete, missing key information needed to track infection and antibiotic effectiveness.
Two residents with complex medical and cognitive conditions did not have properly completed Advance Healthcare Directive Acknowledgement Forms, as required by facility policy. Staff failed to document whether information about advance directives was provided or refused, and interviews with the LVN, SSD, and DON confirmed that the residents’ rights to be informed and assisted in formulating advance directives were not honored.
A resident with multiple chronic conditions experienced a significant change in condition, including right arm pain, swelling, and decreased mobility. Facility staff notified hospice and the family but did not directly inform the resident's physician, as required by policy. Documentation and interviews confirmed the physician was not notified, resulting in a lack of timely medical assessment and intervention.
A resident with significant physical and cognitive impairments, including a history of stroke and high fall risk, was found to have a left floor mat with multiple tears in their room. Staff and the DON acknowledged that the mat should have been free from damage and that maintenance should have been notified to replace it, as required by facility policy for a safe and homelike environment.
A resident with multiple diagnoses, including dementia and diabetes, was discharged from Hospice care due to an improved condition. The facility did not complete the required significant change MDS assessment within the mandated timeframe because the MDSC was unaware of the Hospice discharge, resulting in a delayed assessment and submission.
Several residents did not have person-centered care plans developed or implemented as required, including those with limited mobility, contractures, use of restraints, antibiotics, or anticoagulants. For example, a resident with right arm pain and swelling did not consistently have their arm elevated or skin monitored as outlined in their care plan, leading to unnoticed bruising. Other residents lacked timely care plans for new medications or physical restraints, and some care plans did not reflect all physician or therapy recommendations. Staff interviews and record reviews confirmed these omissions and delays in care planning.
The facility did not update care plans for two residents after significant changes in condition and completion of required MDS assessments. One resident's care plan continued to reflect Hospice care after discharge from Hospice, and another resident's care plan did not address upper extremity ROM needs despite documented limitations and therapy recommendations. These omissions resulted in care plans that did not accurately reflect current clinical needs.
A resident with a stage 4 sacral pressure ulcer was found lying on a low air loss mattress set at the maximum firmness, rather than being adjusted to their actual weight of 124 lbs as required by policy and manufacturer guidelines. The resident reported discomfort, and both the LVN and DON confirmed the mattress should have been set according to the resident's weight and comfort to prevent further pressure injury.
A resident with COPD and respiratory failure received oxygen at 5 LPM via nasal cannula without a physician order, and humidification was not provided as required by facility policy. Nursing staff did not verify or adjust the oxygen flow to match the prescribed 2 LPM, nor did they notify the physician of the discrepancy, resulting in care that did not follow professional standards.
Nurse staffing information was not updated and posted daily as required, with outdated data remaining visible and current postings not displayed in a timely manner. Both the DSD and DON confirmed that this practice did not follow facility policy, resulting in staffing information not being readily accessible to residents and visitors.
Two residents did not receive proper pharmaceutical services when one did not receive complete doses of a prescribed antibiotic due to unavailability and lack of physician notification, and another's controlled pain medication administration was not immediately documented by an LVN, resulting in discrepancies in the controlled drug inventory.
Three medication errors were identified during medication administration, including a missed dose of tiotropium inhalation for a resident with COPD, failure to remove a lidocaine patch after the prescribed period for another resident, and a missed dose of entacapone for a resident with Parkinson's Disease. These errors resulted in a medication error rate of 10%, exceeding the acceptable threshold, and were confirmed through staff interviews and record review.
A resident with a physician-ordered dysphagia advanced mechanical soft texture diet was served cubed chicken instead of ground chicken, as specified in the meal ticket and dietary orders. Multiple staff, including a CNA, Dietary Services Supervisor, cook, and DON, confirmed the meal did not meet the resident's dietary requirements, despite facility policies mandating adherence to therapeutic diet modifications.
The facility failed to maintain complete and accurate medical records for several residents, including missing documentation of a restorative feeding program, lack of records on IDT meeting attendance, and absent optometrist and ophthalmologist visit notes. Staff interviews confirmed that required documentation was not consistently completed or filed, resulting in incomplete records and lack of accountability for care provided.
Two residents were found with exposed or frayed wires on their bed control equipment, despite facility policy requiring maintenance of safe and operable equipment. Staff and the DON confirmed that such hazards should have been identified and reported for immediate repair, but the deficiencies were observed during surveyor visits.
A resident was discharged home with home health services after improvement in condition, but the MDSC did not complete or submit the required discharge MDS assessment within the mandated 14-day period, resulting in the assessment being significantly overdue. Both the MDSC and DON acknowledged the delay during interviews and record review.
Surveyors found that the facility failed to accurately code MDS assessments for several residents, including incorrect documentation of falls with major injury, misidentification of a schizophrenia diagnosis, and improper coding of a planned discharge as unplanned. These inaccuracies were confirmed by the MDSC and DON, and did not align with facility policy requiring precise resident assessments.
Surveyors found that three rooms exceeded the allowed maximum of four residents per room, with two rooms housing five residents each. Observations showed that residents, including those using wheelchairs, had enough space to move freely, and both residents and staff reported no concerns about space or privacy. The administrator confirmed the overcapacity and stated that privacy was maintained.
Sixteen rooms did not meet the required 80 square feet per resident in multiple occupancy rooms, as confirmed by facility documentation and surveyor observations. Staff and residents reported no issues with space, and care was provided without difficulty. The administrator acknowledged the deficiency and stated that residents are screened for needs before placement in these rooms.
A resident with significant physical disabilities was physically assaulted by another resident with a history of behavioral issues, resulting in facial swelling and a nasal bone fracture. The incident was witnessed by staff, who identified it as physical abuse. Facility policies prohibiting abuse were not effectively implemented, and the DON acknowledged the failure to protect the resident from harm.
Two residents' medical records were found to be incomplete and inaccurate due to missing or incorrect documentation of change of condition events, times of notification to representatives and physicians, and care provided after incidents. Required psychosocial and behavioral monitoring was not properly recorded, and entries were sometimes made with incorrect times or after significant delays, contrary to facility policy.
Failure to Care Plan Cane Use and Out on Pass
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for four sampled residents related to use of a cane and out on pass orders. Resident 1 was admitted with an unspecified fracture of the left tibia shaft and difficulty walking. His H&P indicated he had the capacity to understand and make decisions, and his MDS showed intact cognitive skills for daily decisions, use of a wheelchair, and need for supervision with ambulating. The care plan reviewed for Resident 1 addressed ADL assistance, but there was no care plan for cane use despite documentation that he left the facility on out on pass with a cane and left his wheelchair at the facility. During interviews, LVN 2 stated Resident 1 left on out on pass with a cane and that she had only seen him use a wheelchair and was not sure where he got the cane. The MDS Nurse stated there were no care plans developed for cane use and said Resident 1 had a higher chance of falling using a cane. The DOR stated Resident 1 had been assessed for use of a front wheeled walker with restorative nursing assistance and wheelchair use on his own, and that there were no care plans developed for cane use. The DON stated Resident 1 could have safety issues with cane use and could fall as a result, and that if she had been informed he used a cane, rehab would have been asked to evaluate him for safe use of the cane and a care plan would have been created. The facility also failed to develop care plans for out on pass for Residents 1, 4, 5, and 6. Resident 4 had diagnoses including DM, HTN, and unsteadiness on feet, with moderate cognitive impairment, moderate assistance needed for ambulating 10 feet, and wheelchair use. Resident 5 had diagnoses including HTN, DM, and localized edema, with intact cognition and use of walkers and wheelchair. Resident 6 had diagnoses including lymphedema and acute thyroiditis, with intact cognition and wheelchair use. Physician orders allowed each resident to go out on pass, and the facility's out on pass log documented that each of the four residents signed out on pass. LVN 4 stated nurses do not develop a care plan for residents with out on pass orders and that care plans should list interventions specific to residents' care while on out on pass and monitor whether treatment is effective. The DON stated care plans are problems and ongoing interventions that communicate care to all departments, and that without a care plan for out on pass there can be miscommunication among staff on what is expected when residents go out on pass.
Incomplete Out-on-Pass Documentation
Penalty
Summary
The facility failed to maintain accurate and complete medical records for four sampled residents by not fully documenting out-on-pass events and returns. Resident 1 was admitted with diagnoses including an unspecified fracture of the left tibia shaft and difficulty walking. His H&P indicated he had capacity to understand and make decisions, and his MDS showed intact cognitive skills for daily decisions, use of a wheelchair, and need for supervision with ambulating. On 5/11/2026, the progress notes showed he requested to go out on pass, the physician approved a four-hour pass, and LVN 2 later stated Resident 1 left the facility unaccompanied by taxi using a cane and leaving his wheelchair at the facility. The DON stated that if she had been informed Resident 1 used a cane, rehab would have been asked to evaluate him for safe cane use. Review of the record showed no documentation that Resident 1 left with a cane. For Resident 4, the admission record showed diagnoses including DM, HTN, and unsteadiness on feet. The H&P indicated capacity to understand and make decisions, while the MDS showed moderately impaired cognitive skills for daily decisions, need for moderate assistance with ambulating 10 feet, and wheelchair use. The physician order allowed the resident to go out on pass with the ADM until 11:59 p.m. The facility’s Resident Out on Pass Log showed the resident signed out at 9:20 a.m., but the log did not include the LVN initials for departure, expected return time, time returned, or LVN initials for return. LVN 4 stated there was no documentation in the medical record showing when Resident 4 returned, and a late entry by LVN 5 documented the resident leaving and returning twice that day. For Resident 5, the admission record showed diagnoses including HTN, DM, and localized edema. The physician order allowed a four-hour pass if not in conflict with care, the H&P indicated capacity to understand and make decisions, and the MDS showed intact cognitive skills for daily decisions. The out-on-pass log showed the resident signed out at 1:00 p.m., but it did not include the LVN initials for departure, expected return time, time returned, or LVN initials for return. LVN 4 stated there was no documentation in the medical record showing when Resident 5 returned, and a late entry by LVN 1 documented that the resident left with a friend and returned at 8:00 p.m. For Resident 6, the admission record showed diagnoses including lymphedema and acute thyroiditis. The H&P indicated capacity to understand and make decisions, the MDS showed intact cognitive skills for daily decisions, and the physician order allowed a four-hour pass. The out-on-pass log showed the resident signed out at 1:30 p.m., but it did not include the LVN initials for departure, expected return time, time returned, or LVN initials for return, and LVN 4 stated there was no documentation in the medical record showing when Resident 6 returned.
Failure to Assess Safe Use of Cane Before Out on Pass
Penalty
Summary
The facility failed to ensure that one resident was safely assessed for the use of a cane before being allowed to leave the facility on an out on pass order. The resident was admitted with diagnoses including an unspecified fracture of the left tibia shaft and difficulty walking. The resident’s H&P indicated the resident had the capacity to understand and make decisions, and the MDS indicated cognitive skills for daily decisions were intact. The MDS also indicated the resident used a wheelchair and needed supervision with ambulating. The resident’s care plan included assistance with ADL care as needed, and the fall risk evaluation showed the resident had one to two fall incidents in the past three months and required use of an assistive device. On the day of the out on pass, the resident requested to go out, the physician approved a four-hour pass, and the resident left the facility with a cane and left the wheelchair at the facility. LVN 2 stated she had only seen the resident use the wheelchair and was not sure where the cane came from. Staff interviews and record review showed the resident was known to ambulate with assistance and use a wheelchair, and the MDS nurse stated the resident needed supervision to limited assistance with walking and used a FWW and wheelchair. The DOR stated there was no documentation in the medical record for cane use and that the resident had been assessed for use of a FWW and wheelchair, not a cane. The DON stated the resident left using a cane, could have a safety issue with cane use, and the facility failed to assess the resident’s safety on the use of a cane before allowing the resident to leave on pass.
Failure to Accurately Update Fall Risk Evaluation After Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to accurately update and complete a fall risk evaluation for a resident following an unwitnessed fall. The resident was admitted with multiple fractures of the left tibia, difficulty walking, and pain related to internal orthopedic prosthetic devices, implants, and grafts. An H&P documented that the resident had the capacity to understand and make decisions, and an MDS showed the resident required varying levels of assistance with ADLs, including dependence for footwear and lower body dressing and substantial assistance for toileting and showering. On 12/10/2025 at 3:43 a.m., a Change of Condition evaluation documented that the resident experienced an unwitnessed fall. Despite this fall, the Fall Risk Evaluation completed on 12/10/2025 recorded a fall risk score of 6 and indicated that the resident had no falls in the last three months. A subsequent Fall Risk Evaluation dated 12/14/2025, after the resident’s transfer to and return from the hospital, showed a fall risk score of 9 but again documented that the resident had no falls in the last three months. During an interview and concurrent record review, the DON confirmed that the resident had a fall on 12/10/2025 and acknowledged that both Fall Risk Evaluations should have reflected this fall and a higher score, and that inaccurate documentation on the Fall Risk Evaluation would result in the facility not implementing proper fall-prevention interventions. The facility’s Fall Management Program policy stated its purpose was to reduce the risk of avoidable falls and fall-related injuries and to ensure timely, evidence-based post-fall evaluation and management.
Failure to Maintain and Administer Ordered Pain Medication for Severe Orthopedic Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide effective pain management according to physician orders for one resident with significant orthopedic conditions. The resident was admitted and later readmitted with diagnoses including fractures of the lower end and shaft of the left tibia, difficulty in walking, and pain related to an internal orthopedic prosthetic device, implants, and grafts. Assessments documented that the resident had the capacity to understand and make decisions and was able to communicate needs, while requiring varying levels of assistance with ADLs such as dressing, toileting, showering, and hygiene. Physician orders on the resident’s Order Summary Reports included acetaminophen 325 mg, two tablets by mouth every four hours as needed for mild pain (1–4), and hydrocodone-acetaminophen 10-325 mg, one tablet every four hours as needed for moderate pain (5–7), and two tablets every six hours as needed for severe pain (8–9). A fax to the pharmacy requested refills of hydrocodone-acetaminophen for moderate to severe pain. Despite these orders, the Medication Administration Record for January showed that on one evening the resident was given only acetaminophen 325 mg, two tablets, for a documented pain level of 9, even though that medication was ordered only for mild pain (1–4). Interviews confirmed that the resident had not received the ordered hydrocodone-acetaminophen since a prior evening because the facility had run out of the medication. The resident reported current pain of 9 out of 10, stated that the Tylenol provided did not help, and indicated that he typically took his pain medication every six hours due to the severity of his pain. The LVN acknowledged discovering the medication was out on her first day back to work, stated that she usually reorders when six tablets remain, and confirmed she had administered Tylenol for a pain level of 9 despite its order being limited to mild pain, recognizing the possibility that the resident’s pain might not be alleviated. The DON stated that medications should never run out and that staff should maintain at least two to three days’ worth of medication, and recognized the potential for ineffective pain management based on the MAR review. The facility’s pain management policy required licensed nurses to administer pain medication as ordered and document it on the MAR.
Failure to Maintain Ordered Pain Medication Supply and Proper Administration
Penalty
Summary
The facility failed to ensure a resident was free of significant medication error when ordered pain medications were not administered as prescribed. The resident was admitted and later readmitted with multiple left tibia fractures, difficulty walking, and pain related to internal orthopedic prosthetic devices, implants, and grafts. The resident’s history and physical and MDS documented that the resident was cognitively able to understand and make decisions, and required varying levels of assistance with ADLs, but did not indicate cognitive impairment that would prevent reporting pain. The resident had physician orders for acetaminophen 325 mg, two tablets by mouth every four hours as needed for mild pain (1–4), and hydrocodone-acetaminophen 10-325 mg, one tablet every four hours as needed for moderate pain (5–7), and two tablets every six hours as needed for severe pain (8–9). A fax to the pharmacy requested refills of the hydrocodone-acetaminophen prescriptions. Review of the MAR for January showed that on one evening, the resident was administered acetaminophen 325 mg, two tablets, for a documented pain level of 9, even though this medication was ordered only for mild pain levels of 1–4. In interviews, the resident reported being told that the facility had run out of the ordered hydrocodone-acetaminophen and stated not having received it since a prior night. The resident reported current pain at 9 out of 10, described it as very bad and causing a headache, and stated that the prescribed pain medication was normally taken every six hours “on the dot” due to the severity of the pain, but that only Tylenol had been given and it did not help. The LVN acknowledged discovering that the resident was out of pain medication on her first day back to work, stated that she usually reorders when six tablets remain, confirmed that a refill request had been faxed, and admitted giving Tylenol for a pain level of 9 despite the order limiting it to pain 1–4. The DON stated that medications should never run out and that staff should maintain at least two to three days’ worth of medication, and identified a potential for ineffective pain management when reviewing the MAR entry. Facility policies on pain management and medication reordering required administration of pain medications as ordered and timely refills via the EMAR system or fax to the pharmacy.
Failure to Notify Physician of Resident's Significant Behavioral Change
Penalty
Summary
The facility failed to notify the attending physician of a significant behavioral change in a resident, as required by policy. The resident, who had a history of Parkinsonism, muscle wasting, quadriplegia, and depression, exhibited new aggressive behaviors on the date in question, including scratching and drawing blood from a staff member during an altercation. Prior to this incident, the resident had expressed a desire not to be cared for by a particular CNA and had requested to wait for the next shift for personal care, but these requests were not honored. The resident became agitated and physically aggressive when staff proceeded with care despite her objections. Multiple staff interviews confirmed that the resident's behavior during the incident was a new development, with the administrator specifically stating that scratching and drawing blood from staff was not a previously documented behavior for this resident. The care plan for the resident included monitoring for behavioral changes and notifying the physician if significant changes occurred. However, despite the escalation and physical aggression, there was no documentation or evidence that the physician was informed of this change in condition. The facility's policy required prompt notification of the physician and the resident's representative in the event of a significant change in the resident's physical, mental, or psychosocial status. The administrator acknowledged that a change of condition (COC) should have been created and the physician notified to address the new behavioral issue, but this did not occur. As a result, there was a failure to follow established procedures for physician notification in response to a significant behavioral change.
Failure to Implement Abuse Reporting and Investigation Policy
Penalty
Summary
The facility failed to implement its policy and procedure regarding abuse, reporting, and investigations for a resident who alleged physical abuse by staff. The resident, who had diagnoses including Parkinsonism, muscle wasting, quadriplegia, and depression, reported to the Administrator that staff physically fought with her during a care episode. The resident had the capacity to understand and make decisions, and her assessment indicated she could communicate her needs. On the day of the incident, the resident expressed not wanting care from a specific CNA and requested to wait for the next shift, but her request was not honored. Instead, two staff members proceeded to provide care, during which the resident became upset and described the interaction as being grabbed against her will, which she characterized as abuse. The resident communicated the incident to the Administrator via text message shortly after it occurred, stating that staff had physically fought with her and did not respect her wishes. The only response from the Administrator was to ask if the incident had been reported to the charge nurse, and no further action was taken at that time. The resident also informed the oncoming nurse but did not receive a follow-up. Interviews with staff confirmed that the incident was not reported to the required agencies within the mandated two-hour timeframe, and no immediate investigation was initiated. The facility's policy required immediate reporting and suspension of accused employees, but these steps were not followed. Further interviews with staff, including the Director of Staff Development and the Administrator, confirmed that the incident met the facility's definition of abuse and should have triggered an immediate investigation and reporting to outside agencies. However, the Administrator acknowledged that no investigation was conducted, and the required notifications were not made. The failure to act according to policy resulted in a delayed investigation of the alleged abuse and left the resident at risk for further harm.
Failure to Timely Report Alleged Physical Abuse to Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy and procedure by not reporting an allegation of physical abuse involving a resident and two staff members to the State Survey Agency within the required two-hour timeframe. The incident involved a resident with Parkinsonism, muscle wasting, quadriplegia, and depression, who was admitted with the capacity to understand and make decisions. On the day of the incident, the resident expressed not wanting care from a specific CNA and later reported that both a registry RN and the CNA physically forced her into bed against her will, despite her repeated requests to wait for the next shift. The resident described the event as traumatizing and characterized the staff's actions as physical abuse, which she reported to the Administrator via text message shortly after the incident occurred. Multiple staff interviews confirmed that the resident's allegations were not reported to the required authorities within the mandated two-hour window. The resident's nurse for the following shift acknowledged being informed of the incident but did not initiate the abuse reporting process, and the Administrator, who serves as the abuse coordinator, did not direct staff to notify the ombudsman, police, or State Survey Agency as required. The facility's Director of Staff Development and other staff also recognized that the incident met the criteria for abuse and should have been reported immediately, but there was no evidence that the appropriate notifications or suspensions were carried out in accordance with facility policy. The facility's policy clearly states that all allegations of abuse must be reported immediately to the Administrator, and that law enforcement, the ombudsman, and the State Survey Agency must be notified within two hours. The policy also requires the suspension of accused employees pending investigation and mandates written reports to authorities within 24 hours. In this case, the failure to report the resident's allegation of physical abuse in a timely manner constituted a violation of both facility policy and regulatory requirements.
Failure to Investigate and Report Resident's Allegation of Physical Abuse
Penalty
Summary
A deficiency occurred when the facility failed to conduct a thorough investigation following an allegation of physical abuse made by a resident against two staff members. The resident, who had diagnoses including Parkinsonism, muscle wasting, quadriplegia, and depression, reported to the Administrator via text that staff had physically fought with her during a transfer, despite her repeated requests to wait for the next shift for personal care. The resident described the incident as traumatizing and characterized the staff's actions as physical abuse, stating that her requests were ignored and that she was grabbed against her will. Interviews and record reviews revealed that the Administrator, who also served as the abuse coordinator, received the resident's allegation but did not initiate an investigation or report the incident to the required agencies as outlined in the facility's policies. The Administrator acknowledged that the incident should have been considered abuse and that an investigation should have been started, but confirmed that no investigation was conducted. Staff interviews further indicated that the policy required immediate reporting and suspension of accused employees, but these steps were not taken. The Director of Staff Development and other staff also confirmed that the incident met the criteria for abuse and should have been reported and investigated. Documentation showed that the resident's allegations were communicated to the Administrator and other staff, but there was no evidence of timely reporting to law enforcement, the ombudsman, or the state agency, nor was there evidence of employee suspension or notification of investigation results to the resident. The facility's failure to respond appropriately to the abuse allegation left the resident at risk for further abuse and did not comply with established policies for abuse reporting and investigation.
Failure to Honor Resident's Right to Refuse Care
Penalty
Summary
The facility failed to respect a resident's right to refuse care, resulting in a deficiency related to the provision of necessary care and services. The resident, who had diagnoses including Parkinsonism, muscle wasting and atrophy, quadriplegia, and depression, was assessed as having the capacity to make decisions and communicate her preferences. On the day of the incident, the resident expressed that she did not want a particular CNA to provide her care and requested to wait for the next shift for assistance with personal care. Despite these requests, the CNA and an RN proceeded to provide care against the resident's wishes. Multiple interviews and record reviews confirmed that the resident repeatedly asked for the care to be delayed and for the staff to leave her alone, but her requests were not honored. The staff transferred the resident from her wheelchair to her bed and changed her, during which the resident became upset and physically resisted, resulting in minor injuries to the staff. The resident later described the experience as traumatizing and characterized the staff's actions as physical abuse, emphasizing that her right to refuse care was not respected. Facility policy requires that residents' rights to refuse treatment be honored, with staff expected to document refusals and attempt to address concerns. However, in this case, the staff did not follow these procedures, and the resident's preferences and rights were disregarded. The administrator acknowledged that failing to respect a resident's right to refuse care can lead to a lower quality of care and a violation of resident rights.
Failure to Immediately Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors during the review of facility practices and records. The deficiency centers on the facility's failure to ensure that all required parties were promptly informed when significant events impacting the resident occurred, as required by regulation.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. This deficiency was identified through surveyor observation and review of care practices, which revealed that staff did not consistently follow prescribed care plans or honor the expressed wishes and goals of the resident. The lack of adherence to orders and resident preferences resulted in care that was not aligned with the individualized needs of the resident.
Failure to Ensure Staff Competency and Adherence to Physician Orders During Resident Change of Condition
Penalty
Summary
Nursing staff failed to demonstrate appropriate competency in the care of a resident with type 2 diabetes and hypertension, resulting in a series of missed interventions during a significant change in the resident's condition. The resident experienced nausea, vomiting, and a critically high blood sugar reading of 382 mg/dl. Despite physician orders to notify the physician if blood sugar exceeded 350 mg/dl, the LVN on duty did not contact the physician, did not recheck the resident's blood sugar, and did not obtain or document vital signs during this episode. The LVN also provided a trash can instead of a clean basin for vomiting, contrary to infection control policy, and administered scheduled medication early at the resident's request without physician notification. Record reviews and staff interviews confirmed that the LVN was aware of the physician's orders and facility policies but failed to follow them, including not recognizing the need for immediate physician intervention for hyperglycemia and associated symptoms. The LVN admitted to not notifying the physician, not rechecking blood sugar, and not taking vital signs, and stated that these actions should have been performed. Other nursing staff and supervisors corroborated that these omissions were not in line with facility policy and could have warranted further medical intervention. Additionally, the facility failed to ensure annual competency assessments and performance evaluations for several staff members, including CNAs, LVNs, and RNs. Employee files lacked documentation of required annual competency checks and performance reviews, and facility leadership acknowledged uncertainty regarding the frequency of these assessments. Facility policies referenced the need for competency validation and performance evaluation but did not specify required intervals, and the facility assessment tool and employee handbook did not provide clear guidance on this matter.
Failure to Promptly Respond to Resident Call Light
Penalty
Summary
A deficiency occurred when a resident with a history of falls, limited mobility, and intact cognitive skills activated their call light, but the request for assistance was not answered promptly. The resident, who required moderate to maximum assistance for daily activities and ambulation, was observed with their call light on while a respiratory therapist was nearby but did not respond. The respiratory therapist was seen using a cellphone and stated during an interview that he did not hear the call light and acknowledged he should have answered it. The resident later reported being unable to locate their water pitcher and oral hygiene items. Interviews with facility staff, including a licensed vocational nurse and the administrator, confirmed that all staff, including respiratory therapists, are required to answer call lights and that delays can result in unmet resident needs. Review of facility policies indicated that staff are expected to answer call lights promptly and limit personal cellphone use during work hours. The failure to respond to the call light was inconsistent with these policies and resulted in a delay in addressing the resident's needs.
Failure to Hold Medication per Physician Order for Blood Pressure
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with physician orders for one resident. Specifically, nursing staff did not follow the physician's directive to hold midodrine administration when the resident's systolic blood pressure exceeded 110 mmHg. Documentation in the Medication Administration Record showed that midodrine was given on multiple occasions when the resident's blood pressure readings were above the specified threshold, including readings of 132/80 mmHg, 124/87 mmHg, and 124/76 mmHg. The Director of Nursing confirmed that the nurses did not adhere to the order, acknowledging the error during an interview. The resident involved had a history of hemiplegia and hemiparesis following a cerebral infarction, essential hypertension, and a history of falls. The resident's cognitive skills for daily decisions were severely impaired, and they were dependent on staff for activities such as eating and showering. The facility's policy required medications to be administered as directed by a licensed nurse and upon the order of a physician or licensed independent practitioner, but this policy was not followed in this instance.
Failure to Maintain Accurate and Complete Medical Records
Penalty
Summary
The facility failed to maintain accurate and complete medical records for two of three sampled residents. For one resident with diagnoses including type 2 diabetes, hypertension, hyperlipidemia, and chronic kidney disease, a Licensed Vocational Nurse (LVN) did not accurately document blood sugar checks and medication administration. The LVN recorded a blood sugar value and medication administration time that did not match the actual times and values, and admitted to documenting incorrect information in the Medication Administration Record (MAR). The LVN also administered medications earlier than ordered, per the resident's request, but failed to accurately reflect this in the MAR, resulting in discrepancies between the MAR and the progress notes. For another resident with a history of skull and facial bone fractures and severe cognitive impairment, the facility did not document the time or the physician's response after the physician was notified of a urine test result. The resident was dependent on staff for all activities of daily living and was always incontinent. The urinalysis result indicated that the physician was notified, but there was no documentation in the medical record regarding the time of notification or the physician's response. The Director of Nursing confirmed that the medical record was incomplete and that the responsible nurse should have documented the communication with the physician, including the date and time of notification and the physician's response. The facility's policy and procedure on "Completion and Correction" requires that medical records be completed and corrected in a standardized manner to ensure accuracy and quality, including documentation of each time a physician is notified regarding a resident's condition. In both cases, the facility failed to adhere to its own policy, resulting in incomplete and inaccurate medical records for the residents involved.
Failure to Follow Infection Control Protocol During Vomiting Episode
Penalty
Summary
A Licensed Vocational Nurse (LVN) failed to follow the facility's infection control policy and procedure when responding to a resident who was at risk of vomiting. Instead of providing a clean basin, the LVN offered the resident a trash can, which is not considered a sanitary option due to the potential presence of bacteria. This action was identified during a review of the resident's progress notes and confirmed through interviews with the facility's Infection Preventionist and a Registered Nurse, both of whom stated that a clean basin should have been used to prevent cross-contamination. The resident involved had a medical history including type 2 diabetes mellitus with hyperglycemia and hypertension, and was assessed as having the capacity to understand and make decisions. The resident required supervision for activities of daily living but had an intact thought process. The facility's infection control policy, last reviewed in April 2025, requires the use of proper infection control procedures to maintain a safe and sanitary environment, which was not followed in this instance.
Failure to Complete Shift-to-Shift Endorsement
Penalty
Summary
The facility failed to ensure that LVN 2 was competent to follow the current plan of correction for endorsing to the incoming nurse using the shift-to-shift report. Resident 1 was admitted with diagnoses of anemia and osteoarthritis, and the MDS indicated the resident’s thought process was intact and that the resident required supervision assistance with ADLs. On 9/6/2025, Resident 1 had a change of condition with nausea, vomiting, and complaints of feeling sick, stating that food was not digesting and had a bitter taste in the mouth. The Shift-to-Shift Change of Condition Report for that shift showed blanks where the on-shift nurse name, signature, shift, and cart should have been documented, and LVN 1 stated those items were missing. LVN 2 stated an endorsement was given to LVN 3 and the paper was left on top of the medication cart, while LVN 3 stated LVN 2 did not give the required endorsement and left after medication count, with LVN 3 expecting LVN 2 to return. The DSD reviewed LVN 2’s employee file and stated an in-service regarding shift-to-shift report was still being sought, and later stated there was no shift-to-shift endorsement report from LVN 3’s shift and that the absence of signature, name, and date meant the endorsement was not done. RN 1 stated the facility failed to ensure LVN 2 was competent to follow the endorsement procedure.
Failure to Obtain Orders and Consent for Use of Restraint Devices
Penalty
Summary
Surveyors identified that multiple residents were subjected to the use of beds with bolsters or concave mattresses, which functioned as physical restraints, without the required physician's order, informed consent, or restraint assessment. Observations revealed that residents were found lying in beds with bolsters around the edges of the mattress, and staff confirmed that these devices were used to prevent falls but also acknowledged that they could restrict residents' ability to get out of bed freely. Staff interviews further confirmed that the use of these devices could be considered a restraint and that appropriate assessments, orders, and consents were not obtained prior to their use. The records for several residents, including those with chronic pain syndrome, history of falls, muscle wasting, dementia, quadriplegia, and impaired cognition, showed no documentation of a physician's order, informed consent, or restraint assessment for the use of the bolstered or concave mattresses. Care plans and fall risk evaluations indicated that these residents were at high risk for falls, but interventions documented did not include the use of these restraint devices, nor were they incorporated into the residents' comprehensive care plans. Staff and the DON acknowledged during interviews that the required processes for restraint use, including assessment, order, consent, and care planning, were not followed. Facility policies and procedures reviewed by surveyors clearly stated that physical restraints require a physician's order, informed consent, and an interdisciplinary team assessment, and that these steps must be documented in the resident's medical record. Manufacturer guidelines for the mattress products also emphasized the need to follow facility policies for assessment and monitoring. Despite these requirements, the facility failed to ensure compliance, resulting in the use of restraint devices without proper authorization or documentation for several residents.
Failure to Rotate Insulin Injection Sites for Multiple Residents
Penalty
Summary
Licensed nursing staff failed to rotate subcutaneous insulin administration sites for multiple residents with diabetes, as required by professional standards, facility policy, and manufacturer guidelines. For several residents, including those with diagnoses such as dementia, schizoaffective disorder, and metabolic encephalopathy, insulin injections were repeatedly administered in the same anatomical locations over extended periods. Documentation and interviews confirmed that injection sites were not rotated as required, with staff acknowledging the failure to follow established protocols. The residents involved had varying degrees of cognitive impairment and required assistance with activities of daily living. Their medical records indicated ongoing insulin therapy, with orders specifying both short-acting and long-acting insulin. Despite clear physician orders and care plan interventions to administer medications as ordered and monitor for side effects, the administration records showed repeated use of the same injection sites, such as the right lower quadrant (RLQ), left lower quadrant (LLQ), and upper arms, without appropriate rotation. Interviews with nursing staff and the Director of Nursing (DON) confirmed awareness of the requirement to rotate injection sites to prevent complications and ensure proper medication absorption. Facility policy and manufacturer guidelines, both reviewed and acknowledged by staff, explicitly stated the need for site rotation for injectable medications. The failure to rotate sites was observed across multiple residents and confirmed through record review, staff interviews, and policy documentation.
Failure to Maintain a Hazard-Free Environment and Proper Supervision
Penalty
Summary
Surveyors identified multiple deficiencies related to accident hazards and inadequate supervision in the facility. Several residents who were assessed as high risk for falls had fall mats placed at their bedsides as an intervention. However, observations revealed that furniture and medical equipment, such as overbed tables, wheelchairs, and even an unoccupied bed, were placed on top of these fall mats for multiple residents. Staff interviews confirmed that these items should not be on the mats, as they compromise the mats' effectiveness in reducing injury from falls and could cause additional harm if a resident were to fall onto a hard object or a mat with diminished cushioning. In addition to the improper use of fall mats, one resident was found to have medication, specifically Ammonium Lactate 12% moisturizing lotion, left at the bedside. This medication had been brought from the hospital and was not reconciled or stored according to facility policy. Staff acknowledged that medications should not be left at the bedside to prevent accidental overdose or access by other residents, and that all medications should be checked and stored securely in the medication room. The report also documents that care plans and physician orders for fall prevention interventions were not always updated or implemented as recommended by the interdisciplinary team. For example, a resident who required a customized or reclining wheelchair for postural support and fall prevention was observed using a regular wheelchair shared with other residents, and the care plan was not updated to reflect the recommended intervention. These lapses in following care plans and ensuring a hazard-free environment contributed to the deficiencies cited by surveyors.
Failure to Label Urinal Results in Infection Control Deficiency
Penalty
Summary
A deficiency was identified when a resident who was incontinent of bladder did not have their urinal bottle labeled with their name and room number. During an observation, it was noted that the urinal in the resident's room lacked proper identification. Interviews with both a Licensed Vocational Nurse and the Director of Nursing confirmed that urinals should be labeled to prevent switching between residents, especially in semi-private rooms. The facility's infection control policy also requires such measures to prevent cross-contamination and infection. The resident involved had a medical history including acute pyelonephritis, benign prostatic hyperplasia, type 2 diabetes mellitus with chronic kidney disease, and was admitted and readmitted to the facility. The resident was cognitively intact and required supervision for activities of daily living. The care plan for the resident included a goal to remain free from infection. The failure to label the urinal was identified through observation, interview, and record review, and was found to be inconsistent with the facility's infection control policies and procedures.
Failure to Rotate Insulin Injection Sites Results in Medication Errors
Penalty
Summary
Surveyors identified that the facility failed to ensure residents were free from significant medication errors by not rotating subcutaneous insulin injection sites as required by professional standards, manufacturer guidelines, and facility policy. Multiple residents with diabetes, including those with cognitive impairments and complex medical histories, received repeated insulin injections in the same anatomical locations over extended periods. This practice was confirmed through review of medication administration records, interviews with nursing staff, and direct observation of documentation, which showed a pattern of non-rotation for both short-acting and long-acting insulin types. Nursing staff, including LVNs, acknowledged during interviews that injection sites should have been rotated to prevent complications such as pain, redness, irritation, and the development of lipodystrophy, which can affect insulin absorption. The DON also confirmed that failure to rotate sites is a medication error, as it does not follow professional standards, manufacturer instructions, or facility policy. The facility’s policies and procedures, as well as the insulin manufacturers’ guidelines, specifically require rotation of injection sites to ensure proper absorption and minimize adverse effects. The deficiency was observed in several residents, each with orders for insulin administration and care plans that included monitoring for side effects and ensuring medication was given as prescribed. Despite these directives, documentation revealed repeated use of the same injection sites, and staff interviews confirmed the lack of adherence to rotation protocols. The facility’s own policies defined medication errors to include administration not in accordance with prescriber’s orders or manufacturer’s specifications, further substantiating the finding.
Failure to Follow Menu and Meal Tickets Results in Nutritional Deficiency
Penalty
Summary
The facility failed to follow the planned menu and meal tickets for three residents during a lunch service, resulting in meals that did not meet the nutritional needs as specified. Observations and interviews revealed that the kitchen staff did not serve the correct menu items or toppings as indicated on the residents' meal tickets. For example, one resident was not served cheese sauce and shredded lettuce with her chicken fajita, and the rice provided was plain steamed rice instead of the required green chili rice. Another resident did not receive the shredded lettuce and diced tomato topping, and the fiesta corn and green chili rice were not prepared according to the recipe. A third resident was served a square of cake instead of a sugar cookie, and the rice and corn were also not prepared as specified in the menu. The report details that the kitchen staff made unauthorized substitutions and omissions without following the facility's policy for menu changes, which requires approval from the Dietary Services Supervisor (DSS) and Registered Dietitian (RD). The staff failed to document these substitutions in the Menu Substitution Log, and the recipes for the menu items were not followed. The Dietary Services Supervisor and the cook acknowledged that the correct procedures were not followed, often citing being busy as the reason for these lapses. The Director of Nursing (DON) confirmed that all meals should be served as indicated on the meal tickets and that recipes are standardized to meet residents' nutritional needs. The residents involved had significant medical histories, including chronic pain syndrome, protein-calorie malnutrition, diabetes, and muscle wasting. Their care plans and physician orders required specific diets and assistance with meals. The failure to provide the correct menu items and follow standardized recipes resulted in meals that lacked required nutrients and flavor, as directly observed and reported by staff and residents. The facility's policies on menu planning and recipe standardization were not adhered to during the meal service in question.
Failure to Provide Palatable and Correctly Prepared Meal as Ordered
Penalty
Summary
The facility failed to ensure that a resident was served quality and palatable food, as required by facility policy and physician orders. During a lunch service, a resident with multiple diagnoses, including schizoaffective disorder, type 2 diabetes, and a consistent carbohydrate diet order, was served only one quesadilla with a hard tortilla instead of the two soft quesadillas indicated on the meal ticket. Additionally, the resident received a square of cake instead of the prescribed sugar cookie. The meal was found to be of poor quality, not attractive, and not in accordance with the resident's dietary needs and preferences. Observations and interviews revealed that the quesadilla was prepared ahead of time and left on the steam table for at least 30 minutes before being served, resulting in a hard texture. The dietary staff did not follow the meal ticket instructions, and the tray was not checked before being delivered to the resident. Both the Certified Nursing Assistant and the Dietary Services Supervisor confirmed that the resident did not receive the correct amount or type of food, and the food served was not palatable. The resident attempted to eat the quesadilla, found it too hard and bland, and subsequently refused to eat it, expressing dissatisfaction with the meal. Facility policy requires that food be prepared to conserve nutritive value, flavor, and appearance, and that meals be served as written on the menu and meal ticket. The staff interviews and record reviews confirmed that these procedures were not followed in this instance, resulting in the resident not receiving the appropriate meal as ordered and expected.
Deficiencies in Food Storage, Preparation, and Sanitation Practices
Penalty
Summary
Multiple deficiencies were identified in the facility's food storage, preparation, and service practices, as well as in the maintenance of kitchen and resident food storage areas. Surveyors observed that a container of coffee was not labeled with the received or open date, and several kitchen utensils, including a metal cooking pan, basting brush, scooper, ladle, measuring cup, and knife sharpener, were found soiled with food debris and residues. Additionally, a blender jar contained a brownish liquid at the bottom, and the blender machine had food crumbs present. The walk-in refrigerator's blower had a buildup of black oily substance, and raw chicken was stored above ground beef in the freezer, contrary to safe food storage protocols. The Dietary Services Supervisor confirmed these findings and acknowledged the importance of proper labeling, cleanliness, and storage order to prevent contamination. Further observations revealed lapses in the documentation and monitoring of equipment and food storage. The daily cleaning log for the ice machine had multiple missing entries, and the resident refrigerator log lacked temperature recordings and staff names for several shifts. Inside the resident refrigerator, various food items were not labeled with received dates, and some items, such as an unopened can of espresso and ice cream, were missing required information. Two bottles of expired enteral feeding formula were also found in the storage room. Staff interviews confirmed that it was their responsibility to ensure proper labeling, timely disposal of food, and regular temperature checks, but these procedures were not consistently followed. Additional deficiencies included improper hand hygiene and glove use by a cook, who touched a trash can lid with gloved hands and then handled food without changing gloves or washing hands. The facility's outdoor trash bin was observed to be overfilled and left open, which the Maintenance Supervisor acknowledged as his responsibility. Facility policies and procedures reviewed by surveyors outlined the requirements for food labeling, storage, cleaning, and infection control, but these were not adhered to in practice, as evidenced by the observations and staff interviews.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, as evidenced by an observation of an overflowing black trash bin with its lid unable to close. The Dietary Services Supervisor was seen adding more trash to the already overflowing bin. Interviews with the Dietary Services Supervisor, Maintenance Supervisor, and Director of Nursing confirmed that the trash bin should be kept closed to prevent attracting pests and spreading disease, but on this occasion, the bin was left open and overflowing. The Maintenance Supervisor noted that garbage is typically collected daily but was unsure why it had not been collected on this day. A review of the facility's policy indicated that the Maintenance Department is responsible for maintaining the building, including proper refuse disposal, in compliance with regulations.
Failure to Implement Infection Control Practices for Oxygen Therapy, Contact Precautions, and Linen Storage
Penalty
Summary
The facility failed to implement proper infection prevention and control practices in several instances involving both residents and staff. One resident with chronic respiratory conditions, including COPD, pneumonia, and acute respiratory failure, was observed with a nasal cannula that was discolored and wrapped around a bed side rail. The oxygen concentrator was set at 5 LPM without a humidifier, despite a physician's order specifying 2 LPM PRN to maintain oxygen saturation above 92%. Staff did not follow the physician's order, and the nasal cannula tubing was not stored in a sanitary manner, as required by facility policy. The tubing was not replaced promptly, and the oxygen was administered at a higher rate than ordered, with no documentation of a change in the resident's condition or a new order to justify the increase. Another deficiency was observed in the facility's laundry area, where a staff member's personal belongings, including a lunch bag and backpack, were placed next to clean linen on a linen cart. This practice was acknowledged by both the staff member and the maintenance supervisor as inappropriate, as it could lead to contamination of clean linen. The infection preventionist confirmed that personal belongings should not be stored in the clean laundry room, and the facility's policies require separate storage for clean linen and personal items to prevent the spread of infection. Additionally, a certified nursing assistant failed to don a gown while providing care to a resident on contact precautions for a multidrug-resistant organism in a stage four pressure ulcer. The CNA stated she was unaware of the contact precautions signage and did not wear a gown while in the resident's room, despite touching potentially contaminated surfaces. Facility policy and interviews with nursing and infection prevention staff confirmed that a gown should have been worn to prevent the spread of infection. These failures were observed and confirmed through interviews and record reviews, demonstrating lapses in adherence to established infection control protocols.
Failure to Monitor and Document Antibiotic Use and Incomplete Infection Surveillance
Penalty
Summary
The facility failed to implement its antibiotic stewardship policy for two of three sampled residents by not monitoring antibiotic use, signs and symptoms, side effects, or adverse reactions. For one resident admitted with diagnoses including sepsis, acute appendicitis with perforation, localized peritonitis, and gangrene with abscess, there was no documented monitoring for antibiotic use during five nursing shifts while the resident was receiving intravenous ertapenem. The Infection Preventionist confirmed that monitoring and documentation were missing for these periods, which are necessary to assess for adverse reactions and effectiveness of the antibiotic therapy. Another resident, admitted with acute respiratory failure with hypoxia, pneumonia, and dementia, was prescribed oral Zyvox for pneumonia. The Medication Administration Record showed the resident received the antibiotic as ordered, but there was no documentation of monitoring for antibiotic use on two specific shifts. The Infection Preventionist and Director of Staff Development both stated that residents on antibiotics should be monitored for signs and symptoms and side effects every shift, and the Director of Nursing confirmed that this monitoring and documentation did not occur for these residents. Additionally, the facility's Infection Prevention and Control Surveillance Log for the relevant month was incomplete, with missing entries for signs and symptoms of infection and the date antibiotics were completed. The Infection Preventionist and Director of Nursing both acknowledged that the log should have included this information to track infection, monitor treatment, and determine antibiotic effectiveness. The facility's policy required the Infection Preventionist to track and report antibiotic stewardship processes, but this was not done as required.
Failure to Document Advance Directive Discussions for Two Residents
Penalty
Summary
The facility failed to ensure that the medical records of two sampled residents were updated to show documented evidence that advance directives (AD) were discussed, as required by policy and regulation. For one resident, the admission record indicated multiple diagnoses including psychosis, dementia, and muscle wasting, with conflicting assessments of cognitive capacity. The Advance Healthcare Directive Acknowledgement Form for this resident was incomplete, lacking documentation of whether the resident or their representative was provided information about formulating an AD or if they refused such information. Interviews with the LVN, Social Services Director (SSD), and Director of Nursing (DON) confirmed that the form was not properly completed and that the resident’s or representative’s right to be informed and assisted in formulating an AD was not honored. A second resident, admitted with significant cardiac and neurological diagnoses, also had an incomplete Advance Healthcare Directive Acknowledgement Form. The form did not indicate whether the resident or their representative was provided information on advance directives or whether an advance directive had been formulated prior to admission. Staff interviews confirmed that the required documentation was missing, and the SSD acknowledged that the resident’s right to formulate an advance directive was not ensured due to the lack of proper documentation and follow-through. Facility policy required that, at the time of admission, staff inquire about the execution of an advance directive and document any discussion regarding advance directives in the resident’s record, even if the resident chose not to execute one. Both the Basic Record Review and Resident Rights-Quality of Life policies emphasized the importance of documentation and person-centered care. The failure to complete and document the Advance Healthcare Directive Acknowledgement Forms for these residents resulted in a violation of their rights to be fully informed and to participate in decisions regarding their care.
Failure to Notify Physician of Significant Change in Resident Condition
Penalty
Summary
The facility failed to directly notify the primary physician of a significant change in condition for a resident who was under hospice care and had multiple diagnoses, including dementia, diabetes mellitus, epilepsy, and joint stiffness. On 2/14/2025, the resident experienced decreased mobility, increased pain, and swelling in the right arm, with an inability to spread the fingers. The facility's records show that the hospice coordinator was notified, and a hospice nurse was scheduled to assess the resident, but there was no documentation that the resident's primary physician was informed of the change in condition. Subsequent progress notes indicated ongoing pain and swelling in the resident's right arm, with follow-up communications made only with the hospice company. The hospice nurse did not provide new orders, and the primary physician was not contacted directly by the facility staff. Interviews with facility staff confirmed that the standard practice is to notify the physician in the event of a change in condition, but in this case, only the hospice provider was notified. There was no documentation of physician notification, and the director of nursing acknowledged that the physician was not properly notified. Observations and interviews with staff and family members confirmed the resident continued to experience pain and limited use of the right arm. The facility's policy required timely notification of the resident, family, and physician in the event of a significant change in condition, but this was not followed. The deficiency was identified through review of records, staff interviews, and direct observation of the resident's condition.
Failure to Maintain Safe and Homelike Environment Due to Torn Floor Mat
Penalty
Summary
The facility failed to provide a safe, comfortable, and homelike environment for one resident by not ensuring that the resident's left floor mat was free from tears. The resident, who had a history of cerebral infarction resulting in hemiplegia and hemiparesis, as well as schizophrenia, was admitted with a physician's order for bilateral floor mats for safety due to a high risk of falls. During observations, the left floor mat was found to have three L-shaped tears on the top, and the overbed table was placed on top of the mat. Both a Licensed Vocational Nurse and the Director of Nursing confirmed that floor mats should be free from tears and that staff are responsible for notifying maintenance to replace any equipment in disrepair. The resident's medical records indicated a need for assistance with all activities of daily living and a cognitive impairment, further emphasizing the importance of a safe environment. Despite facility policy requiring a safe, clean, and homelike environment, the torn floor mat remained in use, which was acknowledged by staff as not meeting the standard for resident comfort and safety. The deficiency was identified through observation, interviews, and record review.
Failure to Complete Timely Significant Change Assessment After Hospice Discharge
Penalty
Summary
The facility failed to complete a significant change assessment for a resident who was discharged from Hospice care after showing an improved or stabilized condition. The resident, who had diagnoses including dementia, diabetes mellitus, epilepsy, and joint stiffness, was admitted under Hospice care and later had Hospice services discontinued per physician's order. According to the MDS Coordinator, discontinuation from Hospice care is considered a significant change in status, which requires a comprehensive Minimum Data Set (MDS) assessment to be completed within 14 days of the change. However, the significant change MDS assessment for this resident was not completed and submitted until nearly two months after the discontinuation of Hospice care. The delay occurred because the MDS Coordinator was unaware of the resident's discharge from Hospice care. This late completion and submission of the MDS assessment could result in inaccurate information being used for the provision of care and delayed reporting to the Federal database, as noted by the MDS Coordinator during the interview.
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and/or implement person-centered care plans for eight of 35 sampled residents, resulting in deficiencies related to individualized care. For one resident with limited right arm mobility and pain, the care plan included interventions such as elevating the right arm on a pillow and monitoring for skin changes, including discoloration. However, observations and interviews revealed that these interventions were not consistently implemented, as staff did not regularly elevate the arm or monitor for skin changes, leading to the development of a bruise that went unnoticed by staff until later. The care plan was not followed as required, and staff were unaware of the skin issues until they were pointed out during the survey. Another resident with hemiplegia and contractures had physician orders and therapy recommendations for the application of a left hand roll and both elbow extension splints, as well as passive range of motion (PROM) to both arms and legs. While the care plan addressed PROM and splints for the legs, it did not include the necessary interventions for the arms as recommended by therapy and ordered by the physician. Staff interviews confirmed that the omission of these interventions from the care plan was an oversight, and the care plan was not updated to reflect the resident's full needs. Additional deficiencies were identified for residents who were prescribed antibiotics or anticoagulants, as well as those using physical restraints such as beds with bolsters or concave mattresses. In these cases, care plans were either not developed or not updated in a timely manner to address the use of these medications or devices, as required by facility policy. Staff interviews and record reviews confirmed that the absence or delay in care plan development could result in a lack of appropriate monitoring and interventions for these residents. Facility policies required timely and comprehensive care planning, but these were not followed for the affected residents.
Failure to Revise Care Plans After Significant Change and MDS Assessment
Penalty
Summary
The facility failed to revise person-centered care plans for two residents following significant changes in their health status and after required assessments. For one resident, who was admitted under Hospice care with diagnoses including dementia, diabetes mellitus, epilepsy, and joint stiffness, the care plan continued to reflect Hospice interventions even after Hospice care was discontinued by physician order due to an improved prognosis. The care plan was not updated to reflect this change until it was discovered during a therapy session, despite the facility's policy requiring care plan revision after a change in condition. The resident's Minimum Data Set (MDS) assessment, which should have triggered a care plan review, was also not completed within the required timeframe. Another resident, admitted with hemiplegia, dementia, and contractures, had a care plan that addressed lower extremity joint mobility but did not include interventions for upper extremity range of motion (ROM) limitations, despite physician orders and therapy recommendations for both arms and legs. The resident's MDS assessment indicated functional ROM limitations in both arms and legs, but the care plan was not updated to address the upper extremity needs after the assessment was completed. The care plan had not been revised since a previous date, and the omission was confirmed during interviews and record reviews with staff. The facility's policy and procedure on comprehensive person-centered care planning required that care plans be reviewed and revised after changes in condition and following each MDS assessment. In both cases, the required interdisciplinary review and timely revision of care plans did not occur, resulting in care plans that did not accurately reflect the residents' current needs and interventions.
Failure to Set Low Air Loss Mattress According to Resident Weight
Penalty
Summary
A deficiency occurred when a resident with a stage 4 sacral pressure ulcer was not provided care consistent with professional standards to prevent further pressure injury. The resident, who was alert and able to communicate, required total assistance with all activities of daily living and was at high risk for pressure injuries due to mobility issues. Upon observation, the resident's low air loss mattress (LALM) was set at 350 lbs, which is the firmest setting, despite the resident's actual weight being 124 lbs. The resident reported discomfort, stating the bed was too hard, and the attending nurse confirmed that the LALM should be set according to the resident's weight and comfort. The Director of Nursing also acknowledged that the mattress should have been set to the resident's weight to prevent worsening of pressure ulcers. Facility policy and the manufacturer's guidelines both require that the LALM be set according to the resident's weight to ensure proper pressure redistribution and prevention of new or worsening pressure ulcers. However, the staff failed to adjust the mattress setting appropriately, leaving the resident at risk for further skin breakdown. This failure was identified through observation, interviews with staff and the resident, and review of medical records and facility policies.
Failure to Administer Oxygen Therapy as Ordered and Without Required Humidification
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for a resident with a history of COPD, pneumonia, and acute respiratory failure with hypoxia. The resident was admitted with physician orders for oxygen at 2 liters per minute (LPM) via nasal cannula as needed to maintain oxygen saturation above 92%. However, during observation, the resident's oxygen concentrator was set at 5 LPM without a corresponding physician order, and the nasal cannula tubing was found wrapped around the bed rail rather than in use by the resident. Licensed nursing staff confirmed that the oxygen was being administered at 5 LPM, and there was no physician order for this increased flow rate. The staff also failed to provide humidification with the oxygen therapy, despite the facility's policy requiring humidification for oxygen flow rates above 4 LPM. The nurse involved stated she would need to check the order for humidification and acknowledged the importance of following physician orders for oxygen administration. Interviews with additional nursing staff and the Director of Nursing revealed that the nurse should have notified the physician about the increased oxygen flow and should have adjusted the setting to match the physician's order. The facility's policies require that oxygen and related treatments be administered as prescribed, and that humidification be used when oxygen is delivered at higher flow rates. These failures resulted in the resident receiving oxygen therapy inconsistent with both physician orders and facility policy.
Failure to Post and Update Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was posted and updated on a daily basis as required. During an observation at the Nurses Station, the posted staffing information was found to be dated several days prior, and not current for the day of the observation. Interviews with the Director of Staff Development (DSD) and the Director of Nursing (DON) confirmed that the staffing information for the intervening days had been prepared but was not posted in a timely manner. Instead, the outdated information remained visible, and the updated postings were left behind the previous day's sheet. The facility's policy and procedure require that nurse staffing data, including facility name, current date, total number and actual hours worked by RNs, LPNs/LVNs, CNAs, and the resident census, be posted daily at the beginning of each shift. Both the DSD and DON acknowledged that the failure to update and post the staffing information daily was not in accordance with facility policy. As a result, accurate and current staffing information was not readily accessible to residents and visitors during the period in question.
Failure to Administer and Document Medications as Ordered
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate administration and documentation of medications for two residents. For one resident with chronic obstructive pulmonary disease, dysphagia, and multiple contractures, the physician ordered tramadol HCl in two dosages for pain management. However, a Licensed Vocational Nurse (LVN) did not sign the controlled drug inventory sheet immediately after administering the medication, as required by facility policy. The Director of Nursing confirmed that this omission could cause discrepancies during narcotic counts and that the LVN was expected to document administration at the time of delivery. For another resident with acute respiratory failure, pneumonia, and severe cognitive impairment, the physician ordered Zyvox, an antibiotic, to be administered twice daily for seven days. The Medication Administration Record and progress notes showed that three doses of Zyvox were missed because the medication was not available and had not been delivered by the pharmacy. The nursing staff did not check the emergency kit for the medication or notify the physician about the missed doses to obtain further orders or extend the course of antibiotics. Facility policies required medications to be administered as prescribed and for controlled substances to be documented on the inventory sheet at the time of administration. The Director of Nursing acknowledged that the failure to notify the physician about the missed antibiotic doses and the lack of immediate documentation for controlled substances constituted a failure to follow these policies.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required, with three medication errors identified out of 30 observed opportunities, resulting in a 10% error rate. The errors involved three residents: one did not receive a prescribed dose of tiotropium inhalation for COPD, another did not have a lidocaine patch removed after the ordered 12-hour period, and a third did not receive a scheduled dose of entacapone for Parkinson's Disease. These errors were observed during medication administration rounds and confirmed through interviews with nursing staff and review of medical records. For the resident prescribed tiotropium, the medication was neither prepared nor administered during the observed medication pass, and the responsible nurse admitted to forgetting to give the medication, failing to follow the five rights of medication administration. The resident with the lidocaine patch had the previous day's patch still in place well past the 12-hour removal time, as confirmed by both observation and the nurse's statement. The nurse acknowledged that the patch should have been removed according to the physician's order and facility policy, and that this omission constituted a medication error. The resident prescribed entacapone did not receive the medication during the scheduled administration time because it was not available in the medication cart. The nurse responsible did not administer the medication within the required time window and stated that this was a medication error. The Director of Nursing confirmed that these incidents were medication errors and that the involved staff did not follow facility medication administration guidelines or physician orders, as supported by facility policies and procedures reviewed during the survey.
Failure to Provide Proper Food Texture for Resident on Dysphagia Diet
Penalty
Summary
A deficiency occurred when a resident with a physician-ordered dysphagia advanced mechanical soft texture diet was served cubed chicken pieces instead of the required ground chicken during a lunch meal. The resident's meal ticket and physician's order specified ground chicken fajita filling, but the kitchen staff provided chicken cut into larger, cubed pieces. Multiple staff members, including a CNA, Dietary Services Supervisor, cook, and the Director of Nursing, confirmed that the meal did not meet the specified dietary requirements and acknowledged that the resident should have received ground chicken as ordered. The resident involved had a history of chronic pain syndrome, falls, and muscle wasting, and required substantial to maximal assistance with eating. The resident was assessed as having moderately impaired cognition but was able to make her needs known. The care plan and dietary orders emphasized the need for modified diets according to the resident's tolerances and preferences, with specific instructions for food texture to reduce the risk of choking or difficulty swallowing. Facility policies reviewed indicated that food products should be prepared using standardized recipes with adjustments for therapeutic and consistency modifications, and that therapeutic diets are to be planned and served in consultation with a dietitian. Despite these policies, the kitchen staff did not follow the meal ticket instructions, resulting in the resident receiving food in a form inconsistent with her dietary needs.
Incomplete Medical Record Documentation and Accessibility
Penalty
Summary
The facility failed to ensure that medical records for multiple residents were complete, accurately documented, and readily accessible, as required by professional standards and facility policy. For one resident receiving a Restorative Nursing Aide (RNA) feeding program, the RNA flow sheets for two consecutive months were incomplete, with missing documentation of the provision of the feeding program and the initials of the RNA responsible for care. Interviews with staff confirmed that the RNA feeding program was provided daily, but the required documentation was not consistently completed, leaving blank spaces and missing signatures on the flow sheets. Another resident's record lacked documentation of Interdisciplinary Team (IDT) meeting attendance. Although IDT meetings were held, there was no record of who attended, including whether the resident or their representative participated. The Social Services Director and Director of Nursing acknowledged that the facility did not have a consistent process for tracking IDT attendance, and the required sign-in sheets or documentation were missing from the resident's record. Facility policy required prompt, complete, and accurate documentation of all care planning meetings and attendance. A third resident's medical record did not contain optometrist and ophthalmologist visit notes, despite the resident having significant vision-related diagnoses and recent eye care consultations. Nursing staff confirmed that these consult reports were not filed in the resident's chart, which prevented timely follow-up with the primary physician regarding the specialist's recommendations. The Director of Nursing stated that consult notes should be promptly filed and followed up to ensure appropriate care. Facility policy required that all direct services and observations be documented in the resident's record as soon as possible.
Failure to Maintain Safe Electrical Equipment in Resident Rooms
Penalty
Summary
The facility failed to maintain mechanical and electrical equipment in safe operating condition for two residents. For one resident with a stage 4 pressure ulcer and multiple complex diagnoses, the bed controller cord was observed to have exposed wires. The resident was alert and able to communicate, and the exposed wires were noted during a staff observation. The treatment nurse confirmed the presence of exposed red, green, yellow, white, and black wires and stated that maintenance should have been notified immediately, as exposed wires could lead to resident injury. The Director of Nursing (DON) also confirmed that staff should identify and report such hazards during their rounds. For another resident with dementia, intellectual disabilities, and aphasia, the bed remote control cord was found to have frayed wires measuring 12 inches long. This resident was assessed as having the capacity to understand and make decisions and was at high risk for falls. The frayed wires were observed during a staff interview, and the LVN present acknowledged that such a condition could result in accidental electrocution. The DON reiterated that staff are expected to identify and report hazards like frayed wires to the maintenance department for immediate replacement. A review of the facility's maintenance policy indicated that the maintenance department is responsible for ensuring all equipment, including electrical cords in resident rooms, is kept in a safe and operable manner at all times. Despite this policy, the deficiencies were observed and confirmed by both nursing and administrative staff, indicating a failure to follow established procedures for equipment safety and maintenance.
Failure to Timely Submit Discharge MDS Assessment
Penalty
Summary
The facility failed to ensure timely submission of a completed discharge Minimum Data Set (MDS) assessment for one resident. The resident was admitted with diagnoses including spondylosis, stenosis, and type 2 diabetes mellitus, and was later discharged home with home health services and durable medical equipment. Documentation showed that the discharge was initiated by the facility due to improvement in the resident's condition, and all necessary discharge planning steps, such as medication reconciliation and communication with the family, were completed. However, review of the electronic health record revealed that the discharge MDS assessment was not completed or submitted by the Minimum Data Set Coordinator (MDSC), resulting in the assessment being 133 days overdue. Both the MDSC and the Director of Nursing confirmed that the discharge MDS assessment should have been completed and submitted within 14 days of discharge, as required by facility policy and regulatory guidelines. The failure to submit the assessment in a timely manner was identified during interviews and record reviews.
Inaccurate MDS Coding for Resident Assessments and Discharges
Penalty
Summary
Surveyors identified deficiencies related to the facility's failure to ensure accurate assessments for multiple residents, as required by policy and federal guidelines. For one resident with a history of orthopedic aftercare, bilateral lower limb amputations, and dementia, the Minimum Data Set (MDS) was inaccurately coded regarding falls with major injury. The resident experienced a fall resulting in abrasions to the right stump, but the MDS did not accurately reflect the absence of a major injury. Both the MDS Coordinator (MDSC) and Director of Nursing (DON) confirmed that the MDS was not coded correctly, which could misrepresent the resident's clinical status and care needs. Another resident with diagnoses including psychosis, dementia, and muscle wasting was inaccurately coded on the MDS as having an active diagnosis of schizophrenia, despite the admission record and psychiatrist's progress note not supporting this diagnosis. The MDSC acknowledged the error, noting that the inaccurate coding could cause confusion regarding the resident's status and potentially delay appropriate care and services. The DON also confirmed that the MDS should have accurately reflected the resident's diagnoses to ensure proper care planning. A third resident, admitted with Alzheimer's disease, history of falls, and major depressive disorder, was discharged to home with home health services. The MDS was coded as an unplanned discharge, although records indicated the discharge was planned and coordinated with appropriate referrals and services. The MDSC and DON both stated that the discharge should have been coded as planned, as the resident was prepared for discharge in advance. The facility's policy required that assessments accurately depict resident-specific issues and objectives, which was not met in these cases.
Rooms Exceed Maximum Resident Capacity
Penalty
Summary
The facility failed to ensure that bedrooms accommodated no more than four residents, as required, for three rooms. Observations and record reviews revealed that two of these rooms each housed five residents, while another housed four. Documentation showed that the rooms in question had sufficient square footage per resident, and during the survey, residents were observed to have enough space to move freely, including those who were wheelchair-bound or ambulatory. Interviews with residents and staff indicated that there were no reported concerns regarding space or privacy, and staff confirmed they had enough room to provide care. Despite the absence of complaints from residents or staff, the facility's own records and direct observations confirmed that the number of residents in these rooms exceeded the regulatory maximum. The administrator acknowledged that the rooms had a capacity greater than four residents and confirmed that privacy was maintained. The facility had a policy for screening residents for placement in waiver rooms, but the deficiency was identified due to the actual number of residents residing in the rooms at the time of the survey.
Failure to Meet Minimum Room Size Requirements in Multiple Resident Rooms
Penalty
Summary
The facility failed to provide the required minimum of 80 square feet per resident in multiple occupancy rooms for 16 out of 33 rooms, as determined through observation, interviews, and record review. Documentation provided by the facility confirmed that these rooms did not meet the square footage requirement, and a waiver request had been submitted for these rooms. During the survey, it was observed that the space in these rooms did not interfere with the care and services provided, and residents were able to move about freely with adequate space for beds, dressers, and care equipment. Interviews with staff and residents indicated that there were no reported concerns regarding the available space, and staff were able to provide necessary care without issue. The administrator confirmed the deficiency in room size and stated that no complaints had been received from residents regarding space. The facility's policy indicated that residents are screened for medical and personal needs before placement in waiver rooms.
Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Injury
Penalty
Summary
A deficiency occurred when a resident was subjected to physical abuse by another resident within the facility. The incident began with a verbal altercation between two residents sharing a room, which escalated when one resident punched the other twice in the face with a closed fist. The assaulted resident, who had a history of monoplegia, hemiplegia, hemiparesis, and chronic obstructive pulmonary disease, was unable to defend himself due to his physical limitations and required assistance with mobility. As a result of the altercation, the resident sustained significant facial swelling and reported severe pain, later being diagnosed with a displaced nasal bone fracture after being transferred to an acute care hospital. The resident who committed the assault had a documented history of behavioral symptoms, including verbal aggression, and was diagnosed with schizophrenia and an unspecified mood disorder. The care plan for this resident identified a potential for verbal aggression and included interventions to document observed behaviors and attempted interventions. However, the care plan did not prevent the escalation to physical aggression, and the facility failed to protect the assaulted resident from abuse. Staff interviews confirmed that the incident was witnessed, and both the LVN and CNA present identified the event as physical abuse. Facility policy explicitly prohibits all forms of abuse, including physical and verbal abuse, and emphasizes the importance of maintaining a safe environment for all residents. Despite these policies, the facility did not prevent the physical altercation, resulting in injury and psychological distress for the assaulted resident. The Director of Nursing acknowledged that the facility failed to ensure the resident was not subjected to abuse and recognized the potential for negative psychosocial effects following the incident.
Incomplete and Inaccurate Medical Record Documentation for Two Residents
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents by not documenting the actual times of change of condition (COC) events, notifications to representatives and physicians, and the care provided following these events. For one resident, documentation was missing regarding the time an ice pack was applied after an altercation and the time pain medication was refused. Additionally, the Social Services Director did not document required psychosocial evaluations on specific days following the resident's return from the hospital, and the COC evaluation contained inaccurate times for when the physician and representative were notified, with entries recorded before the incident occurred. For the second resident, the facility did not document observed behaviors and interventions as required by the care plan and physician orders. The COC evaluation for this resident also contained inaccurate times for notifications, and there was no documentation of behavioral monitoring or interventions in the Medication Administration Record (MAR) for incidents of aggression. The resident's refusal to be assessed after an altercation was noted, but the required documentation of behaviors and interventions was incomplete. Interviews with nursing staff and the Director of Nursing confirmed that documentation was not completed promptly or accurately, and that entries were sometimes made hours after events or with incorrect times. The facility's own policy requires prompt, complete, and accurate documentation, and prohibits documenting events before they occur. The failure to follow these standards resulted in incomplete and inaccurate medical records for both residents.
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Illustrative
What surveyors actually found near you
We read the 6,832 citations issued within 25 miles in the last 12 months — including the 35 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Los Angeles
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Los Feliz Healthcare & Wellness Center, Lp | 0 mi | ★★★★★ | 12 | 0 |
| Hollywood Presbyterian Medical Center D/p Snf | 1.5 mi | ★★★★★ | 22 | 0 |
| Glendale Healthcare Center | 1.7 mi | ★★★★★ | 10 | 0 |
| Leisure Glen Post Acute Care Center | 1.7 mi | ★★★★★ | 2 | 0 |
| Garden Crest Rehabilitation Center | 1.8 mi | ★★★★★ | 20 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.