Below average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Stoney Point Healthcare Center during CMS and state inspections, most recent first.
The facility failed to ensure PASRR Level II recommendations were carried out for two residents after positive PASRR Level I screens. One resident with unspecified psychosis and severely impaired cognition had PASRR II recommendations for neuropsychology and sleep specialist consultations, but there was no documented evidence they were implemented. Another resident with psychosis, dementia, depression, and anxiety had a PASRR II recommendation for a smoking cessation program, but the ADON stated there was no documented evidence it was implemented.
A resident with unspecified psychosis and moderately impaired cognition did not receive a scheduled Abilify Maintena IM injection as ordered because the medication was not delivered and was unavailable in the facility. An LVN said she contacted the pharmacy and waited for delivery, while the ADON and DON confirmed the dose should have been given and that staff did not follow through with pharmacy and provider communication.
An EKG ordered for a resident taking Abilify was not completed as ordered. The resident had heart disease and moderately impaired cognition, and the ADON confirmed during record review that the EKG should have been done but there was no documented reason for the missed test.
A resident with dementia, bipolar disorder, and schizophrenia was readmitted with no capacity to make decisions and was ordered Lorazepam for anxiety and agitation. An RN documented verbal consent from the resident and RP and stated Bioethics Committee involvement was not needed, but the DON confirmed the resident was under Bioethics Committee care decisions and that the committee should have been involved in decisions about the psychotropic medication.
Failure to Provide Ordered Foot Care and Skin Monitoring: A resident with DM, diabetic polyneuropathy, and moderate pressure-injury risk developed a worsening left lateral foot ulcer and a new right great toe ulcer after staff did not document daily skin checks, did not provide daily foot washing, did not implement the podiatry and wound care recommendations, and did not keep the heels fully offloaded while in bed.
Failure to Protect PHI on Meal Tickets: A Dietary Aide was observed discarding meal tickets with leftover tray waste into a trash can during dishwashing, and the DS stated this was the normal process. The meal tickets contained resident names, room numbers, ID numbers, diet orders, allergies, preferences, and pictures, and both the DS and DON stated the tickets should have been shredded before disposal because they contained PHI.
Kitchen and food service areas had widespread sanitation and food safety issues, including dirty freezer vents and shelves, spills and debris in the walk-in refrigerator and dry storage, residue on condiment covers and a residents’ refrigerator, and food splatter on the trayline roof. Surveyors also observed damaged food-contact surfaces, mislabeled and expired sandwiches, dented cans stored with regular stock, staff drinks on food prep surfaces, jewelry worn during food handling, and multiple instances of staff failing to wash hands after touching trash, faces, or dirty surfaces.
Improperly covered and unclean garbage receptacles were observed when one dumpster was left open, two kitchen trash cans were not completely closed during trayline, and the outside dumpster had dirt, food debris, and soiled gloves nearby. The DS and RD stated trash should be covered when not in use, and the MS stated the dumpster needed to be covered and clean to prevent birds from picking up trash and spreading infections.
The facility failed to promote dignity during meals by serving side dishes in paperware and by having a CNA stand over a resident while feeding him. A resident with HTN, DM, and COPD objected to disposable cups, utensils, and side dishes, and staff acknowledged paperware was used because items were being thrown away. Another resident with dementia who needed help with eating was fed while the CNA stood over him instead of sitting at eye level, despite staff and policy stating feeding should be done with attention to dignity.
A facility failed to properly monitor and administer psychotropic medications for two residents. One resident receiving risperidone had physician-ordered orthostatic BP checks that were not clearly documented as separate lying and sitting readings, while another resident’s quetiapine order used vague behavior language and the alprazolam order had an NTE 0.75 mg/24 hr limit that was exceeded when two doses were given in one day. Staff interviews confirmed the orders were not followed or clarified as required.
Kitchen staff were not routinely trained or competency checked before performing duties, and dietary employees were observed using improper hand hygiene and cross-contamination practices. A dietary aide from a sister facility was allowed to dishwash without facility training or competency verification and threw meal tickets containing PHI into the trash. Another dietary aide dipped hands into a sanitizer bucket instead of washing at the sink, and a third staff member handled clean pans after wiping counters without washing hands.
Dietary staff failed to follow the menu and standardized recipe for roast beef portioning, serving inconsistent amounts on regular and therapeutic diet trays. The menu and recipe specified 3 oz portions, but the DS observed pieces weighing 2 oz to 4 oz and initially stated one piece was one serving before changing the serving method. The DS acknowledged the correct portion was needed so residents received their full protein, and the report stated 70 of 126 residents on regular and therapeutic diets were affected.
A resident with CHF, COPD, acute respiratory failure, moderate cognitive impairment, and dependence for ADLs had edema in both hands observed by an LVN, but the finding was not reported to the RN or physician and was not documented. The DON stated the edema was a change in condition that should have been escalated, and the RN confirmed the physician was not notified.
Improper Use of Wedge Pillow as a Physical Restraint: A resident with a history of falls, a femur fracture, bilateral hip replacements, depression, and metabolic encephalopathy was observed with a wedge pillow placed under the mattress at the foot of the bed. Staff stated the device was being used for repositioning and wound prevention, but an LVN explained that placing it under the mattress made it immovable and turned it into a physical restraint. The DON also stated the wedge pillow should be placed on top of the mattress, not under it, and the facility policy defined restraints as devices that cannot be easily removed and restrict movement.
A resident with PTSD and moderate cognitive impairment had a positive PASARR Level I for SMI, but the facility did not ensure a Level II evaluation was completed. DHCS documented that staff were unresponsive to repeated contact attempts, and the MDSN stated no communication with DHCS had occurred and that follow-up was needed for the resident to receive the proper Level II assessment.
Failure to Maintain Facial Hygiene During ADL Care: A resident with dementia, dysphagia, and significant ADL dependence was observed with yellow/white discharge on both cheeks from the eyes shortly after morning care. A CNA stated the resident could not wash her own face and was not certain the face had been cleaned, while the DON stated residents have the right to a clean face and that facial hygiene should be provided daily and as needed for dignity and hygiene.
Failure to Assess and Document Hand Edema: A resident with CHF, COPD, respiratory failure, and diuretic use was observed with edema in both hands, including 2+ pitting edema. The LVN stated the swelling was seen during rounds but was not documented because she forgot and was not reported to the RN or MD because it improved with repositioning. The chart reviewed did not show edema documented in the admission/readmission assessment, skin evaluation, or weekly summaries, and the RN and DON stated the change in condition required assessment and documentation.
Failure to Offload Heels for a Resident at High Risk for Skin Breakdown: A resident with a high Braden risk score and a care plan calling for heel offloading was observed in bed with a wedge pillow placed under the mattress, leaving both heels in contact with the mattress. CNA and nursing staff stated the wedge was being used for repositioning, but TN and the DON confirmed that this placement did not float the heels as required by the care plan and facility policy.
The facility failed to keep the resident environment free of accident hazards for two residents. One resident with DM, CKD, vascular dementia, and high fall risk had a wheelchair placed on top of a landing pad beside the bed, and RN 2 stated the pad must remain clear. Another resident with unspecified psychosis and repeated falls had a physician order for a soft protective helmet when out of bed, but the helmet was observed with a missing chin strap and was not secured; CNA 2, the COTA, and the DON all noted it was unsafe without a secure strap.
Incomplete Hemodialysis Communication Assessments: A resident with ESRD and dependence on HD had incomplete hemodialysis communication assessments, with missing post-dialysis weights on two occasions and missing vital signs plus pre- and post-dialysis weights on another. The resident had orders for a tunneled catheter, routine catheter checks, and HD three times weekly, and the care plan included monitoring I&O, weights, vital signs, and catheter complications. An LVN and the DON stated the form is used to document the resident’s condition before, during, and after HD and that nurses are responsible for completing it and obtaining missing information when needed.
Failure to Document Duration of Lovenox Therapy: A resident admitted with subdural hematoma and severe cognitive impairment had an order for enoxaparin (Lovenox) 40 mg SQ daily for DVT prophylaxis, but the facility did not document a duration of therapy. The pharmacist flagged the missing duration in the MRR, and the LVN, ADON, and DON stated it should have been addressed on admission; however, no physician documentation, order, or care plan note reflecting a stopping condition was available.
Medication Labeling Error: A bottle of carboxymethylcellulose sodium eye drops for a resident was observed on a med cart labeled with a room number and bed letter instead of the resident’s name. An LVN stated the medication should be labeled with the resident’s first and last name because residents may move rooms, and the DON confirmed the facility policy required medications to be labeled with the resident’s name.
A resident receiving O2 via NC had unlabeled tubing despite orders to change it on a set schedule, and staff stated the label was needed to show when it was last changed. In a separate event, an LVN wore an isolation gown while leaving a resident’s room and approached the med cart outside the doorway before removing it, despite staff stating gowns should be removed before contact with anything outside the room to prevent cross contamination.
A resident’s RP requested copies of the resident’s medical records, but the facility did not release them in a timely manner. The MRD confirmed the request was received and said the facility waited for additional records before sending anything, with no contact made to the RP after the request. The DON confirmed the facility’s policy required copies to be provided within two business days of a completed authorization, but the records were not provided until 41 days after the request was received.
Incomplete Documentation of Resident Eye Injury: A resident with dementia, DM, HTN, pneumonia, and a history of falls reported hitting the left eye on a bedside table, and staff assessed the eye and notified the MD. However, the LVN and RNS did not document the incident, the assessment, or the MD notification in the resident's medical record, despite facility policy requiring objective, complete, and accurate charting of incidents and changes in condition.
Improper Linen Use on Low Air Loss Mattress: A resident with impaired cognition, incontinence, and significant ADL dependence was observed lying on a low air loss mattress while wearing an incontinence brief, with a flat sheet and cloth incontinence pad placed over the mattress. CNA, TxN, and DON interviews confirmed the setup was inconsistent with the facility’s LALM guidance, which called for minimal linen layering and use of a disposable moisture management pad when indicated.
A resident with encephalopathy, depression, and dementia, who required moderate to maximal assistance with ADLs, expressed discomfort with their room, and the responsible party requested a room change through Social Services. Social Services confirmed that another room was available and notified the RN Supervisor, but the transfer was not completed because the RN Supervisor reported being too busy during shift change. The DON confirmed that a room was available and that such requests should be acted on promptly, and facility policies state that residents are to be treated with dignity and that room changes are to be made when requested by the resident. This resulted in a failure to timely honor the resident’s request for a room change.
A resident's right to privacy and confidentiality was violated when the Social Services Director gave that resident's medical records to another resident's responsible party who had requested records. The SSD printed records from the printer and handed them over without confirming they matched the correct resident and without following the facility's required Authorization for Release of Records process, which involves review and approval by the MRD, DON, and Administrator. Facility policies on release of records and resident rights specified that records may only be released with proper authorization and that residents are entitled to confidentiality of their personal and medical information.
A resident with respiratory failure and severe cognitive impairment experienced a significant drop in oxygen saturation while receiving oxygen via nasal cannula. Facility staff did not increase the oxygen flow rate or switch to a non-rebreather mask as required by physician orders and facility policy. Paramedics arriving on scene found the resident still on low-flow oxygen and had to initiate high-concentration oxygen therapy before transferring the resident to the hospital.
Three residents received psychotropic medications without proper justification or monitoring. One resident was given an antipsychotic without documentation of required symptoms or evidence that non-drug interventions were attempted. Another was administered an anti-anxiety medication without first trying non-pharmacological approaches as ordered. A third resident received an anti-anxiety medication for weeks without behavioral monitoring to justify its use. These actions did not comply with facility policy or physician orders.
A resident did not receive the necessary care to maintain or improve range of motion or mobility, and there was no documented medical reason for the decline.
The facility did not act on consultant pharmacist recommendations for three residents, including failing to complete an EKG for a resident on Quetiapine, not ensuring proper documentation and monitoring for a resident on Seroquel, and lacking physician documentation for continued Klonopin use. These actions were not in accordance with facility policies and placed residents at risk for adverse effects.
Leftover food brought in by families and visitors was found in a resident refrigerator without proper labeling or resident identification. The Administrator in Training confirmed that all such food should be labeled with an identifier and use-by date, as required by facility policy, but this was not done in the observed instance.
Therapy staff did not accurately document the timing and completion of Rehab Joint Mobility Screens for several residents, failing to indicate late entries or how assessments were performed after the scheduled date. Additionally, a resident's diagnosis of anxiety was omitted from the medical record despite ongoing treatment, resulting in incomplete and inaccurate clinical documentation.
Staff did not knock or ask permission before entering the rooms of two residents with severe cognitive impairment and total dependence for ADLs. The CNA acknowledged forgetting to knock, and the DON confirmed that facility policy requires staff to do so to respect resident privacy and dignity.
A resident with impaired cognition and a need for supervision was found in bed with the call light on the floor and out of reach. Staff confirmed the call light should have been accessible, and facility policy requires it to be within easy reach for residents in bed or in a chair.
Two residents with significant medical needs had executed Advance Directives (ADs) that were not present in their active medical charts, despite facility policy requiring ADs to be accessible for staff reference. Both the Medical Records Director and Social Service Director confirmed the absence of these documents, and the ADON acknowledged that this failure meant staff could not easily access or honor the residents' healthcare wishes.
A resident with multiple diagnoses, including dementia and obstructive uropathy, was admitted with an indwelling catheter, but the baseline care plan developed within 48 hours did not document the catheter or related care needs. Facility staff confirmed the omission, which was inconsistent with policy requiring all immediate care needs to be addressed in the baseline care plan.
Two residents prescribed psychotropic medications did not have person-centered care plans developed or implemented to address their medication use. One resident with dementia and anxiety was given olanzapine without a corresponding care plan, and another resident with major depressive disorder and ADHD was prescribed amphetamine-dextroamphetamine without a care plan. Facility staff and policies confirmed that care plans were required for these medications to ensure proper monitoring and management.
A resident with cognitive impairment and multiple diagnoses lost her upper dentures, and although a dental evaluation was performed and further treatment was declined by the resident, the dental care plan was not updated or revised to reflect these changes, contrary to facility policy requiring care plan review after significant changes.
The facility did not accurately complete or update fall risk assessments for two residents with cognitive and mobility impairments after they experienced falls. In one case, a resident's fall was not documented in the fall risk assessment, and in another, staff failed to conduct a required fall risk assessment after a witnessed fall. These actions were not in accordance with facility policy, which requires timely and accurate fall risk assessments following such incidents.
A resident with end stage renal disease who was dependent on hemodialysis did not have their post-dialysis weight recorded by the dialysis center, and facility nursing staff did not follow up to obtain this information, resulting in incomplete documentation of dialysis care.
A resident was prescribed amphetamine-dextroamphetamine without a documented ADHD diagnosis, and staff failed to develop a care plan or obtain orders to monitor for adverse effects or effectiveness of the medication. Nursing and administrative staff confirmed that required monitoring and care planning for psychotropic medications were not completed, contrary to facility policy.
A resident with a documented egg allergy did not have this allergy indicated on her meal tray ticket, and was not provided with a protein substitute at breakfast when eggs were omitted. Multiple staff confirmed the allergy should have been marked on the tray ticket, and facility policy required both documentation and appropriate food substitutions for allergies and intolerances.
Two residents had inaccurate MDS assessments: one was incorrectly documented as discharged to a hospital instead of another SNF, and another did not have an active anxiety diagnosis listed despite clinical records and medication use for anxiety. These errors resulted in discrepancies between the MDS and other clinical documentation, as confirmed by staff interviews and record reviews.
A resident with mobility impairments and multiple medical conditions was discharged without her rollator walker, and there was no documented follow-up or timely replacement of the missing mobility aid, despite facility policy requiring provision of necessary adaptive equipment.
A resident with severe cognitive impairment was transferred to a new facility without being provided comprehensive information about the new location, as required by the facility's discharge policy. The Social Services Director informed the resident and their responsible party about the transfer but failed to include details about the services, quality measures, or care providers at the new facility, leading to a deficiency.
A facility failed to obtain informed consent from a resident's responsible party for the administration of Olanzapine, an antipsychotic medication. The resident, with diagnoses of psychosis and epilepsy, received the medication for six days without consent. The oversight was confirmed through record reviews and staff interviews, revealing a breach in the facility's policy requiring informed consent for psychotropic medications.
The facility failed to develop person-centered care plans for seven residents, including those with diabetes, psychotropic medication needs, viral hepatitis C, and UTIs. This deficiency involved the absence of care plans for insulin use, psychotropic medications, and antibiotic treatments, which are crucial for outlining interventions and ensuring appropriate care. The oversight was confirmed by the ADON and DON, who acknowledged the importance of care plans in managing residents' specific medical needs.
A resident with severe cognitive impairment was left with unattended medications, violating facility policy requiring nurse supervision during administration. Another resident's bed was not kept in the lowest position as ordered for fall prevention, and a high-risk resident lacked prescribed landing mats, both increasing fall risk. These deficiencies highlight lapses in following physician orders and facility policies.
Failure to Implement PASRR Level II Recommendations for Two Residents
Penalty
Summary
The facility failed to ensure that PASRR Level II recommendations were provided for two sampled residents after their PASRR Level I screens were positive. Resident 2 was admitted with unspecified psychosis and had a severely impaired cognition on the MDS, with assistance needs for eating, oral hygiene, toileting hygiene, and personal hygiene. During record review and interview, the MDS Nurse stated that Resident 2’s PASRR Level I screen was positive and required a PASRR Level II mental health evaluation referral. Resident 2’s PASRR Level II personalized care recommendations dated 5/3/2021 included referrals for a neuropsychology consultation and a sleep specialist consultation. The Assistant Director of Nursing stated there was no documented evidence that these recommendations were implemented. The ADON stated that social services should have referred Resident 2 to neuropsychology and a sleep specialist per the PASRR Level II recommendations. Resident 3 was admitted with unspecified psychosis, unspecified dementia, depression, and anxiety, and had moderately impaired cognition on the MDS with assistance needs for eating, oral hygiene, personal hygiene, and toileting hygiene. The MDS Nurse stated that Resident 3’s PASRR Level I screen was positive and required a PASRR Level II mental health evaluation referral. The ADON reviewed Resident 3’s PASRR Individualized Determination Report and progress notes and stated there was no documented evidence that the PASRR Level II recommendation for a smoking cessation program was implemented, and that PASRR II recommendations should have been relayed to the IDT and the resident’s physician for coordination of care.
Missed Monthly Abilify Injection
Penalty
Summary
The facility failed to ensure that one resident received Abilify Maintena as prescribed by the physician. The resident was admitted with a diagnosis of unspecified psychosis and had moderately impaired cognition, with partial to substantial assistance needed for activities such as eating, oral hygiene, personal hygiene, toileting hygiene, and bathing. A physician order dated 6/1/2026 directed Abilify intramuscular prefilled syringe 300 mg to be given every 30 days for psychosis manifested by calm to aggressive behavior toward staff, including trying to hit staff during ADLs. During record review and interviews, staff confirmed that the resident’s Abilify intramuscular injection was not administered on 6/2/2026 because the medication had not been delivered and was not available in the facility. The LVN stated she called the pharmacy and waited for delivery, but by the end of her shift the medication still had not arrived. The ADON and DON stated the injection should have been administered, that nursing staff should have followed up with the pharmacy and informed the prescribing provider, and that the medication was intended to treat the resident’s psychosis and aggressive behavior.
EKG Ordered for Abilify Was Not Completed
Penalty
Summary
The facility failed to ensure that an EKG ordered by a physician for one resident was completed. The resident was admitted with diagnoses including heart disease and unspecified psychosis, and the MDS showed moderately impaired cognition with partial to substantial assistance needed for several activities of daily living. A physician order dated 6/20/2026 directed an EKG every day shift every 12 months starting on the 22nd for one day for the use of Abilify per pharmacy recommendation. During a concurrent interview and record review, the ADON reviewed the resident’s physician orders and nursing progress notes and stated that the EKG was not done as ordered. The ADON stated the EKG should have been completed on 6/22/2026 and that there was no documented evidence explaining why it was not done. The ADON also stated the EKG was important because it was a pharmacy recommendation related to the resident’s use of Abilify.
Failure to Involve Bioethics Committee in Psychotropic Medication Consent
Penalty
Summary
The facility failed to ensure that Resident 1 had the Bioethics Committee assess the need for continued psychotropic medication and sign the consent form for Lorazepam upon readmission to the facility. Resident 1’s record showed diagnoses including dementia, anemia, bipolar disorder, and schizophrenia. The record also showed that Resident 1 did not have the capacity to understand and make decisions, and an interdisciplinary conference form indicated that Resident 1 had no resident representative and impaired cognition, so the IDT would act on the resident’s behalf in selecting the attending physician. After Resident 1 was readmitted following hospitalization, a physician order was written for Lorazepam 0.5 mg twice a day for anxiety manifested by increased agitation. A facility verification of informed consent form completed by an RN documented that Resident 1 and RP 1 provided verbal consent for Lorazepam and were given information about the risks and benefits of the psychotropic drug, and it also stated that Resident 1 did not require Bioethics Committee involvement for care decisions. During interview, the DON confirmed that the form documented consent for Lorazepam and that Resident 1 did not require Bioethics Committee involvement, but also confirmed that Resident 1 was under the Bioethics Committee for care decisions at that time and that the committee should have been notified and involved in decisions regarding Resident 1’s psychotropic medications upon readmission.
Failure to Provide Ordered Foot Care and Skin Monitoring
Penalty
Summary
The facility failed to provide proper foot care and skin monitoring for a resident with type 2 DM, diabetic polyneuropathy, vascular dementia, CKD, protein-calorie malnutrition, and impaired mobility. The resident’s Braden score was 13, indicating moderate risk for pressure injury, and the care plan for skin breakdown called for skin checks during daily care and notification of the physician for abnormal findings. The resident’s admission record and MDS showed the resident was at risk for skin impairment and required assistance with bed mobility. On 6/26/2026, a Podiatry NP evaluated the resident after complaints of painful thick toenails and numbness and tingling in both feet and identified a diabetic ulcer on the left lateral foot measuring 0.9 cm x 0.9 cm x 0.1 cm. The NP recommended aggressive pressure offloading with heel protectors and pillows, daily inspection for cracks, blisters, and sores, daily washing of the feet with warm water, drying between the toes, lotion use, and supportive footwear. The resident’s treatment record showed an order to cleanse the left foot ulcer and apply xeroform with a dry dressing daily. The resident later developed worsening foot wounds. On 7/9/2026, the WCC documented the left lateral foot ulcer had increased to 1.8 cm x 1.8 cm x UTD with about 80% necrotic eschar and 20% slough, and a new diabetic ulcer was found on the right great toe measuring 0.8 cm x 0.8 cm x 0.2 cm with necrotic tissue and tenderness to palpation. During observation on 7/15/2026, the resident was wearing socks with both heels in contact with the bed surface, and CNA 1 stated the resident needed heel elevation but the pillow under the lower legs still allowed the heels to touch the bed. CNA 1 also stated she washed the resident’s feet only on shower days, not daily. TN 1 stated there was no documented evidence that skin observations were done during the reviewed period, that the frequency had been set to as necessary rather than daily, and that the additional recommendations from the Podiatry NP and WCC were not implemented. The DON also stated the diabetic foot care measures from the facility policy and the specialists’ recommendations should have been incorporated into the resident’s care plan.
Failure to Protect PHI on Meal Tickets
Penalty
Summary
The facility failed to keep residents’ personal and medical records private and confidential when Dietary Aide 3 was observed throwing leftover food, plastic, and meal tickets into a grey trash can during dishwashing in the dishmachine area. On multiple observations, the aide continued placing meal tickets in the trash while stripping soiled trays, and the Dietary Supervisor stated that the dishwashing process started by throwing all trash, including meal tickets, into the garbage can. The supervisor also stated the aide had come from a sister facility and had not been trained before starting work at the facility. During interview, the Dietary Supervisor stated the meal tickets contained residents’ food likes and dislikes, food allergies, names, ID numbers, diet orders, room numbers, and pictures, and that the tickets should have been separated and shredded before disposal because they contained PHI. The DON also stated the menu tickets contained resident identifiers and PHI, and that they should have been shredded before being thrown in the trash. Facility policy stated PHI must be protected from unauthorized release or disclosure and that all personnel with access to resident information are required to receive HIPAA compliance training.
Unsanitary kitchen conditions and improper food handling
Penalty
Summary
The facility failed to maintain sanitary food storage and food preparation conditions in the kitchen and related food service areas. During surveyor observations, multiple areas contained dirt, food debris, spills, dust buildup, and residue, including the reach-in freezer vent, meat freezer shelves, walk-in refrigerator floor, refrigerator vents and shelves, dry storage floor, condiment container covers, hot water dispenser spout, trayline roof, utensil drawer, trayline fans, and a residents’ refrigerator. Surveyors also observed kitchen equipment and surfaces that were not cleanable surfaces, including a corroded metal rack, a black rack with peeling paint, and a chopping board with scratches and knife marks. Surveyors also found food storage and labeling problems in the walk-in refrigerator and dry storage area. Trays of sandwiches were observed with incorrect or missing dates, including cheese sandwiches and ham and cheese sandwiches with dates that did not match proper labeling practices. A cut lemon was wrapped in a paper towel, and prepared foods such as a hamburger patty and sliced zucchini were stored in a plastic bag. Four dented cans were stored with non-dented cans. Personal staff beverage containers were observed on the mixer table and dishwashing countertops, and dietary staff were observed wearing jewelry while preparing food and washing dishes. Hand hygiene and food handling practices were also observed to be inconsistent with sanitary procedures. Four dietary staff did not wash their hands during food preparation, dishwashing, and other kitchen tasks. One dietary aide wiped countertops with a soiled towel, handled trash, drank Gatorade, touched clean carts and resident beverage items, and washed hands for only 5 seconds before returning to food service tasks. Another dietary aide wiped hands on pants, handled trash, and dipped hands in a sanitizer bucket instead of washing at the handwashing sink. Two dietary staff members were also observed handling food after touching trash, removing gloves, touching their faces, or cleaning surfaces without washing hands. The dietary supervisor and registered dietitian acknowledged several of these practices during the observations.
Improperly Covered and Unclean Garbage Receptacles
Penalty
Summary
Garbage and refuse were not properly disposed of when one of two dumpsters was observed open while not actively being used. During interview, the Maintenance Supervisor stated the dumpster needed to be covered all the time to prevent birds from picking up trash and spreading infections to residents. In the kitchen, two trash cans in the preparation and dishwashing areas were observed not completely closed while not in use during lunch trayline. The Dietary Supervisor and Registered Dietitian both stated the trash cans should be covered when not in use, and the Registered Dietitian stated it was important to cover the trash securely. The outside dumpster body was observed to have dirt and food debris, and soiled gloves were observed on the floor in the dumpster area. The Dietary Supervisor stated food was thrown into the outside dumpster and that the debris on the dumpster body was not okay because flies could go to it and spread germs to residents. The Maintenance Supervisor stated he maintained the dumpster area, that the dumpster needed to be clean to prevent birds from picking up trash and spreading infections, and that the dumpster was not clean due to visible debris. The facility policy required garbage and trash cans to be inspected daily to ensure no debris was on the ground or surrounding area and that lids were closed, and the Food Code required receptacles and waste handling units to be kept covered and cleaned to prevent attraction of insects, rodents, and contamination.
Dignity During Meals and Feeding Assistance
Penalty
Summary
The facility failed to provide care in a manner that promoted dignity and respect by serving side dishes in paperware during lunch service. Resident 39 was admitted with diagnoses including HTN, type 2 DM with hyperglycemia, and COPD with acute exacerbation. The resident’s MDS indicated he understood others, could make himself understood, and was independent with eating. His order summary showed a consistent carbohydrate diet with IDDSI level 6 texture and thin liquids. During observations, dietary staff and a dietary aide were seen serving corn coleslaw on paperware bowls in the trayline and during a test tray observation. The Dietary Supervisor stated paperware had been used since he started employment because of COVID-19 and because residents threw them away, and he stated residents did not request paperware and that it was not okay and good practice due to residents’ dignity. The RD stated paperware was used because side dishes were thrown away and that residents may not eat the food and lose weight as a potential outcome of food served on paperwares. Resident 39 stated he would prefer cups, spoons, forks, and side dishes not be disposable or plasticware and said it would be nice to serve regular beverage containers and silverware because they were sturdier. The facility also failed to ensure CNA 3 did not stand over Resident 101 while assisting with eating. Resident 101 was admitted with dementia, and the MDS indicated severe cognitive impairment and that the resident required partial/moderate assistance with eating. The care plan stated the resident’s needs would be anticipated and met by staff and later identified that the resident required extensive assistance with eating. During a concurrent observation and interview, CNA 3 was seen feeding Resident 101 in a wheelchair by the bed while standing and not at eye level. When asked how she feeds a resident, CNA 3 stated she should be sitting in a chair, left the room, returned with a chair, and then fed Resident 101 while seated. During interview, CNA 3 stated the practice is to feed a resident sitting in a chair at eye level with the resident, and that this is important for comfort and to explain what is being fed. The DON stated residents who need assistance with eating are to be fed at eye level to provide dignity. The facility policy titled Assistance with Meals stated residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity, including not standing over residents while assisting them with meals.
Psychotropic Medication Monitoring and Order Compliance Deficiencies
Penalty
Summary
The facility failed to ensure that two residents receiving psychotropic medications were monitored and administered medications in accordance with physician orders and facility policy. One resident was admitted with psychosis, dementia, and hypertension, had severe cognitive impairment, and was dependent for ADLs and mobility. That resident was ordered risperidone for psychosis manifested by agitation and attempts to hit staff during ADLs, along with orthostatic blood pressure monitoring every Saturday while lying and sitting. The record review and interview with the ADON showed the MAR did not clearly reflect two distinct blood pressure checks in the positions ordered, and the ADON stated the resident was supposed to have separate lying and sitting blood pressures documented. The facility also failed to ensure that another resident’s psychotropic regimen was specific and followed as ordered. That resident was admitted with psychosis, anxiety, and a history of falls, and the MDS showed severe cognitive impairment and need for substantial/maximal assistance with eating. The physician ordered quetiapine for psychosis manifested by sudden anger outburst of anger, but the pharmacist’s medication regimen review stated the behavior was too vague and subjective and should be clarified. Staff interviews confirmed the order was not specific enough for licensed nurses to assess behavior consistently or determine whether the medication was effective. The same resident also had an alprazolam order for anxiety with a not-to-exceed limit of 0.75 mg in 24 hours. The MAR showed two doses were administered on one day, totaling 1 mg. During interviews, the LVN and DON stated that two doses in a day exceeded the ordered daily limit and that the psychiatrist should have been contacted to clarify the dosing parameter. The facility policy stated medications are to be administered in accordance with prescriber orders and that staff should contact the prescriber if a dosage is believed to be inappropriate or excessive.
Kitchen Staff Training and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to ensure kitchen staff were routinely trained and evaluated for competency skills. During dishwashing observations, Dietary Aide 3 from a sister facility was seen throwing leftover food, plastic, and meal tickets into the trash while working in the dishmachine area. The Dietary Supervisor stated Dietary Aide 3 came from the sister facility, had not been trained before starting work in the facility, and had not had his competency evaluated before being allowed to dishwash. The Dietary Supervisor also stated the meal tickets contained resident names, room numbers, diet orders, allergies, medical record numbers, and pictures, and that they should have been shredded before disposal because they contained PHI. The Dietary Supervisor, Administrator, Director of Nursing, and Director of Staff Development each stated that staff from the sister facility could be shared, but also stated that training, credential review, and competency verification were expected before an employee started working in the kitchen. The Director of Staff Development stated she was not aware the sister facility was bringing an employee into the facility and did not provide handwashing or HIPAA training to Dietary Aide 3. The DON stated there was no signed job description, competency, or training completed for Dietary Aide 3 before he worked in the kitchen. The facility also failed to ensure dietary staff understood hand hygiene and clean-versus-dirty work practices. Dietary Aide 2 was observed dipping his hands into a sanitizer bucket while working in the dishwashing area and then putting away clean dishes. He stated he did so because a coworker told him to, but he did not know why. The Dietary Supervisor stated the sanitizer bucket was for cleaning surfaces and carts, not hands, and that handwashing should be done at the sink to prevent cross-contamination. In a separate observation, [NAME] 2 wiped countertops with a blue towel and then put away clean pots and pans without washing her hands. [NAME] 2 stated she had been taught to wash hands when touching dirty items and believed it was acceptable not to wash because the towel and surfaces were clean. The Dietary Supervisor stated she needed to wash her hands to prevent cross-contamination, and the Infection Preventionist stated dietary staff should wash hands when moving from dirty to clean areas and before handling food or clean equipment.
Inconsistent Roast Beef Portioning on Menu Trays
Penalty
Summary
The facility failed to follow its menu and standardized recipe for roast beef portioning when dietary staff served inconsistent amounts of roast beef on regular and therapeutic diet trays. The menu spreadsheet for the summer menu specified French dip roast beef at 3 oz per serving, and the facility’s recipe for French Dip Sandwich also listed the roast beef portion size as 3 oz. During observation in the trayline, a pan of roast beef was seen with different portion sizes, some appearing larger and some smaller. When the Dietary Supervisor weighed portions, individual pieces measured 2 oz, 3.8 oz, 2 oz, 4 oz, 2 oz, 3.2 oz, 3 oz, and 3 oz, and the supervisor stated one serving was one piece of roast beef before later stating he would serve 2 pieces moving forward. The Dietary Supervisor later stated the roast beef portion size should be 3 oz and that staff needed to serve the correct portion so residents would receive their full protein. He also stated that underportioning could leave residents hungry and overportioning could contribute to weight loss or weight gain. The facility’s policies stated menus are planned to meet nutritional needs, standardized recipes are to be used in food preparation, and portion sizes are to better meet resident needs. The report identified that 70 of 126 residents on regular and therapeutic diets were affected by the portioning issue.
Failure to Report Resident Hand Edema to Physician
Penalty
Summary
The facility failed to notify the physician of a change in condition for Resident 14 when edema was observed in both hands. Resident 14 had diagnoses including CHF, acute respiratory failure, and COPD, was dependent for ADLs and mobility, and was taking a diuretic. The resident also had moderate cognitive impairment and was conserved, with the H&P stating the resident could not make own medical decisions. During observation, Resident 14 was seen lying in bed with edema in the left hand, and later both hands were observed to have pitting edema rated 2+. LVN 2 stated the swelling had been seen during rounds and that it decreased when the resident’s arms were elevated on a pillow. LVN 2 did not report the edema to an RN or the physician and did not document the finding, stating she forgot and did not think it needed to be reported because it improved with repositioning. Record review did not show documentation of edema in the admission/readmission assessment, skin evaluations, or weekly summaries. RN 2 stated the edema should have been assessed when first observed and the physician should have been notified of the change in condition. The DON stated the edema was a change in condition that should have been reported to the RN for assessment and then to the physician, and that not notifying the physician resulted in no orders being in place to address the change.
Improper Use of Wedge Pillow as a Physical Restraint
Penalty
Summary
The facility failed to ensure that a resident was free from the use of a physical restraint when a wedge pillow was placed under the mattress on the right side at the foot of the bed for Resident 121. Resident 121 was admitted with diagnoses including history of falling, right femur displaced comminuted fracture, bilateral artificial hip joints, major depressive disorder, and metabolic encephalopathy. The resident's MDS indicated the resident could understand others and make self-understood, had moderately impaired cognitive skills for daily decision making, was dependent for bed mobility, and had no physical restraints or alarms in use. The H&P stated the resident had the capacity to understand and make decisions. During observation, Resident 121 was seen with the wedge pillow placed under the mattress. CNA 3 stated the wedge pillow was used for repositioning to prevent wounds and that the resident required two-person assistance for bed mobility. LVN 3 stated the wedge pillow should be placed on top of the mattress, not beneath it, and explained that placing it under the mattress turns it into a physical restraint because it becomes immovable and prevents the resident from getting out of bed. The DON stated the wedge pillow should be used to help prevent wounds in residents with mobility issues and should be placed beneath the sheet along the mid-lateral part of the body, not under the mattress. The facility policy defined physical restraints as devices attached to or near the resident's body that cannot be easily removed and restrict freedom of movement or normal access to the body.
Failure to Complete PASARR Level II Evaluation After Positive Level I Screening
Penalty
Summary
The facility failed to ensure that Resident 7, who was admitted with a diagnosis of PTSD and had a MDS showing moderate cognitive impairment and a need for skills required for daily decision making, received a Level II PASARR evaluation after a Level I screening was positive for serious mental illness. The resident’s trauma-informed care plan, initiated on 3/27/2026, identified risk for decreased psychosocial well-being and emotional distress related to combat or exposure to a warzone in the military, with a goal for the resident to demonstrate effective coping strategies and an intervention to encourage verbalization of feelings. The resident’s PASARR dated 3/26/2026 indicated a positive Level I result, and the DHCS letter dated 4/12/2026 stated facility staff were unresponsive to two or more separate attempts of communication within 48 hours of the Level I screening. During interview and record review, the MDS Nurse stated the facility had not spoken to DHCS staff and no attempts were made to communicate with them, and acknowledged he should have followed up with DHCS. The facility policy stated that when a Level I screen indicates possible MD, ID, or RD, the resident is referred to the state PASARR representative for the Level II screening process.
Failure to Maintain Facial Hygiene During ADL Care
Penalty
Summary
The facility failed to ensure a resident who was unable to perform ADLs maintained grooming and personal hygiene when yellow/white discharge was observed on both sides of the resident’s face coming from the eyes. Resident 54 was admitted with dysphagia, unspecified dementia, and limitation in activities due to disability. The resident’s MDS indicated the resident was never or rarely understood and required substantial assistance from staff for showering and bathing. The care plan directed staff to provide assistance with ADLs as indicated. During a concurrent observation and interview, a CNA observed the discharge on the resident’s bilateral eyes and cheeks in the hallway outside the resident’s room. The CNA stated the resident was unable to wash her own face and that morning care had been provided about 15 minutes earlier, but she was not certain the face had been washed. The CNA stated she should have paid more attention because the discharge can feel uncomfortable or affect the resident’s dignity. The DON stated residents have the right to have a clean face and that the resident’s face should be cleaned daily and as needed for good hygiene and dignity. The facility’s Resident Rights policy stated residents have a right to a dignified existence, and the ADLs policy stated residents unable to carry out ADLs independently will receive services necessary to maintain grooming and personal and oral hygiene.
Failure to Assess and Document Hand Edema
Penalty
Summary
The facility failed to perform and document an assessment of edema of the hands for one resident with CHF who was receiving Lasix. The resident’s admission information listed diagnoses including CHF, acute respiratory failure, and COPD. The MDS indicated the resident had moderate cognitive impairment, was dependent for ADLs and mobility, and was taking a diuretic. The resident’s H&P also stated the resident could not make own medical decisions and was conserved. During observation, the resident was seen lying in bed with edema noted in the left hand, and later both hands were observed with edema. At that time, an LVN applied pressure and identified 2+ pitting edema in both hands. The LVN stated the resident had edema on and off since return from hospitalization, then later stated she observed edema in both hands during medication pass and that it was 1+ the previous day. The LVN stated she did not document the edema because she forgot and did not report it to the RN or physician because the swelling decreased with repositioning. Record review showed the admission/readmission assessment, skin evaluation, and weekly summaries did not document edema, and the admission/readmission assessment indicated no edema. The RN stated the edema should have been documented and reported for further assessment. The DON stated the edema was a change in condition requiring assessment and should have been documented by the LVN and escalated to the RN for assessment and evaluation. Facility policy required examination and assessment of abnormalities in health status and documentation of changes in the resident’s medical or mental condition.
Failure to Offload Heels for a Resident at High Risk for Skin Breakdown
Penalty
Summary
The facility failed to ensure pressure ulcer prevention care was provided for one sampled resident, Resident 121, by not offloading the heels while the resident was in bed in accordance with the care plan titled, At Risk for Skin Breakdown. Resident 121 was admitted on 4/30/2026 with diagnoses including history of falling, right femur displaced comminuted fracture, bilateral artificial hip joints, major depressive disorder, and metabolic encephalopathy. The MDS dated 5/7/2026 indicated the resident could understand others and make self-understood, had moderately impaired cognitive skills for daily decision making, and was dependent for bed mobility. The H&P dated 5/1/2026 indicated the resident had capacity to understand and make decisions. A Braden Scale assessment dated 6/1/2026 identified the resident as high risk for pressure injuries, and the care plan initiated on 4/30/2026 included turning and repositioning, inspecting the skin during daily routines, offloading heels while in bed, and using lift pads to reduce friction and shear. During observation on 7/13/2026, Resident 121 was seen with a wedge pillow placed under the mattress on the right side at the foot of the bed, while both heels remained in contact with the mattress surface rather than being offloaded. CNA 3 stated the resident required two-person assistance for bed mobility and that the wedge pillow was used for repositioning to prevent wound development. TN 1 reviewed the care plan and stated the resident was at increased risk based on the Braden assessment, that the care plan included floating the heels while in bed, and that placing the wedge pillow under the mattress left the heels in contact with the bed surface and increased the risk of redness and open wounds. TN 1 also stated the wedge pillow should be positioned at the hip or lateral side and not at the heel area. The DON stated the wedge pillow should be used beneath the sheet along the mid-lateral portion of the body rather than under the mattress, because placement under the mattress does not reduce pressure appropriately. The facility policy on prevention of pressure injuries stated that heels of at-risk residents should be elevated so they are not in contact with the support surface.
Unsafe resident environment and unsecured protective helmet
Penalty
Summary
The facility failed to keep the resident environment free of accident hazards for two residents. For one resident, the record showed admission with diagnoses including type 2 DM with diabetic polyneuropathy and foot ulcer, difficulty walking, CKD, and vascular dementia. The MDS indicated the resident had moderately impaired cognitive skills for daily decision making, required partial to substantial assistance with ADLs, and used a manual wheelchair and walker. The fall risk assessment identified the resident as high risk for falls. During observation, the resident’s wheelchair was placed on top of the landing pad on the right side of the bed. RN 2 stated landing pads are used to prevent injuries by providing a soft surface landing, but they must remain clear of objects, and that it was unacceptable for a wheelchair to be left on top of the landing pad. The DON stated landing pads should be documented as interventions in the care plan and must remain clear of objects because obstacles could compromise their effectiveness. For the second resident, the record showed diagnoses including unspecified psychosis and repeated falls, and the H&P indicated the resident had the capacity to understand and make decisions. A physician order required the resident to wear a soft protective helmet when out of bed for safety every shift. During observation, the resident was seen in a wheelchair wearing the helmet, but the left chin strap was missing and the helmet was not secured to the resident’s head. CNA 2 and the COTA both stated the helmet was not safe without a way to secure it, and the DON stated the resident had a history of hitting his head and must wear a soft helmet secured with a chin strap.
Incomplete Hemodialysis Communication Assessments
Penalty
Summary
Failure to ensure safe, appropriate dialysis care/services occurred for a resident receiving hemodialysis when the facility did not complete the hemodialysis communication assessment on 3/27/2026, 4/20/2026, and 6/19/2026. The resident was admitted on 11/29/2022 with diagnoses including anemia, end stage renal disease, and dependence on renal dialysis. The resident’s MDS dated 4/8/2026 indicated intact cognitive skills for daily decision making and that the resident required set up/clean-up assistance to moderate assistance with ADLs. The resident had physician orders for a left chest hemodialysis tunneled catheter to be checked every shift for color, warmth, and edema, for the catheter dressing to remain intact every shift, and for hemodialysis on Mondays, Wednesdays, and Fridays. The care plan for altered renal tissue perfusion included intake and output monitoring, weight tracking and reporting changes to the doctor, notifying the doctor if edema, chest pain, high blood pressure, or shortness of breath occurred, checking the hemodialysis catheter site for complications, and monitoring vital signs as indicated. During interview and record review, LVN 2 confirmed the hemodialysis communication assessment was incomplete on the identified dates, with post-dialysis weight left blank on two dates and vital signs plus pre-dialysis and post-dialysis weight left blank on one date. LVN 2 and the DON stated the form is used to document the resident’s condition before, during, and after dialysis, including tolerance, medications, access condition, vital signs, and weights, and that nurses are responsible for completing it and obtaining missing information from the dialysis facility when needed.
Failure to Document Duration of Lovenox Therapy
Penalty
Summary
The facility failed to place a duration of therapy for one resident’s enoxaparin (Lovenox) order. The resident was admitted with diagnoses including subdural hematoma and was severely cognitively impaired with skills required for daily decision making. The physician order dated 6/12/2026 directed enoxaparin 40 mg subcutaneously once daily for DVT prophylaxis, and the resident’s MDS indicated anticoagulant use. The pharmacist’s medication regimen review covering 6/15/2026 to 6/16/2026 recommended that the duration of therapy for Lovenox be clarified. The resident’s anticoagulant care plan, initiated 6/15/2026, addressed bleeding and bruising monitoring and included periodic drug regimen review, but the facility could not provide documentation that the duration had been discussed with the physician or that an order with a stopping condition had been entered. During interviews, the LVN, ADON, and DON each stated the duration should have been addressed upon admission, and the DON stated the physician said Lovenox could be discontinued when the resident was able to walk 150 feet, but no progress note, physician order, or care plan documentation reflecting that condition was available.
Medication Labeling Error
Penalty
Summary
The facility failed to label and store drugs and biologicals in accordance with accepted professional principles when a bottle of carboxymethylcellulose sodium drops 0.5% for Resident 82 was observed on Medication Cart 3 labeled with a room number and bed letter instead of the resident’s name. Resident 82 was admitted to the facility on 4/13/2023 and re-admitted on 12/4/2024 with diagnoses including hypertension. The resident’s MDS dated 4/11/2026 indicated moderately impaired cognition with skills required for daily decision making and that the resident was independent with personal hygiene. During the medication cart observation on 7/15/2026, LVN 3 identified the eye drops as belonging to Resident 82 and stated the box should have the resident’s name on it. LVN 3 stated medications should be labeled with the resident name rather than a room number and bed letter because residents move rooms and the medication could be mixed up with another resident’s medication. The resident’s physician order dated 7/14/2026 directed carboxymethylcellulose sodium drops 0.5%, one drop in both eyes every 12 hours for dry eyes. The DON reviewed the facility policy titled Medication Labeling and Storage, which stated all medication should, at a minimum, be labeled with the resident’s name.
Infection Control Lapses With Oxygen Tubing and Gown Use
Penalty
Summary
Resident 14 was admitted and later re-admitted with diagnoses including acute respiratory failure, COPD, and CHF. The resident’s MDS indicated moderate cognitive impairment, dependence for ADLs and mobility, and use of oxygen therapy. The resident’s care plan and physician orders required oxygen via nasal cannula and directed that the oxygen tubing be changed weekly, with the tubing changed on Sunday night shift and as needed when soiled or broken. During observation, Resident 14 was lying in bed receiving oxygen via nasal cannula, and the oxygen tubing was not labeled. When interviewed, LVN 1 stated the tubing should have a label showing the date it was last changed and explained that without a label it was unknown whether the tubing had been changed timely as ordered. LVN 1 stated the lack of a label placed the resident at risk for infection from bacteria or microorganisms that could accumulate on the tubing if it was not changed as scheduled. The DON also stated that respiratory tubing should be labeled with the resident’s name and the date it was changed so it is known when it is due to be changed again. Resident 34’s MDS indicated severe cognitive impairment, a gastrostomy tube, and receipt of nutrition through the G-tube. During medication administration, LVN 6 was observed taking the resident’s blood pressure while wearing an isolation gown and gloves, then removing the gloves and walking toward the medication cart outside the room while still wearing the gown. LVN 6 was about to open the cart when stopped by the survey team and stated he did not know he had to remove the gown before leaving the room area. The IPN and DSD stated it is best practice to remove the gown before contacting anything outside the room to prevent cross contamination, and the facility’s gown policy stated gowns must be discarded in the appropriate container located in the room after completing the treatment or procedure.
Delay in Release of Resident Medical Records
Penalty
Summary
The facility failed to ensure that the medical records of one sampled resident were released in a timely manner to the resident’s Responsible Party after a valid request was received. Resident 1 was admitted with diagnoses including dementia, anemia, bipolar disorder, and schizophrenia. The resident’s H&P dated 5/30/2011 indicated the resident had the capacity to understand and make decisions. RP 1 submitted a request for a copy of Resident 1’s medical records on 5/27/2026 during the resident’s stay at the facility. During interview and record review, the Medical Records Director confirmed the request was received on 5/27/2026, but the facility did not send the records at that time. The MRD stated the facility had received records from 2011 through 2017 but was waiting to receive records from 2017 through 2021 before sending anything to RP 1, and no contact was made with RP 1 after the request was received. The DON reviewed the facility’s policy stating copies of records are to be provided within two working business days of receipt of a completed authorization, and confirmed the facility should have communicated with RP 1 and provided the requested records in a timely manner. The records were ultimately provided to RP 1 on 7/7/2026, 41 days after the request was received.
Incomplete Documentation of Resident Eye Injury
Penalty
Summary
The facility failed to ensure that the medical record for one sampled resident was complete and accurately documented after the resident reported hitting the left eye on a bedside table. The resident was admitted with diagnoses including pneumonia, type 2 DM, HTN, dementia, and a history of falling, and the MDS indicated moderately impaired cognition with assistance needs for eating, oral hygiene, personal hygiene, toileting hygiene, showering, lower body dressing, and footwear. During observation, the resident had discoloration on the left eye and stated that the injury occurred the evening before when the privacy curtain was closed and the roommate's bedside table hit the resident's left eye. LVN 1 stated that the resident reported the incident during the evening shift and that an assessment of the left eye was completed, with no discoloration noted at that time. LVN 1 also stated that the MD was notified and instructed staff to continue monitoring, but LVN 1 did not document the incident, the assessment, or the MD notification in the medical record. RNS 1 confirmed that the resident reported hitting the left eye on the bedside table, that both staff assessed the eye and observed no discoloration and no pain, and that the incident should have been documented. The DON stated that the incident was not reported to the DON at the time and that the facility later began an investigation once informed. The facility policy required documentation of incidents, objective observations, treatments or services performed, changes in condition, and events involving the resident, and stated that documentation must be objective, complete, and accurate.
Improper Linen Use on Low Air Loss Mattress
Penalty
Summary
The facility failed to ensure proper use of a low air loss mattress for one resident who was admitted with diagnoses including peripheral autonomic neuropathy, traumatic brain injury, and benign prostatic hyperplasia. The resident’s MDS indicated moderately impaired cognitive skills for daily decision making, dependence for showering, maximum assistance with toileting hygiene, lower body dressing, and footwear, and moderate assistance with oral hygiene, personal hygiene, upper body dressing, bed mobility, and transfers. The physician ordered a low air loss mattress for skin management, and the care plan identified the resident as at risk for skin breakdown related to impaired ADLs and bowel and bladder incontinence, with the low air loss mattress included as an intervention. During a concurrent observation and interview, the resident was found lying on the low air loss mattress while wearing an incontinence brief, with a flat sheet and a cloth incontinence pad covering the mattress surface. The CNA stated the cloth pad should not have been used and should have been replaced with a disposable/paper pad, and that the resident should not have been wearing an incontinence brief when an incontinence pad and sheet were placed over the mattress. The TxN stated the mattress should be covered only with a flat sheet and a disposable incontinence pad, and the DON stated that the least amount of linen possible should be used on a low air loss mattress. The facility policy stated linens on a low air loss mattress should not interfere with the therapeutic function of the mattress system and listed a recommended setup of the mattress cover, one fitted breathable sheet, one breathable draw sheet if needed, and one approved moisture management pad if indicated.
Failure to Timely Honor Resident Request for Room Change
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to be treated with respect and dignity by not completing a requested room change in a timely manner. The resident was admitted with encephalopathy, depression, and dementia, and while a History and Physical documented capacity to understand and make decisions, a subsequent MDS showed severely impaired cognition and a need for moderate to maximal assistance with ADLs. The resident’s responsible party reported requesting a room change from Social Services on 1/8/2026 because the resident felt uncomfortable in the current room, and Social Services confirmed that a suitable room was available and agreed to the change. Social Services staff stated they informed the RN Supervisor of the room change request on the same day but were unsure why the transfer was not completed. The RN Supervisor acknowledged being informed of the request and stated the room change was not done because it was very busy during change of shift, and further acknowledged that the room change should have been completed as soon as possible. The DON confirmed that when a room change is requested, it is to be discussed with social services, the DON, and the admissions coordinator, and that a room was available for this resident at the time of the request and the change should have occurred as soon as possible. Review of facility policies on Resident Rights and Room Change/Roommate Assignment showed that residents are to be treated with kindness, respect, and dignity, and that room changes are to be made when the resident requests them, which did not occur in this case.
Unauthorized Disclosure of a Resident's Medical Records to Another Resident's Representative
Penalty
Summary
The facility failed to maintain privacy and confidentiality of a resident's personal and medical records when the Social Services Director (SSD) provided the wrong chart to another resident's responsible party. Resident 2, who had been admitted with a lumbar vertebral fracture, type 2 DM, COPD, and dementia, had documentation indicating severely impaired cognition and a lack of decision-making capacity. Resident 1, admitted with encephalopathy, depression, and dementia, also had severely impaired cognition but was documented in the H&P as having capacity to understand and make decisions. During a meeting, Responsible Party 1 (RP 1) requested medical records for Resident 1, and the SSD printed records from the printer and handed them to RP 1 without verifying that they belonged to the correct resident. RP 1 later informed the facility that the records received were for a different resident, identified as Resident 2. Interviews with the Medical Records Director (MRD) and the Director of Nursing (DON) revealed that facility policy required any requester of medical records to complete an Authorization for Release of Records, which must be reviewed and approved by the MRD, DON, and Administrator before records are released. The MRD and DON both stated that the SSD should not have provided Resident 2's medical records to RP 1 and that the established authorization and review process was intended to prevent disclosure of records to the wrong recipient. Review of facility policies on release of records and resident rights confirmed that records are to be released only upon properly completed authorization and that residents have rights to privacy and confidentiality of their records.
Failure to Provide Appropriate Oxygen Therapy for Resident with Low Oxygen Saturation
Penalty
Summary
Facility staff failed to provide respiratory care services consistent with professional standards of practice for a resident with a history of respiratory failure, prostate cancer, and dementia. The resident, who had severely impaired cognition and required significant assistance with daily activities, was admitted with physician orders to receive oxygen at 2 to 5 liters per minute (LPM) via nasal cannula, with instructions to titrate oxygen if saturation fell below 90%. On the morning in question, the resident was documented to have an oxygen saturation level of 80% while receiving oxygen via nasal cannula. Despite the low oxygen saturation, there was no documented evidence that staff increased the oxygen flow rate or administered high concentration oxygen using a non-rebreather mask prior to the arrival of paramedics. Interviews with the DON and a registered nurse confirmed that the resident continued to receive oxygen at 5 LPM via nasal cannula and was not switched to a non-rebreather mask. The facility's own policy required staff to adjust oxygen delivery devices and flow rates as needed and to document all assessment data and interventions, but this was not done in this case. When paramedics arrived, they found the resident with an oxygen saturation of 83% on 4 LPM via nasal cannula, a heart rate of 122, and a respiratory rate of 41. Paramedics questioned facility staff about the lack of appropriate oxygen therapy, but no explanation was provided. The paramedics then administered oxygen at 15 LPM via non-rebreather mask and provided additional care before transferring the resident to the hospital.
Failure to Prevent Unnecessary Psychotropic Medication Use and Inadequate Monitoring
Penalty
Summary
The facility failed to ensure that three residents were free from unnecessary psychotropic medication use by not meeting required conditions for prescribing and monitoring these medications. For one resident with dementia and mood disturbance, Seroquel was prescribed for 'psychosis manifested by sudden anger outburst' without documentation that the symptoms were due to mania, psychosis, or delusions, or that the behaviors presented a danger to the resident or others. There was also no evidence that the symptoms were not due to a medical condition expected to resolve, or that non-pharmacological interventions had been attempted and found ineffective. The resident’s family member, who was the primary decision maker, refused a gradual dose reduction despite recommendations from the pharmacist and nurse practitioner, and staff interviews indicated the resident’s behaviors were limited to yelling or screaming, with no significant aggression or danger noted. Another resident with cognitive and coordination deficits was prescribed Ativan on an as-needed basis for anxiety manifested by agitation and verbal aggression. The physician’s order required that non-pharmacological interventions be attempted prior to medication administration. However, documentation showed that Ativan was administered without any record of such interventions being tried first, contrary to the order and facility policy. The DON confirmed that non-pharmacological approaches should have been attempted and documented before medicating the resident. A third resident with generalized anxiety disorder and bipolar disorder was prescribed Clonazepam for anxiety. Behavioral monitoring was not initiated at the start of medication administration, and for several weeks, there was no documentation of behavioral assessments prior to giving the medication. The RN and DON both acknowledged that behavioral monitoring should have started with the initiation of Clonazepam, and that the lack of documentation meant the medication was being administered without an indication. Facility policy required monitoring for effectiveness and adverse consequences of psychotropic medications, which was not followed in this case.
Failure to Provide Appropriate Care for Range of Motion and Mobility
Penalty
Summary
A deficiency was identified regarding the provision of care to maintain or improve a resident's range of motion (ROM), limited ROM, and/or mobility. The facility failed to ensure that appropriate care was provided to prevent a decline in these areas unless such decline was due to a documented medical reason. The report notes that the necessary interventions or services to support or enhance the resident's ROM or mobility were not implemented as required.
Failure to Act on Pharmacist Recommendations for Medication Regimen Review
Penalty
Summary
The facility failed to ensure that recommendations from the consultant pharmacist's monthly Medication Regimen Review (MRR) were acted upon for three residents. For one resident prescribed Quetiapine, the pharmacy recommended an EKG to monitor for potential cardiac effects, but the EKG was not completed as ordered. Both the registered nurse and the assistant director of nursing confirmed that the EKG was missed and not documented in the resident's record, despite the pharmacy's recommendation and the facility's policy requiring such follow-up. Another resident was prescribed Seroquel for psychosis manifested by sudden anger outbursts. The consultant pharmacist recommended ensuring proper documentation for the use of Seroquel, including evidence that the symptoms were due to mania or psychosis, that non-drug interventions had been attempted, and that the behaviors presented a danger or significant distress. The pharmacist also recommended monitoring for orthostatic hypotension and obtaining specific lab tests. The facility did not ensure that these recommendations were followed, and the required documentation and monitoring were not completed in a timely manner. The resident's family member refused a gradual dose reduction, but the facility did not escalate the issue to the medical director as outlined in their policy. A third resident was receiving Klonopin for behavioral control without a documented progress note from the physician explaining why this long-acting benzodiazepine was the best choice. The consultant pharmacist requested updated documentation, but the physician's progress note did not address the rationale for continued use. The director of nursing confirmed that the required documentation was missing, and the resident could be receiving the medication without an appropriate indication. These failures were contrary to the facility's policies and procedures regarding psychotropic medication use and documentation.
Improper Labeling and Storage of Resident Food Brought from Outside
Penalty
Summary
The facility failed to ensure that leftover food brought in by residents' families and visitors was properly labeled with a resident identifier and use-by date before being stored in the resident refrigerator. During an observation with the Administrator in Training (AIT), two plastic bags containing undetermined leftover food were found in the residents' refrigerator at the nurse's station without any labeling or resident identification. The AIT confirmed that the refrigerator is used for storing residents' food and acknowledged that all leftover food should be labeled with an identifier and date. The facility's policy requires perishable foods to be stored in resealable containers with tightly fitting lids, labeled with the resident's name, the item, and the use-by date, and specifies that nursing staff are responsible for discarding perishable foods on or before the use-by date. However, the observed practice did not comply with this policy.
Failure to Accurately Document Clinical Records and Resident Diagnoses
Penalty
Summary
The facility failed to maintain accurate clinical records in accordance with accepted professional standards and practices for four residents. Specifically, therapy staff did not accurately document the completion of Rehab Joint Mobility Screens (JMS) for three residents. For each of these residents, the JMS was dated for a specific quarter but was actually completed and signed several months later. The documentation did not indicate that these were late entries, nor did it specify how the range of motion (ROM) measurements were obtained after the fact. Both the co-Director of Rehabilitation and the Assistant Director of Nursing confirmed during interviews that the JMS should have been completed on time, and if late, should have been clearly documented as such with an explanation for the delay and the method of assessment. For one resident, the facility also failed to ensure that a diagnosis of anxiety was included in the resident's medical record, despite evidence in the history and physical, care plan, and psychiatric progress notes that the resident was being treated for anxiety with Ativan. The omission of this diagnosis from the resident's official diagnosis list meant that the medical record did not accurately reflect the resident's conditions or the rationale for prescribed medications. Multiple staff, including the Quality Assurance Nurse, MDS Nurse, and Director of Nursing, acknowledged during interviews that the anxiety diagnosis should have been included in the resident's record to ensure accurate documentation and appropriate care planning. The facility's policy and procedure on charting and documentation, last reviewed in January 2025, requires that all services provided to residents and any changes in their medical or mental condition be documented in the medical record. The failure to accurately document the timing and method of JMS assessments, as well as to include all relevant diagnoses, resulted in incomplete and inaccurate medical records for the affected residents.
Failure to Knock and Request Permission Before Entering Resident Rooms
Penalty
Summary
Facility staff failed to honor residents' rights to dignity and privacy by not knocking or asking permission before entering the rooms of two residents. Both residents had severe cognitive impairments and were totally dependent on staff for activities of daily living. During an observation, a Certified Nurse Assistant (CNA) was seen entering the rooms of these residents without knocking or requesting permission, despite the residents being present in their beds at the time. Upon interview, the CNA acknowledged forgetting to knock and recognized the importance of doing so, as this is considered the residents' home. The Director of Nursing confirmed that facility policy requires staff to knock and request permission before entering any resident's room, emphasizing the need to respect residents' privacy and dignity. A review of the facility's policy further supported this expectation for staff behavior.
Call Light Not Accessible to Resident in Bed
Penalty
Summary
A deficiency was identified when a resident with diagnoses including dysphagia and schizophrenia, and documented impaired cognition, was observed in bed without their call light within reach. The call light was found on the floor, making it inaccessible to the resident. The resident's Minimum Data Set indicated a need for supervision with activities of daily living, highlighting the importance of having the call light accessible for requesting assistance. During the observation, a Certified Nurse Assistant confirmed that the call light should be placed behind the pillow to ensure it is within reach. The Administrator in Training also acknowledged that the call light is the primary means for residents to request help and should always be accessible. Facility policy reviewed stated that the call light must be within easy reach when a resident is in bed or confined to a chair. The failure to ensure the call light was accessible constituted a deficiency in accommodating the resident's needs and preferences.
Failure to Maintain Advance Directives in Resident Medical Charts
Penalty
Summary
The facility failed to ensure that copies of executed Advance Directives (ADs) were kept in the active medical charts and were easily retrievable for two residents. For one resident with diagnoses including dysphagia, type 2 diabetes, and anemia, the admission record and Minimum Data Set (MDS) confirmed the resident was able to communicate and required staff assistance for several activities of daily living. The Advance Directive Acknowledgement (ADA) form indicated that the resident had executed an AD and that the facility had received a copy. However, during a review with the Medical Records Director, it was found that the AD was not present in the resident's chart, despite facility policy requiring it to be accessible in case of emergency. The Assistant Director of Nursing (ADON) confirmed that the AD should have been in the chart to guide staff regarding the resident's wishes. For a second resident with diagnoses including dysphagia, dementia, and anemia, the MDS showed severely impaired cognitive skills and a need for substantial staff assistance. The ADA form and a Physician Orders for Life-Sustaining Treatment (POLST) form both indicated that the resident had executed an AD and that the facility had received a copy. However, during a review with the Social Service Director, it was determined that the AD was not present in the resident's chart. The Social Service Director and the ADON both stated that the AD should have been in the active chart to ensure staff could reference the resident's healthcare wishes. The facility's policy and procedure on Advance Directives, last reviewed in January, required that AD documents be placed in a prominent, accessible location in the medical record and that the resident's wishes be communicated to direct care staff and the physician. In both cases, the facility did not follow its own policy, resulting in the absence of the residents' ADs from their medical charts.
Failure to Include Indwelling Catheter in Baseline Care Plan
Penalty
Summary
The facility failed to develop a complete baseline care plan within 48 hours of admission for a resident who had an indwelling catheter. Upon review, it was found that the resident was admitted and readmitted with multiple diagnoses, including dysphagia, dementia, obstructive uropathy, and reflux uropathy, and had an order for an indwelling catheter. The resident's assessments and medical records consistently documented the presence of the catheter and the need for substantial assistance with activities of daily living due to severely impaired cognitive skills. Despite this, the baseline care plan created at admission did not include any information regarding the resident's indwelling catheter. Interviews with facility staff, including the MDS nurse and the Assistant Director of Nursing, confirmed that the baseline care plan was incomplete and did not address the catheter, contrary to facility policy and procedure. This omission meant that the resident's immediate care needs related to the indwelling catheter were not documented in the baseline care plan.
Failure to Develop and Implement Person-Centered Care Plans for Psychotropic Medications
Penalty
Summary
The facility failed to develop and implement person-centered care plans for two residents who were prescribed psychotropic medications. For one resident with diagnoses including generalized anxiety disorder and dementia, there was an active order for olanzapine to manage psychosis and agitation. Despite this, a review of the resident's care plans revealed that no care plan was created to address the use of olanzapine, including interventions to prevent or manage potential adverse effects. The Director of Nursing confirmed that a care plan should have been developed to guide staff in managing the medication's side effects. For another resident admitted with major depressive disorder, hypertension, and atrial fibrillation, there was an order for amphetamine-dextroamphetamine to treat ADHD. The resident was assessed as having the capacity to understand and make decisions and was independent in activities of daily living. However, a review of the care plans showed that no care plan was developed for the use of the ADHD medication. Nursing staff acknowledged that a care plan was required for any medication that could alter a resident's mental state, and the Assistant Director of Nursing confirmed that a care plan should have been written for the psychotropic medication. Facility policies required comprehensive, person-centered care plans with measurable objectives and timetables for each resident, including those receiving psychotropic medications. The policies also specified that behavioral interventions and monitoring for effectiveness and adverse consequences should be included. The absence of care plans for these medications meant that staff lacked documented guidance for monitoring and managing the residents' medication regimens as required by facility policy.
Failure to Update Dental Care Plan After Loss of Dentures
Penalty
Summary
The facility failed to update and revise a resident's dental care plan after the resident's upper dentures went missing. The resident, who had diagnoses including major depressive disorder, type two diabetes mellitus, and schizophrenia, was noted to have moderately impaired cognitive skills and required staff assistance for various activities of daily living, including supervision for oral hygiene. The resident's care plan for dental problems, initiated at admission, included interventions for daily oral care and dental consultations as needed, and originally indicated the resident was wearing full top dentures. After the resident reported her top dentures missing, documentation showed that a dental evaluation was performed and extractions were recommended to prepare for new dentures, but the resident declined further dental procedures. Despite this significant change, the care plan was not reviewed or revised to reflect the loss of the dentures or the resident's decision to decline further dental treatment. Interviews with facility staff confirmed that care plans are required to be reviewed and updated quarterly and after significant changes, but this was not done in this case.
Failure to Complete and Accurately Document Fall Risk Assessments After Resident Falls
Penalty
Summary
The facility failed to ensure that fall risk assessments were completed accurately and in a timely manner for two residents, resulting in deficiencies related to accident prevention and supervision. For one resident, who had diagnoses including metabolic encephalopathy, lack of coordination, and mild cognitive impairment, the facility did not accurately document a fall that occurred. Despite the resident being found on the floor next to her bed, the subsequent fall risk assessments incorrectly indicated that she had not fallen in the previous 90 days. Both the registered nurse and the director of nursing confirmed that this omission was incorrect and could affect the accuracy of the fall risk score. Another resident, admitted with unspecified dementia, Alzheimer’s disease, and lack of coordination, experienced a witnessed fall when sliding from a wheelchair to the floor. However, after this incident, licensed staff did not complete a fall risk assessment as required by facility policy. Both the MDS nurse and the assistant director of nursing acknowledged that a fall risk assessment should have been completed after the fall, in accordance with the facility’s procedures for assessing falls and their causes. The facility’s policies and procedures specify that after a fall, staff must complete a fall risk assessment, document appropriate interventions, and record relevant information in the resident’s medical record. In both cases, the failure to follow these procedures resulted in incomplete or inaccurate documentation of fall risk, which could impact the identification and implementation of interventions to prevent further falls.
Failure to Document Post-Dialysis Weight for Resident Receiving Hemodialysis
Penalty
Summary
The facility failed to ensure that a post-dialysis assessment was completed for a resident who required hemodialysis. Specifically, the dialysis center did not record the resident's post-dialysis weight on the communication record for a specified date. This omission was verified during record reviews and interviews with both a Licensed Vocational Nurse (LVN) and the Assistant Director of Nurses (ADON), who confirmed that the post-dialysis weight was missing and acknowledged that the nursing staff should have contacted the dialysis center to obtain this information. The resident involved had a diagnosis of end stage renal disease and was dependent on hemodialysis, with a care plan in place that included monitoring weight and reporting significant changes to the physician. The facility's policy required documentation of dialysis treatment in the resident's medical record. Despite these requirements, the absence of the post-dialysis weight was not addressed by the nursing staff, resulting in incomplete documentation of the resident's dialysis care.
Failure to Monitor Stimulant Medication Use and Effectiveness
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary drugs by not adequately monitoring the use of amphetamine-dextroamphetamine, a stimulant medication typically used to treat ADHD. The resident in question was admitted with diagnoses including major depressive disorder, hypertension, and unspecified atrial fibrillation, but did not have a documented diagnosis of ADHD. Despite being prescribed amphetamine-dextroamphetamine, there was no corresponding care plan or physician’s order to monitor for adverse effects or effectiveness of the medication. During interviews and record reviews, it was confirmed that nursing staff did not create a care plan or obtain an order to monitor the resident’s behavior or potential adverse effects related to the stimulant medication. Both the registered nurse and the assistant director of nursing acknowledged that such monitoring and care planning were required by facility policy, especially for psychotropic medications. The facility’s policies also specified the need for behavioral interventions and monitoring for effectiveness and adverse consequences, which were not implemented in this case.
Failure to Document and Accommodate Food Allergy and Preferences
Penalty
Summary
The facility failed to properly document and accommodate a resident's egg allergy and food preferences, resulting in deficiencies in care. The resident, who had a documented allergy to eggs in multiple records including the admission record, history and physical, dietary interview, and care plan, did not have this allergy indicated on her meal tray ticket. Observations confirmed that the tray ticket only listed eggs as a dislike, not as an allergy, and staff interviews revealed that the allergy should have been clearly marked to prevent exposure. The dietary supervisor, registered nurse, registered dietician, and director of nursing all acknowledged that the allergy was not properly documented on the tray ticket, which could lead to the resident being served eggs. Additionally, the facility failed to provide an appropriate food substitution for the resident during breakfast when eggs were not served. On observation, the resident's breakfast tray did not contain eggs, but also lacked a protein substitute. The dietary supervisor confirmed that a protein should have been provided in place of the egg and subsequently added yogurt to the tray after the deficiency was noted. The resident expressed a preference for yogurt, and the dietary supervisor emphasized the importance of protein in the diet. The facility's own policy and procedure on food allergies and intolerances required that all resident-reported food allergies be documented in assessment notes, care plans, and diet slips, and that appropriate substitutions be offered for foods that cannot be eaten. Despite these policies, the resident's egg allergy was not properly communicated on the tray ticket, and a suitable substitution was not provided at breakfast, resulting in a failure to meet the resident's nutritional needs and accommodate her allergy.
Inaccurate MDS Assessments for Discharge Disposition and Active Diagnoses
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessments for two residents, resulting in inaccurate documentation of their status and diagnoses. For one resident, the MDS assessment incorrectly indicated that the resident was discharged to a short-term general hospital, while multiple other records, including physician orders, nursing progress notes, and the discharge summary, all documented that the resident was actually discharged to another skilled nursing facility. The MDS nurse responsible for completing the assessment acknowledged that the wrong discharge disposition was selected in error, leading to an inaccurate medical record. For another resident, the MDS assessment did not include an active diagnosis of anxiety, despite the resident's history and physical, psychiatric progress notes, and care plan all documenting anxiety as a current condition. The resident was receiving Ativan for anxiety, and the care plan specifically addressed interventions for anxiety-related behaviors. The MDS nurse confirmed that anxiety should have been included as an active diagnosis in the MDS to ensure accurate documentation of the resident's medications and diagnoses. Facility policy requires that MDS assessments be completed accurately and reflect information consistent with progress notes, care plans, and resident observations. The deficiencies identified were due to staff errors in completing the MDS, resulting in discrepancies between the MDS and other clinical documentation for both residents.
Failure to Provide Medically-Related Social Services: Missing Mobility Aid at Discharge
Penalty
Summary
The facility failed to provide medically-related social services to meet the needs of a resident by not ensuring the return or timely replacement of a missing rollator walker, a mobility aid necessary for safe ambulation. The resident, who had diagnoses including systemic lupus erythematosus, cerebral infarction, and difficulty walking, was admitted with a documented need for assistance with mobility and other activities of daily living. Upon discharge, the inventory list indicated the resident had a walker, but there was no documentation or signatures confirming the walker was returned to the resident. A review of records and interviews with the Social Services Assistant confirmed that the resident was discharged without her rollator walker and that there was no documented follow-up to obtain or replace the missing equipment. The facility's policy required the provision of adaptive equipment to maintain or improve residents' physical and psychosocial needs, but this was not followed in this case.
Inadequate Discharge Planning for Resident Transfer
Penalty
Summary
The facility failed to ensure proper discharge planning for a resident, resulting in a deficiency. The resident, who had severe cognitive impairment and required maximum assistance for daily activities, expressed a desire to transfer to another facility. The Social Services Director (SSD) assisted in finding a new facility and informed the resident and their responsible party (RP) about the transfer. However, the SSD did not provide comprehensive information about the new facility, such as the services offered, quality measures, or details about the care providers, which is required by the facility's discharge policy. The Director of Nursing (DON) confirmed that the correct process for transferring a resident includes providing detailed information about the new facility to the resident and their RP. The facility's policy on discharging residents outlines the need to inform them about the location, size, services, and care providers at the new facility, as well as the reason for the discharge. The failure to provide this information could potentially lead to decreased quality of care and continuity of care for the resident.
Failure to Obtain Informed Consent for Antipsychotic Medication
Penalty
Summary
The facility failed to obtain informed consent from a resident's responsible party (RP) for the administration of the antipsychotic medication Olanzapine. This oversight involved a resident who was originally admitted with diagnoses including psychosis and epilepsy. The resident's Minimum Data Set indicated intact cognition and required assistance with various activities of daily living. Despite these needs, the facility administered Olanzapine for six days without obtaining the necessary informed consent from the RP, as documented in the resident's records. The deficiency was identified during a review of the resident's physician orders and informed consent forms, which showed that consent was obtained for other medications but not for Olanzapine. Interviews with a registered nurse and the administrator in training confirmed that the medication was started at the hospital and continued upon the resident's return to the facility without proper consent. The facility's policy requires informed consent for psychotropic medications, but this was not adhered to in this case, resulting in the administration of Olanzapine without the RP's informed agreement.
Failure to Develop Person-Centered Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement person-centered care plans for seven residents, leading to deficiencies in addressing their specific medical needs. For three residents with diabetes, the facility did not create care plans for their insulin use, despite having physician's orders for insulin administration. This oversight was confirmed by the Assistant Director of Nursing (ADON) and the Director of Nursing (DON), who acknowledged the absence of care plans that should have included treatment goals, specified interventions, and evaluation dates. Another resident, who was readmitted with bipolar disorder and unspecified psychosis, was prescribed psychotropic medications such as Latuda, Seroquel, and Trazodone. However, the facility did not develop care plans for these medications, which are crucial for monitoring drug risks and ensuring the resident's care needs are met. The DON emphasized the importance of care plans in recognizing the right interventions for specific medications to manage the resident's behaviors effectively. Additionally, the facility failed to create care plans for a resident diagnosed with viral hepatitis C and two residents with urinary tract infections (UTIs) who were on antibiotics. The lack of care plans for these conditions meant that necessary interventions, goals, and communication with the care team were not outlined. The DON highlighted that care plans are essential for detailing interventions and treatments based on residents' diagnoses and medications, ensuring appropriate care and effective communication among the care team.
Medication and Fall Prevention Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure proper supervision during medication administration for a resident with severe cognitive impairment. The resident was found with several medications left unattended on the bedside table, which were supposed to be administered at 9 a.m. The nurse responsible for administering the medications became distracted and left the medications without witnessing the resident take them. This oversight was acknowledged by the nurse and the Director of Nursing, who confirmed that the resident was not authorized to self-administer medications, and the facility's policy required nurses to observe residents taking their medications. Another deficiency involved a resident whose bed was not positioned in the lowest position as ordered by the physician for fall prevention. The resident had a history of falls and required assistance with daily activities. A Certified Nursing Assistant admitted to not following the physician's order because it was easier for the resident to stand up from a higher bed position. The Director of Nursing emphasized the importance of following physician orders to potentially reduce the severity of injuries from falls. The facility also failed to provide a high-risk resident with bilateral landing mats as ordered by the physician. The resident, who had fluctuating capacity and required assistance with mobility, was observed without the prescribed landing mats in her room. The Director of Staff Development confirmed the absence of the mats and acknowledged that no other interventions were in place to prevent falls, despite the resident's high fall risk score. The facility's policy required the implementation of a resident-centered fall prevention plan, which was not adhered to in this case.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 3,709 citations issued within 25 miles in the last 12 months — including the 16 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Chatsworth
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Chatsworth Park Health Care Center | 0.5 mi | ★★★★★ | 31 | 0 |
| Topanga Terrace | 2.5 mi | ★★★★★ | 17 | 0 |
| Holiday Manor Care Center | 2.7 mi | ★★★★★ | 21 | 0 |
| West Hills Health And Rehabilitation Center | 2.9 mi | ★★★★★ | 13 | 0 |
| Canyon Oaks Nursing And Rehabilitation Center | 3.3 mi | ★★★★★ | 22 | 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 October 2026) and official state health department websites.