Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Studebaker Healthcare Center during CMS and state inspections, most recent first.
A resident with a history of falls, subarachnoid hemorrhage, muscle weakness, failure to thrive, and progressively worsening cognition was assessed as a high fall risk and totally dependent for ADLs, yet the care plan only directed staff to keep the call light within reach and encourage its use, without addressing the resident’s disorientation or inability to communicate needs or use the call light. After two unwitnessed falls in which the resident was found on the floor, unable to describe the events due to confusion, fall reports repeatedly identified confusion, gait imbalance, incontinence, and recent admission as predisposing factors. Although the IDT later identified the resident’s diagnoses, cognitive and functional limitations, unfamiliar environment, and impaired safety awareness as contributing factors and discussed specific interventions such as a low bed, floor pads, a tab alarm, and grab bars, these interventions were not incorporated into the care plan, and nursing leadership acknowledged that the resident’s confusion and need for increased monitoring and targeted fall-prevention measures were not timely care planned.
A resident with severe cognitive impairment, significant neurologic diagnoses, and total dependence for ADLs was newly admitted, but the attending physician did not complete or document an initial H&P or any progress notes following admission. Medical record review confirmed there was no evidence the physician had evaluated the resident, even though the physician was in the facility seeing other residents. The MR staff reported that the physician was notified of the admission but no follow-up reminder was made, and the physician acknowledged not following the facility’s physician services policy, which required an evaluation and written physical exam within a defined timeframe after admission.
A resident with severe cognitive impairment, significant neurologic diagnoses, and a care plan requiring maximal assistance with ADLs and repositioning had no ADL documentation recorded on the task sheet for one evening shift. The CNA assigned to that shift later reported providing oral care, incontinence care, and repositioning but acknowledged forgetting to document these services, resulting in a gap in the medical record. Review by the DSD and statements from the DON confirmed that this lack of documentation was inconsistent with facility policies requiring clear, accurate ADL and medical record documentation for each shift.
Failure to validate nursing competencies for CPR, RNA tasks, and splinting: the facility did not in-service or competency-check all licensed nursing staff on CPR and emergency response for unresponsive residents, did not complete annual competency validation for RNAs, and did not document a 2025 performance evaluation for an LVN. During observation, an RNA performed PROM on a resident with quadriplegia by hyperextending the resident’s fingers and forcefully pushing them down, and CNAs were applying and removing the resident’s wrist splints even though leadership stated Rehab and RNA were responsible for splinting and CNAs were not qualified.
Inaccurate MARs, assessments, and weight records were found for multiple residents. An LVN documented a medication as given when it was not available and not administered, an RN failed to document IV cefepime doses that were given, and another resident’s MAR showed several meds documented at times that did not match when they were administered. The facility also completed an inaccurate JMA for a resident with ROM impairment, and weekly weights and nutrition notes were not accurately documented for a resident with malnutrition and weight loss.
QAA Committee failed to identify systemic issues affecting all residents, including 94 of 94 licensed nursing staff not being in-serviced or competency validated for CPR and emergency response, 3 of 3 RNAs not receiving annual in-service or competency validation, and 5 of 19 resident records containing inaccurate or incomplete documentation. The Administrator stated these issues were not identified by the committee, despite the facility QAPI policy requiring the committee to continually identify and address quality of care issues.
Failure to Obtain Informed Consent for Psychotropics and Restraint Use: Two residents received psychotropic medications before consent was obtained, and one resident also had an abdominal binder used to limit movement without prior informed consent. One resident had dementia, severe cognitive impairment, and psychosis, while the other had Down syndrome, severe cognitive impairment, and lacked decision-making capacity. Facility records and staff interviews confirmed the consents were completed after medication administration and that the binder was used to prevent g-tube removal.
Call lights were not kept within reach for three residents with mobility and fall-risk needs, despite care plans directing staff to place the call light where each resident could reach it. One resident with a wheelchair, another with bilateral leg amputations, and a third with Parkinson’s disease and dementia were all observed with call lights out of reach, and an LVN and CNA acknowledged the call lights should be accessible. The facility also did not provide one resident with an appropriately sized wheelchair; Rehab documentation did not show an evaluation for a properly fitted chair, and the resident reported the wheelchair was too large, difficult to maneuver, and did not fit through doors or into a van.
The facility failed to develop comprehensive care plans for a resident at risk for dehydration and receiving furosemide, a resident who refused PT and RNA despite ROM and mobility concerns, and a resident using bilateral wrist splints. Interviews and record review showed no care plans were in place to address diuretic monitoring, therapy refusals, or splint use, wear schedule, and skin checks, even though staff confirmed these needs and the residents had significant functional limitations.
A resident with a left humerus fracture did not receive the ordered ortho follow-up, while another resident with quadriplegia was given bilateral wrist splints without a physician order or formal splint assessment for fit and wear tolerance. In a separate event, a resident with severe cognitive impairment had incomplete COC monitoring and later became unresponsive with shallow breathing, a weak pulse, and undetectable BP; staff delayed calling 911 until after the resident deteriorated further.
The facility failed to complete required ROM assessments and quarterly JMAs for residents with significant mobility limitations. One resident with a left humerus fracture and left-sided ROM concerns did not have the left shoulder or left hand fully assessed, another resident with quadriplegia had incomplete PT ROM measurements for the hips, knees, and ankles, and a third resident with quadriplegia and spasticity missed multiple quarterly JMAs. Facility leadership confirmed that all arm and leg joints should be assessed and objectively measured to monitor ROM changes.
A resident with atrial fibrillation, severe protein-calorie malnutrition, dysphagia, and severe cognitive impairment had repeated meals with less than 50% intake and a 10-lb weight loss in one week. The LVN, RD, and RNS stated there was no documentation that the MD was notified for the poor intake or the significant weight loss, and there was no documentation that the resident was monitored by the Weight Variance IDT committee as required by facility policy.
A medication pass error rate exceeded the 5% threshold when staff held carvedilol based on conflicting BP hold parameters, documented bismuth subsalicylate as given even though it was not in stock and not administered, and applied diclofenac gel without a clear dose amount. The nurse and DON both identified discrepancies between the physician order, pharmacy label, and MAR, and the resident records showed the affected residents had significant cardiac, metabolic, and pain-related conditions.
An unsecured E-Kit in the med room was found open with controlled and noncontrolled meds accessible, including several controlled substances. In addition, insulin products for two residents in one med cart were stored without required open dates, and an opened insulin vial for another resident was kept in a med cart despite being expired and not properly labeled. Staff stated the E-Kit should have been sealed and locked and that insulin vials needed open dates to track the 28-day use period.
Improper Food Labeling and Expired Dry Storage Items: The facility failed to store food safely in dry storage, with multiple items found unlabeled or undated, including potatoes, tortilla chips, seasoning, and opened spices. Several canned and dry goods were also found with old received or best-by dates, and the DS stated some items were expired and had not yet been discarded. The facility policy required labels to be exposed and storage products to be labeled and dated.
Staff failed to follow infection control procedures when an LVN entered a resident’s room without PPE for care and med administration despite EBP for a Foley catheter, and did not wash hands after handling trash before applying diclofenac gel. An RNA also provided ROM to another resident on EBP without an isolation gown. The facility further did not document implementation of its water management plan and failed to include two residents receiving antibiotics for UTIs in the infection surveillance log.
Failure to monitor antibiotic use: Two residents received antibiotics without documented McGeer Criteria supporting infection. One resident received cefdinir for a UTI diagnosis, but the IPN found no urine test or McGeer assessment in the chart. Another resident received Invanz and doxycycline for UTI/ESBL, but the IPN stated cloudy urine was not documented and no McGeer criteria assessment was completed. The DON stated McGeer criteria were used to identify infections and the need for antibiotics.
A resident with muscle weakness, UTI, acute encephalopathy, and dementia received the flu vaccine, but the record had no consent on file. The IPN stated the consent form should document the risks and benefits before administration, and the DON confirmed residents or representatives should be educated and able to consent or decline prior to vaccine administration. The facility policy required documentation of education and informed consent/refusal in the medical record.
The facility failed to document COVID-19 vaccine screening, education, administration, and/or declination for two sampled staff members, including the MD and PH. The IPN and DSD reviewed the employee tracking and vaccine files and found no vaccine records for either staff member, and the DSD stated the facility did not screen for or offer the vaccine to them. The DON stated all staff should have been screened and that vaccine record-keeping was important to help prevent spread to residents and within the facility.
A facility failed to maintain a safe and functional environment when two residents shared a bathroom with a clogged sink that was overflowing, with wet linen on the floor and a leaking bidet tube observed. Staff confirmed the sink needed repair. The facility also failed to keep a shower’s water temperature stable; a resident and CNAs reported the water fluctuated from hot to cold, so staff avoided using that shower and used another one instead. The DON stated fluctuating shower temperatures were unsafe and could cause discomfort or harm.
Failure to keep a married couple together in the same room. A wife with intact cognition and a husband with severe cognitive impairment had lived together for months, but the husband was moved to another room without documented consent or the wife's agreement. The wife reported repeated requests to SSD and admin to reunite them, while the husband was observed wandering and searching for her because he could not remember her room. The facility stated it accommodates couples together, but no signed room-change consent was found.
Resident medication information was left unattended on a med cart in public view, exposing a resident’s identifiers and medication details on a bubble pack containing Eliquis for DVT. The resident had fluctuating capacity to understand and make decisions, and both an LPN and the DON stated the card should not have been left visible because it contained private medical information.
A resident with Down syndrome, depression, unspecified psychosis, and severe cognitive impairment was found wearing an abdominal binder without a physician order, informed consent, or documented assessment supporting its use. An LVN stated the binder was on the resident despite no order, and the DON confirmed that an abdominal binder used to prevent pulling on a g-tube is considered a restraint requiring an order and informed consent.
A resident with dysarthria, anarthria, cerebral palsy, and unclear speech was observed having difficulty communicating with CNA staff, and no communication board was found in the room. CNA, ST, AD, SSD, and DON interviews confirmed the resident needed a communication aid and alternative communication strategies, but the board was not provided at admission and was issued only later by Social Services.
A resident with dysphagia, gastrostomy, and dementia had tube feeding infusing, but the feeding container label did not include the start date and time. The LVN stated she started the feeding at 2:00 p.m. and that the label should have included the resident’s name, room, date/time started, and rate. The DON confirmed the formula was only usable for 48 hours after connection and the facility policy required the label to document when the formula was hung.
A resident with COPD was observed receiving oxygen via nasal cannula at 3.5 L/min, although the physician’s order called for 2 L/min. The resident also had a humidifier bottle in use that was dated months earlier than the observation, despite an order and facility policy requiring weekly changes. An LPN stated she did not verify the oxygen flow rate or check the humidifier bottle, and the DON stated oxygen administration should match the physician’s order.
The facility failed to ensure that one of two CNAs, a RNA, had a documented annual performance evaluation and skills competency review. Record review showed no 2025 evaluation in the personnel file, and the DSD stated the last CNA performance evaluation for the RNA was in 2021. The DON stated performance evaluations were important to ensure staff was competent, and the facility P&P required annual competency evaluations.
A resident with DM and ESRD had hydrocodone-acetaminophen ordered PRN for severe pain, but the controlled drug record did not match the eMAR after a dose was given. In addition, two medication carts contained open red containers with loose tablets and capsules that were still retrievable. The DON and LPNs acknowledged the documentation and disposal issues.
A resident with epilepsy and other neurologic diagnoses had a monthly MRR noting that Ultram (tramadol) was ordered PRN for pain despite the seizure disorder, and the consultant pharmacist documented that tramadol could lower seizure threshold and recommended an alternative analgesic and discontinuation. The physician response agreed to D/C, but the active order summary still showed tramadol on the MAR along with seizure meds such as phenytoin and valproic acid.
Medication Held Due to Conflicting Carvedilol Parameters A resident with CHF, AFib, prior TIA/CVA history, hypotension, and HTN missed a carvedilol dose when an LVN relied on the pharmacy label hold parameter of SBP less than 110 instead of the physician order of SBP less than 100. The resident’s BP was 106/83 with a pulse of 74, and the MAR showed conflicting carvedilol entries. The nurse stated the order and label did not match and needed clarification, while the DON stated the parameters should have been consistent.
A resident with atrial fibrillation, severe protein-calorie malnutrition, dysphagia, and severe cognitive impairment had ordered CBC, BMP, and LFT testing. The RNS reviewed the lab results and COC documentation and found low K, high BUN, and low albumin, but only the potassium result was reported to the physician. The DON stated all lab values, including abnormal results, are to be reported, and the facility policy required physician notification based on lab/x-ray results.
Failure to Honor Resident Food Preference: A resident with intact cognition and documented dislike for eggs received scrambled eggs for breakfast despite the tray card noting the preference. The resident stated they would not eat eggs, and the CNA confirmed the tray card indicated the resident disliked eggs. The DS and DON stated resident dietary preferences should be honored, and facility policy required meals consistent with tray card preferences.
A resident with a history of stroke and PTSD, who was cognitively intact and required maximal assistance with ADLs, reported concern after a CNA cursed in the resident’s presence while providing care. The CNA acknowledged spilling water in the room and using foul language, and the DON confirmed the resident stated she did not appreciate the outburst. Facility policies stated residents have the right to be free from abuse and defined verbal abuse as the use of disparaging or derogatory language within a resident’s hearing.
A cognitively intact resident with ALS and major depressive disorder, dependent for ADLs, reported that a CNA made a sexually inappropriate pelvic thrusting gesture on a stool in the resident’s room, which the resident perceived as mocking his sexual orientation and which made him angry. The resident informed the DSD, a mandated reporter, of the incident, but the DSD did not report the allegation to CDPH or other required authorities. The DON later acknowledged that the allegation constituted abuse and should have been reported immediately in accordance with the facility’s abuse policy, which requires reporting all abuse allegations within two hours to the state survey agency, law enforcement, and the Ombudsman.
A resident with ALS and major depressive disorder, who was cognitively intact and dependent for ADLs, reported that a CNA made an inappropriate sexual thrusting gesture on a stool in the resident’s room, which the resident perceived as mocking his sexual orientation. The resident informed the DSD, who acknowledged being a mandated reporter but did not report or initiate an investigation. A CNA and the DON both characterized such conduct as a form of abuse that should be reported. Facility P&Ps required prompt, thorough investigation of abuse allegations and defined abusive conduct to include disparaging or derogatory gestured language, but these procedures were not followed in this case.
A resident with multiple serious health conditions experienced a delay in care after abnormal lab results were not promptly communicated to the physician as required. Nursing staff failed to document or directly notify the physician, instead sending lab results via text message, which was not the physician's preferred method. As a result, the resident's transfer to a hospital for treatment of severe dehydration, hypernatremia, and acute kidney injury was delayed.
A LVN did not document abnormal lab results or their communication to a physician for a resident with complex medical conditions, despite facility policy requiring such documentation. Instead, the LVN texted photos of the lab results to the physician and did not enter this information into the medical record, resulting in incomplete and inaccurate records and potential disruption of care continuity.
A resident with ALS, diabetes, and major depressive disorder, who was cognitively intact, filed multiple grievances about care and rights violations. Despite repeated requests, neither the resident nor their responsible party received written updates or resolutions, as required by facility policy. Staff confirmed that only verbal updates were given, leading the resident to escalate concerns to the state health department.
A resident with ALS, diabetes, and depression experienced symptoms including headache, cough, congestion, and fear of choking, but the nurse only notified the physician about cough and congestion via text, omitting key symptoms. The physician did not respond during the nurse's shift, and there was no follow-up call or escalation to the DON or Medical Director. The resident's condition worsened, leading to a hospital transfer and diagnosis of pneumonia and hypoxia. Documentation of communication and events was incomplete.
A resident with ALS, diabetes, and depression experienced cough, congestion, and fear of choking overnight. The nurse notified the physician by text about some symptoms but did not communicate the resident's fear of choking or shortness of breath. The physician did not respond for over eight hours, and the nurse did not escalate the issue to the DON or Medical Director as required by policy. The resident's family later called 911, and the resident was hospitalized with pneumonia and hypoxia.
A resident with ALS and intact cognition was not treated with dignity when a CNA removed his glasses without consent during care, leading to feelings of violation and distrust. Additionally, the resident was not provided with an admission packet or orientation, leaving him unaware of his rights and facility policies. Staff interviews confirmed these omissions, which resulted in the resident's confusion and lack of trust in the care team.
A resident with ALS, fully dependent on staff for transfers, was injured when a mechanical lift tipped and the sling bar struck the resident's head during a transfer. The incident occurred without a required physician order for lift use, resulting in head and chest contusions and hospital evaluation.
A resident who was alert and continent, but dependent on staff for toileting hygiene due to ALS, was not properly assessed or placed on a toileting program. Staff failed to assist the resident in a timely manner to use a urinal, instead encouraging use of an incontinence brief for staff convenience, which led to the resident being left in soiled conditions and feeling humiliated. Facility policies requiring continence assessment and individualized care planning were not followed.
A resident with ALS, depression, and diabetes refused to accept medications from an LVN due to concerns about respect. The LVN pre-charted the medications in the MAR before administration, and after the resident refused, another LVN prepared and administered new medications. The MAR was not updated to reflect the correct nurse or the resident's refusal, resulting in inaccurate documentation.
The facility failed to secure controlled drugs, including Oxycodone and Lorazepam, as per policy. A resident's Oxycodone was found in an unlocked drawer, and Lorazepam was not locked in the medication refrigerator. This involved residents with fibromyalgia and epilepsy, respectively.
The facility failed to follow professional standards for food service safety, as observed in the improper labeling and dating of food items and inadequate cleaning of kitchen equipment. Sack lunches for residents going out for dialysis were not labeled with preparation dates, and a container of liquid eggs was found open without an open date. Additionally, a can opener had a black sticky substance, indicating it was not cleaned as required. These deficiencies could lead to pathogen exposure and foodborne illnesses.
The facility failed to ensure that two residents had completed advance directive acknowledgments and POLST forms in their medical records. One resident, with developmental disorder and psychosis, lacked decision-making capacity, and the forms were sent to the Regional Center but not followed up. Another resident, with multiple diagnoses and severe cognitive impairment, also lacked a completed advance directive. The facility's policy requires these forms to be maintained, but the lack of follow-up and documentation led to incomplete records, potentially delaying care during emergencies.
The facility failed to implement comprehensive care plans for two residents, one with an intellectual/developmental disability and another using a bipap machine. The first resident lacked a care plan addressing their IDD, while the second resident's care plan did not cover bipap use, leading to issues with the humidifier. The facility's policy requires person-centered care plans, but these were not developed, potentially affecting the residents' quality of life.
A resident with end-stage renal disease and diabetes did not receive adequate dialysis care. The facility failed to update the resident's hemodialysis schedule, document refusals, or notify the MD of missed sessions. Out-of-range A1C levels were not reported, and the resident did not receive appropriate snacks on dialysis days. These deficiencies highlight a breakdown in communication and documentation within the facility.
The facility failed to administer medications as ordered for two residents, leading to a deficiency in pharmaceutical services. One resident with schizophrenia and other mental health disorders had several medications not documented as administered, while another resident with dementia and psychotic disorder also experienced lapses in medication administration. The Director of Nursing confirmed that physician orders should always be implemented as ordered.
Failure to Care Plan and Implement Fall-Prevention Interventions for a High-Risk, Non-Communicative Resident
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a complete, person-centered care plan with measurable objectives and timetables for a resident who was at high risk for falls and unable to effectively communicate his needs. The resident was admitted and later readmitted with diagnoses including subarachnoid hemorrhage, muscle weakness, failure to thrive, and a history of falls. An MDS dated 1/27/2026 showed moderately impaired cognition and complete dependence on staff for all ADLs. Upon readmission, the nursing admission assessment on 2/10/2026 identified the resident as a high fall risk and documented that he was alert and oriented only to name, and a subsequent MDS indicated severely impaired cognition and continued total dependence for ADLs. The resident’s care plan dated 1/23/2026 identified him as being at risk for falls due to unawareness of safety needs, a diagnosis of traumatic subdural hemorrhage, and a history of falls. The goal was for the resident to be free from falls, and interventions included ensuring the call light was within reach and encouraging him to use it to call for assistance. However, the care plan did not include interventions addressing his disorientation or his inability to communicate his needs or use the call light because of confusion. After the resident experienced an unwitnessed fall on 2/11/2026, documented in an SBAR and Unwitnessed Fall Report as being found on his knees with urine on the floor and unable to describe the event due to disorientation, the updated care plan on 2/11/2026 again failed to add interventions targeting his confusion and inability to communicate or use the call light. The resident sustained a second unwitnessed fall on 2/12/2026, documented in an SBAR and Unwitnessed Fall Report as being found in a sitting position on the floor with facial grimacing due to buttock pain and an ordered hip X-ray, and again was unable to describe the event due to disorientation. Predisposing fall factors on both fall reports included confusion, gait imbalance, incontinence, and recent admission within the last 72 hours. An IDT Post Event Review on 2/13/2026 identified contributing factors to the two falls as the resident’s diagnoses, comorbidities, functional and cognitive limitations, recent readmission with an unfamiliar environment, adjustment period, and impaired safety awareness, and indicated that the care plan was to be updated with specific fall-prevention interventions. However, review of care plans from 2/16/2026 to 4/24/2026 showed no documentation that ordered interventions such as a low bed with bilateral floor pads, a tab alarm in bed, and bilateral grab bars were added to the care plans. In interviews, RN 1 and the DON acknowledged that the resident’s confusion and need for increased monitoring and fall-prevention interventions were not addressed in the care plan at admission or after the falls, and that the omission of interventions discussed by the IDT was an oversight.
Failure to Complete and Document Timely Initial Physician Assessment for New Admission
Penalty
Summary
The deficiency involves the facility’s failure to ensure that the attending physician conducted and documented a timely initial history and physical (H&P) assessment for a newly admitted resident. The resident was admitted with serious neurological diagnoses, including subarachnoid hemorrhage and cerebral infarction, and had severely impaired cognition, required two-person assistance for ADLs, and was incontinent of bowel and bladder. Review of the medical record for the month following admission showed no documentation that the attending physician evaluated the resident, completed an H&P, or wrote any progress notes. The Medical Records Assistant confirmed that there was no evidence the physician had seen the resident, despite the physician being in the facility and seeing other residents during that period. The Medical Record Director stated that the attending physician was notified of the admission but that no follow-up reminder call was made after the initial notification. The attending physician acknowledged not following the facility’s policy on physician services and visits, explaining that she typically sees residents on specific days of the week and was unsure whether she had been reminded of the admission; she stated that she should have completed the initial assessment and documentation. The DON stated that the physician was supposed to perform a physical examination within three days of admission to identify the resident’s current condition and inform the resident and responsible party of goals, care, and treatment services. The facility’s written policy required the attending physician to perform a patient evaluation, including a written report of the physical examination, within five days prior to admission or within seventy-two hours after admission, which did not occur for this resident.
Failure to Accurately Document ADL Care by CNA
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate documentation of activities of daily living (ADLs) for one resident by a CNA. The resident, who had diagnoses including subarachnoid hemorrhage and cerebral infarction, was severely cognitively impaired per the Minimum Data Set and required two-person assistance for ADLs such as bathing, dressing, transferring, and repositioning, and was incontinent of bowel and bladder. The resident’s care plan documented a self-care deficit for ADLs and included interventions for maximal assistance with all ADLs, repositioning every two hours, and pressure-injury prevention measures. However, review of the resident’s Task Sheet for a specific date showed no documentation of ADL care provided during the 3 p.m. to 11 p.m. shift. During a telephone interview, the CNA assigned to the resident for that shift stated she had provided ADL care, including oral care, incontinence care, and repositioning, but admitted she forgot to document these tasks on the Task Sheet. Concurrent review of the Task Sheet with the Director of Staff Development confirmed there was no documentation of ADL care for that shift. The DON stated that all nursing staff are responsible for timely documentation of each resident’s status and response to care so that medical records remain complete and accurate. Facility policies on Nursing Documentation and Medical Record Content required concise, clear, pertinent, and accurate documentation of resident status and care, including ADLs, by the CNA who provided the care according to the date and shift, and maintenance of a medical record sufficient to support diagnoses, justify medical necessity, and facilitate continuity of care.
Failure to Validate Nursing Competencies for CPR, RNA Tasks, and Splinting
Penalty
Summary
The facility failed to ensure nursing staff had appropriate competencies and skill sets to provide care and services to all 94 residents. The report states that 94 out of 94 licensed nursing staff were not in-serviced and their competency was not validated for CPR and emergency services for residents who were unresponsive. The Director of Staff Development confirmed that CPR and emergency response for unresponsive residents were not included in the competency skills check, and the Director of Nursing stated that validating CPR competency was important to reassess staff knowledge in emergency response. The facility also failed to ensure that one LVN had a performance evaluation in 2025, and that three Restorative Nursing Aides had annual in-service education and competency validation for RNA duties. The Director of Staff Development stated the facility had three RNAs and did not in-service or check RNA competency to ensure they were providing RNA services competently. The facility's competency checklist did not assess RNA tasks such as ROM exercises and splinting, and the DSD stated the facility did not have a way to ensure RNA staff were competent in their job duties because RNA competencies were not conducted. Resident 42 was admitted with diagnoses including quadriplegia, polyneuropathy, and muscle spasm, and was cognitively intact and dependent for multiple activities of daily living. During observation, RNA 1 assisted with PROM to both arms and hyperextended all of Resident 42's fingers backward at the knuckles approximately 45 degrees past neutral, then forcefully pushed the fingers down at the end of the movement 20 times on each side. RNA 1 stated she performed PROM by bending and straightening joints as far as possible and pushing down at the end range to obtain increased stretch. OT 2 stated RNA should never hyperextend a resident's joint during ROM because it could cause fractures, pain, joint damage, and injury. The facility also failed to ensure CNAs were competent to apply and remove Resident 42's wrist splints. Resident 42 stated the CNAs applied both wrist splints in the morning and removed them at night, and that staff did not remove and/or check his skin throughout the day. CNA 9 confirmed CNAs assisted with applying and removing the splints and stated she only looked for redness when removing them at 11 p.m. The DOR, DON, LVN 7, and DSD stated Rehab and/or RNA were responsible for splint application and removal, and that CNAs were not qualified or competent to provide splinting services.
Inaccurate MARs, Assessments, and Weight Documentation
Penalty
Summary
The facility failed to maintain accurate and complete medical records for multiple residents by documenting medications as administered when they were not, failing to document administered medications, and recording assessments and weights inaccurately. For one resident admitted with type 2 diabetes mellitus with hyperglycemia and GERD, LVN 1 documented bismuth subsalicylate oral suspension as given on the MAR even though the medication was not in stock and was not administered. During interview, LVN 1 stated the medication was not administered and that the MAR entry was incorrect. For another resident admitted with sepsis and Bell’s palsy, the MAR did not reflect cefepime IV doses that were administered for sepsis treatment. RNS 1 stated she administered the cefepime doses but did not document them, and the DON stated the IV antibiotic should have been documented right after administration. For a third resident with ALS, spinal stenosis, diabetes, GERD, hypertension, and gait impairment, the MAR and medication audit showed multiple medications were documented at times that did not match the scheduled administration times. LVN 1 stated she administered the medications but documented them later, and the DON stated licensed nurses should document medications right after administration. The facility also failed to accurately complete a Joint Mobility Assessment for a resident with osteoarthritis and quadriplegia. The PT evaluation had identified ROM impairment in both legs, but it did not assess both hips and both ankles, and the JMA later recorded severe limitations in both hips, moderate limitations in both knees, and no limitations in both ankles while also stating there had been no change in ROM. The DOR stated the baseline ROM was not objectively established in the PT evaluation and confirmed the JMA was inaccurate. In addition, for a resident with atrial fibrillation, severe protein-calorie malnutrition, and dysphagia, weekly weights were not documented accurately in the medical record, and nutrition notes were not documented when the resident was experiencing weight loss.
QAA Committee Failed to Identify Systemic Staff Competency and Documentation Deficiencies
Penalty
Summary
The facility's QAA Committee failed to identify and implement corrective action for multiple systemic problems affecting 94 of 94 residents. During interview, the Administrator stated the committee did not identify that 94 of 94 licensed nursing staff were not in-serviced and had not had competency validated for CPR and emergency services for residents who are unresponsive. The Administrator also stated the committee did not identify that 3 of 3 Restorative Nursing Aides were not in-serviced and had not had annual competency validation for the skill set needed to function as RNAs. The Administrator further stated the committee did not identify that 5 of 19 residents' medical records, including Resident 3, Resident 4, Resident 15, Resident 37, and Resident 101, were not accurate and complete because of inaccurate and incomplete documentation by facility staff. Review of the facility's policy and procedure titled Quality Assurance Performance Improvement Program, revised [DATE], showed the QAA committee was to continually identify and address specific quality of care issues and implement action plans to resolve these issues.
Failure to Obtain Informed Consent for Psychotropics and Restraint Use
Penalty
Summary
The facility failed to ensure informed consent was obtained before administering psychotropic medications to two residents and before using a restraint on one of those residents. Resident 78 was readmitted with diagnoses including dementia, major depressive disorder, and unspecified psychosis, and the MDS showed severely impaired cognitive skills for daily decision-making. The order summary showed Mirtazapine was started on 11/27/2025 and Quetiapine was started on 12/16/2025, but the psychotropic consent forms were effective 1/22/2026, months after the medications were ordered. During review with the RNS, it was confirmed the consents were not obtained prior to medication administration and were not signed by the physician. Resident 106 was admitted with diagnoses including Down syndrome, depression, and unspecified psychosis. The H&P stated the resident did not have the capacity to understand and make decisions, and the MDS indicated severe cognitive impairment and dependence for all ADLs. The MAR showed Mirtazapine 30 mg and Seroquel 25 mg were administered on 2/14/2026, while the consent for these psychotropic medications had an effective date of 2/17/2026, after the first administration. During interview, the DON stated the consents were obtained late and that medications should not be administered without informed consent. Resident 106 also had an abdominal binder in place to prevent pulling out the g-tube. LVN 6 stated the binder was being used for that purpose, and the DON stated the binder restricted movement and would require informed consent from the resident's legal representative. The facility's policies stated informed consent was required before psychotherapeutic drugs and physical restraints were used, and that the physician/LHP was responsible for obtaining consent before initiating such treatment. The DON stated the order notation that consent was obtained did not serve as the actual consent form.
Call Lights Not Within Reach and Improper Wheelchair Size
Penalty
Summary
The facility failed to ensure that call lights were within reach for three sampled residents. Resident 52 was admitted with diagnoses including asthma, COPD, and dysphagia following cerebral infarction, and his MDS indicated he used a wheelchair and needed substantial to maximal assistance with multiple ADLs, including toileting, dressing, hygiene, and transfers. His care plan identified ADL self-care difficulties and fall risk and directed staff to attach the call light within reach and encourage its use. During observation, Resident 52 was verbally calling out for a nurse and stated he did not know where his call light was; the call light was later observed dangling on the left side of the bed outside his reach, and an LVN stated it should be where the resident could reach it. Resident 67 was admitted with diagnoses including Parkinson’s disease, muscle weakness, and bilateral below-the-knee amputations. His MDS indicated he needed substantial to maximal assistance for bed-to-chair or wheelchair transfers and was dependent on staff for toilet transfers and showering. His care plan identified fall and injury risk related to his leg amputations and directed staff to attach the call light within reach and encourage its use. During observation, the call light was hanging behind his bed and he stated he could not reach it. An LVN stated CNA staff usually placed the call light within reach after morning incontinent care, and also stated the call light should always be within reach because the resident could fall if unable to reach it for assistance. Resident 89 was admitted with diagnoses including Parkinson’s disease and dementia. His MDS indicated he used a walker for mobility, and his care plan identified fall risk related to gait and balance problems, Parkinson’s disease, and dementia. The care plan directed staff to ensure the call light was within reach and to provide prompt response to requests for assistance. During observation, Resident 89 was lying in bed with eyes closed and the call light was found under the bed. A CNA stated that if the call light was not within reach, the resident could fall while attempting to complete tasks independently without proper assistance, such as when needing to use the restroom. The facility also failed to accommodate Resident 84’s mobility needs by not providing an appropriately sized wheelchair since admission. Resident 84 was admitted with diagnoses including peripheral autonomic neuropathy, cellulitis of both lower limbs, chronic venous hypertension with bilateral lower-extremity ulcers, gait and mobility abnormalities, and muscle weakness. The PT evaluation documented wheelchair management training and noted that Resident 84 had a manual wheelchair for community mobility, but did not identify an appropriate wheelchair size. IDT meeting minutes did not show that Rehab Services evaluated her for a wheelchair appropriate for her size or provided one. Resident 84 stated the facility provided a 26-inch wheelchair that was too big for her size, made her legs slant, and caused her to move side to side to help herself up. She stated the wheelchair did not fit into the van, clinic rooms, or bathroom, and that it scraped doorways. The DOR stated she was not aware the wheelchair was too big, acknowledged she should have assessed it properly, and stated it could be embarrassing to have a wheelchair not fitted properly.
Failure to Care Plan Dehydration, Therapy Refusals, and Wrist Splints
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for Resident 101's risk for dehydration and for monitoring the use and side effects of furosemide. Resident 101 was admitted with diagnoses including atrial fibrillation, severe protein-calorie malnutrition, and dysphagia. The MDS dated 11/1/2025 indicated severe cognitive impairment, supervision needed for eating, moderate assistance for oral hygiene, and dependence for toileting hygiene, bathing, and lower body dressing. The physician orders included furosemide 20 mg daily for hypertension, but the MDS nurse confirmed there was no care plan addressing dehydration risk or furosemide monitoring. During interview, the RNS stated care plans were important to ensure interventions met resident goals and that diuretic side effects needed monitoring because increased urination placed the resident at risk for excessive diuresis, weight loss, and dehydration. The DON stated Resident 101 was at risk for dehydration and should have had a care plan addressing dehydration risk and diuretic use and monitoring, including monitoring for low urine output, altered mental status, and/or low blood pressure. The facility policy stated the comprehensive care plan was to include measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychosocial needs. The facility also failed to develop and implement a comprehensive care plan for Resident 34's refusals to participate in PT and RNA programs. Resident 34 was admitted with paraplegia and reduced mobility. The MDS indicated cognitive intactness, dependence or substantial assistance for multiple ADLs, and functional ROM limitations in both legs. The PT evaluation dated 8/6/2025 documented maximal to total dependence for mobility and ROM loss in both ankles and both knees, and stated PT services were not indicated because Resident 34 declined PT and an RNA program after explanation and education. The DOR confirmed Resident 34 refused PT and RNA services and that no care plan was developed for those refusals, although staff should have care planned refusals to ensure awareness of limitations and interventions related to the identified concerns. The facility further failed to develop and implement a comprehensive care plan for Resident 42's bilateral wrist splints. Resident 42 was admitted with quadriplegia, polyneuropathy, and muscle spasm, and the MDS indicated cognitive intactness, dependence for eating, hygiene, toileting, bathing, dressing, rolling, and transfers, with ROM limitations in both arms and legs. Observations showed Resident 42 wearing both wrist splints while seated in a motorized wheelchair, and the resident stated the splints were worn all day because both wrists bent downward without them. Staff interviews showed CNAs applied the splints in the morning and removed them at night, but skin checks were not done throughout the day. An LVN stated she did not know the resident had wrist splints and confirmed there was no care plan for them. The DOR and DON both confirmed a care plan for the splints should have been developed, including the type of splints, wear schedule, and monitoring needed to ensure tolerance and routine skin checks.
Missed orthopedic follow-up, unsupervised wrist splints, and delayed emergency response
Penalty
Summary
Resident 3 had a left humeral shaft fracture and an orthopedic consultation note recommended a repeat x-ray in 6 weeks and follow-up with orthopedics. The resident’s record also included a physician order for orthopedic follow-up in 6 weeks. Facility staff, including the charge nurse and the nursing case manager, acknowledged that the follow-up appointment was supposed to be scheduled, but the record showed it was not completed. During observation, Resident 3 was lying in bed with the left elbow and wrist bent and resting on the chest, and the resident stated he was unable to move the left shoulder, wrist, and hand. Resident 42, who had quadriplegia, polyneuropathy, and muscle spasm, was observed wearing splints to both wrists. The resident stated the splints were applied in the morning and removed at night, and that staff did not remove or check the skin throughout the day. The DOR stated she issued the wrist splints without a physician’s order and did not formally assess the resident for splint fit or establish wear time tolerance. The DOR also stated the resident was especially at risk for skin breakdown because he had no sensation to both arms. Resident 101 had change-of-condition documentation for low potassium and poor oral intake. Nursing staff stated the resident should have been monitored every shift for 72 hours, but there was no documentation showing monitoring during the overnight shifts identified in the record. On another occasion, Resident 101 was documented as too sleepy to eat, non-reactive to verbal stimuli, with slow shallow breathing, a weak pulse, and an undetectable blood pressure. The nursing note showed CPR was initiated and 911 was activated later, and staff interviews confirmed the facility should have called 911 when the resident was unresponsive with undetectable blood pressure and a weak pulse.
Incomplete ROM Assessments and Missed Quarterly Monitoring
Penalty
Summary
The facility failed to provide appropriate ROM services for three residents with ROM concerns by not completing required assessments and measurements and by missing required quarterly monitoring. The deficiency involved Resident 3, Resident 4, and Resident 42, all of whom had diagnoses and functional limitations affecting mobility and ROM. The report states that the facility’s own Director of Rehabilitation and Director of Nursing confirmed that all arm and leg joints should be assessed during OT/PT evaluations and during quarterly Joint Mobility Assessments (JMAs), and that goniometer measurements should be used to objectively document ROM limitations. Resident 3 had a left humeral shaft fracture, osteoarthritis of the left shoulder and left elbow, and cerebral palsy. The orthopedic note documented a left humerus fracture with a 5-pound weight-bearing restriction for 6 weeks, AROM to the left shoulder and elbow as tolerated, and PROM to begin in 6 weeks. The OT evaluation identified impaired ROM of the left arm and stated the left shoulder was not assessed due to the fracture, but it did not assess the left hand. The later JMA also did not evaluate the left shoulder or left-hand ROM. During observation, Resident 3 was lying in bed with the left elbow and wrist bent on the chest, the left hand open with hyperextended middle joints and bent fingertips, and stated he was unable to move the left shoulder, wrist, and hand. Resident 4 had osteoarthritis and quadriplegia. The PT evaluation documented impaired ROM in both knees but did not assess both hips or both ankles, and it did not objectively measure the knee limitations with a goniometer. The later JMA documented severe ROM limitations in both hips, moderate limitations in both knees, and no limitations in both ankles. During observation, Resident 4 was in bed while restorative nursing staff performed PROM to both arms and legs, but were unable to straighten the right hip and knee or the left hip and knee. The staff stated the legs were tight and contracted, with the right side more than the left, and splints were applied to both knees after the session. Resident 42 had quadriplegia, polyneuropathy, and muscle spasm, and was dependent for eating, hygiene, toileting, bathing, dressing, rolling, and transfers. The resident stated both wrists and hands could not be moved and that splints were worn on both wrists all day because the wrists bent downward without them. The DOR reviewed the record and confirmed quarterly JMAs were missing for March 2025, June 2025, September 2025, and December 2025. The facility policy required residents to be reviewed for contractures and ROM upon admission and at least quarterly, with ROM documented in the medical record.
Failure to Notify Physician and Review Weight Variance for Resident with Poor Intake and Significant Weight Loss
Penalty
Summary
The facility failed to notify the physician when Resident 101 had oral intake below 50% and failed to notify the physician when the resident had a 10-pound weight loss in one week. Resident 101 was admitted with atrial fibrillation, severe protein-calorie malnutrition, and dysphagia. The MDS dated 11/1/2025 showed severe cognitive impairment, supervision needed for eating, moderate assistance with oral hygiene, and dependence for toileting hygiene, bathing, and lower body dressing. The physician orders included admission and weekly weights for four weeks starting 11/18/2025. A review of the nutrition records showed multiple meals in December 2025 with less than 50% consumed, including several meals at 26%-50% and 0%-25%. LVN 4 stated poor oral intake was less than 50% of a meal and that the physician should be notified if a resident had poor oral intake two meals in a row. LVN 4 and the RD stated there was no documentation that the physician was notified for the poor intake on 12/11/2025, and the RD stated there was no documentation of interventions or notifications until 12/18/2025. Weekly weights showed Resident 101 weighed 111 pounds on 11/19/2025, 101 pounds on 11/26/2025, 96 pounds on 12/3/2025, and 95 pounds on 12/10/2025. RNS 1 stated the resident had a 10-pound weight loss from 11/19/2025 to 11/26/2025 and that there was no documentation the physician was notified. The RD stated the resident had a 10-pound, 9% weight loss in one week and a 15-pound, 13.5% weight loss in two weeks, and there was no documentation that the resident was being monitored by the Weight Variance IDT Committee. The facility policy stated the Nutrition & Weight Variance Committee was to meet at least monthly to review residents at risk for unplanned weight loss, including residents with 2% weight change in one week, 5% in one month, or 10% in six months.
Medication Pass Errors With Unclear Orders and Missing Stock
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5% during medication pass for two sampled residents. For one resident with diagnoses including CHF, atrial fibrillation, prior TIA/cerebral infarction, hypotension, and essential hypertension, the morning carvedilol order on the pharmacy label instructed staff to hold the medication if SBP was less than 110, while the physician order in the electronic record instructed staff to hold it if SBP was less than 100. During the medication pass, the resident’s blood pressure was 106/83 with a pulse of 74, and the nurse held carvedilol based on the pharmacy label rather than the physician order. The nurse later stated the hold parameters on the label and the physician order were different and needed clarification. For the second resident, who had diagnoses including neuromuscular dysfunction of bladder, generalized muscle weakness, type 2 DM with hyperglycemia, and GERD, the nurse prepared and administered multiple medications during the medication pass. The nurse did not have bismuth subsalicylate in stock and stated it was not administered, yet the MAR documented it as administered at 9:00 a.m. The nurse later stated the medication was not in stock, was not given, and should not have been documented as administered when it was not actually administered. The same resident’s diclofenac gel order was also not clear. During the medication pass, the nurse initially prepared an unmeasured amount of diclofenac gel and stated she usually just calculated it for the resident’s back. Later, the nurse was not observed applying the gel, then stated she had thrown away the medicine cup by mistake and searched the trash before preparing another unmeasured amount and applying it to the resident’s lower back. The nurse stated the order did not indicate a dose to be applied and that the physician should have been contacted to clarify the instructions. The DON stated medication orders should include strength, dose, frequency, location, and route, and the facility policy required discrepancies between the physician order, pharmacy label, and MAR to be resolved before administration.
Unsecured E-Kit and Improper Insulin Storage and Labeling
Penalty
Summary
The facility failed to ensure the Emergency Kit (E-Kit) in the Station 2 Medication Room was sealed and locked. During a concurrent observation and interview, the E-Kit box had a tamper-proof zip tie placed on top, but it was not being used to lock the kit, and the four drawers were easily accessible by sliding them out. The E-Kit contained 44 medications, including seven controlled medications: zolpidem, Ativan, Lomotil, Restoril, Tylenol #3, Ultram, and Xanax. The Director of Staff Development stated the E-Kit was open and unsecure, and the Director of Nursing stated it should have been sealed and locked. The facility also failed to store and label insulin products in accordance with manufacturer requirements and facility policy in the Station 2 Medication Cart. Resident 122, who had Type 2 DM without complications, had one unopened vial of Lantus and one unopened vial of Novolog stored in the medication cart with no open date. Resident 33, who also had Type 2 DM without complications, had one opened prefilled syringe of Lantus Solostar stored in the cart with no open date. LVN 5 stated the insulin products should have been labeled with an open date if stored in the medication cart so nursing staff could determine when to remove them after 28 days. The facility further failed to remove an expired insulin vial from the Station 3 Medication Cart. Resident 13, who had Type 2 DM without complications and fluctuating capacity to understand and make decisions, had one opened vial of insulin lispro with a pharmacy label showing a fill date and a handwritten expiration date, but no open date. LVN 4 stated it was unclear when the vial was opened and that it would not be safe or effective to administer. The DON stated sealed insulin vials should have been stored in the refrigerator instead of the medication cart, and if insulins were not labeled with an open date after opening or removal from refrigeration, nursing staff would not know how long they had been out.
Improper Food Labeling and Expired Dry Storage Items
Penalty
Summary
The facility failed to store food in a safe and sanitary manner to prevent growth of microorganisms that could cause foodborne illness for 94 of 98 residents. During a concurrent observation and interview on 2/17/2026 at 8:37 a.m. with the Dietary Supervisor, dry storage contained potatoes in a bin with no date and label, two prune cans with a received date of 3/22/2025 and a best by date of 7/3/2025, a bag of regular tortilla chips with no received date, two cans of pork and beans with a received date of 12/13/2024, two country style gravy mix items with a received date of 2/12/2024 and a best by date of 5/23/2025, barbeque seasoning in a plastic bag with no date, and an opened cayenne pepper seasoning bottle with no date. The Dietary Supervisor stated the pork and beans were expired and said he had not gotten to check and throw everything that was expired away. He also stated expired items should be thrown away so residents do not get sick, and that items need to be labeled so staff know what is being labeled and how long the items are good for. The facility policy and procedure titled Food Storage, revised 7/24/2025, indicated cans should be stored with labels exposed for easy identification, and dry storage guidelines included labeling and dating storage products.
Failure to Follow EBP, Hand Hygiene, Water Management, and Infection Surveillance Procedures
Penalty
Summary
The facility failed to follow infection prevention and control procedures when a licensed vocational nurse did not wear PPE before entering a resident’s room for care and medication administration even though the resident was on Enhanced Barrier Precautions for Foley catheter use. The resident had diagnoses including neuromuscular dysfunction of the bladder and generalized muscle weakness, had intact cognition, and was dependent on staff for several ADLs. During the observation, the nurse checked blood pressure and oxygen saturation, prepared multiple oral medications, and also prepared diclofenac gel for application to the resident’s lower back without wearing PPE before entering the room. The nurse later stated she was supposed to wear PPE because the resident was on EBP due to the Foley catheter. The nurse also failed to wash hands after reaching into the trash and before preparing and applying diclofenac gel to the resident’s lower back. The nurse stated she had thrown away the medicine cup containing diclofenac gel by mistake and then looked for it in the trash can before preparing a new dose. The facility’s topical medication policy required handwashing before and after topical medication administration, and the DON stated the nurse should have washed hands before applying the diclofenac gel. The facility also failed to ensure an RNA wore an isolation gown while providing passive range of motion exercises to another resident who was on EBP due to a suprapubic catheter. That resident had diagnoses including quadriplegia, polyneuropathy, and muscle spasm, and the observation showed the RNA assisted with ROM to both arms and both legs while wearing gloves but not an isolation gown. In addition, the facility did not implement its Water Management Plan as written, with the ESD stating he only measured water temperatures and checked the ice machine and that there was no documentation of the plan’s tasks. The facility also failed to include two residents receiving antibiotics for UTIs in the infection surveillance log, and the IPN stated she did not add those infections to the logs.
Failure to Monitor Antibiotic Use
Penalty
Summary
The facility failed to implement its Antibiotic Stewardship Program when two sampled residents received antibiotics without documented evidence that they met McGeer Criteria for infection. Resident 101 was admitted with diagnoses including muscle weakness and UTI, and the physician ordered cefdinir 300 mg by mouth. The MAR showed cefdinir was given daily, but the Infection Prevention Nurse stated there was no urine test documented in the chart to show a UTI, no record showing Resident 101 met McGeer criteria, and no McGeer criteria assessment was kept for residents on antibiotics. Resident 121 was admitted with diagnoses including dementia and UTI, and the care plan identified antibiotic therapy related to UTI. Physician orders included Invanz 1 gram IV for UTI-ESBL urine, doxycycline 100 mg orally twice daily for active infection, and contact isolation for ESBL. The MAR showed both antibiotics were started, but the Infection Prevention Nurse stated cloudy urine was remembered during admission and was not documented in the medical record, and no McGeer criteria assessment was completed to determine infection or the appropriateness of antibiotic use. The DON stated antibiotic use was determined by McGeer criteria to identify infections and the need for antibiotics.
Missing Flu Vaccine Consent and Education Documentation
Penalty
Summary
The facility failed to ensure that Resident 101 and the resident representative consented to and were educated on the risks and benefits of the influenza vaccine before it was administered. Resident 101 was admitted with diagnoses including muscle weakness and UTI, and the H&P also listed acute encephalopathy and dementia. During review of the immunization record, the resident was documented as having received the flu vaccine, but the Infection Prevention Nurse stated there was no consent on file for the vaccination and that the consent form should include the risks and benefits for the resident or representative to sign before administration. During interview, the DON stated it was important for residents and representatives to understand the risks and benefits of vaccines and have the opportunity to consent or decline before vaccine administration. The facility policy titled Influenza Prevention & Control stated that before offering the influenza vaccine, each resident or resident representative receives education regarding the benefits and potential side effects of the vaccination, and that the medical record includes documentation that the resident or resident representative was provided this education and was given a copy of the informed consent/refusal form to be placed in the record.
Missing COVID-19 Vaccine Documentation for Staff
Penalty
Summary
The facility failed to provide documented evidence of COVID-19 vaccine screening, education, administration, and/or declination for two of four sampled staff members, the Medical Director (MD) and the Pharmacist (PH). During a concurrent interview and record review with the Infection Prevention Nurse, the facility’s Employee Tracking Template was reviewed and showed no COVID-19 vaccine documentation for either staff member. The Infection Prevention Nurse stated that vaccine declination forms were obtained and filed by the Director of Staff Development. During a concurrent interview and record review with the Director of Staff Development, the employee vaccine files were reviewed and there was no record of COVID-19 vaccine screening, education, administration, and/or declination for the MD and PH. The Director of Staff Development stated the facility did not screen for, or offer, COVID-19 vaccines to these two staff members. During an interview with the DON, it was stated that all facility staff should have been screened for COVID-19 vaccine status and administration, and that COVID-19 vaccines and record-keeping were important to help prevent the spread of COVID-19 to residents and within the facility. The facility policy titled COVID-19 Vaccination stated the facility will educate and offer COVID-19 vaccinations to staff and consultants and maintain documentation of education, offering, and consent/declination/exemption forms in personnel files.
Clogged Sink and Fluctuating Shower Temperature
Penalty
Summary
The facility failed to provide a safe and functional environment when two sampled residents shared a bathroom with a clogged sink. Resident 42 was admitted with quadriplegia and had intact cognition on the 12/5/2025 MDS. Resident 82 was admitted with nontraumatic intracerebral hemorrhage and had severely impaired cognition on the MDS. During an interview, Resident 82 stated the bathroom sink had been clogged all weekend and kept overflowing. During a concurrent observation with CNA 4 in the shared bathroom, wet linen was observed on the floor, a tube connected to the bidet was leaking, a bucket was collecting water drips, and the sink was clogged. CNA 4 stated the sink was clogged and needed to be fixed. The facility also failed to ensure Shower 1 had stable water temperature. Resident 42 stated Shower 1 water temperature fluctuated from hot to cold and had been broken for a while. CNA 5 and CNA 6 both stated Shower 1 water temperature fluctuated from hot to cold, so staff used Shower 2 instead; CNA 6 stated staff constantly had to check the temperature and ended up not using Shower 1, which had been broken for about a year. The ESD stated the facility needed to ensure sinks and showers were working properly, and the DON stated fluctuating shower temperatures were unsafe and could cause discomfort or harm if too cold or too hot. The facility policy stated residents would be provided a safe, clean, and comfortable environment, and the Facility Assessment Tool stated building structures and equipment would be maintained to protect and promote resident health and safety.
Failure to Keep Married Residents Together
Penalty
Summary
The facility failed to accommodate a husband and wife, Resident 89 and Resident 90, who wanted to live in the same room and receive written notice before a room change was made. Resident 90 was admitted with diagnoses including muscle weakness, neuropathy, atrial fibrillation, hypertension, osteoarthritis, hyperlipidemia, gout, and cardiomyopathy, and had a BIMS score of 14, indicating cognitive intactness. Resident 89 was admitted with diagnoses including dementia, Parkinson's disease, gastrostomy, diabetes mellitus type 2, and generalized anxiety, and had a BIMS score of 4, indicating severe cognitive impairment. The couple had lived together in the same room for about eight months after admission, and the facility had originally agreed to keep them together. Resident 90 stated that Resident 89 was later moved to a different room without her consent or attendance at any IDT meeting, and that she had requested to SSD and administration that they be placed back together but did not receive an answer. During observation, Resident 90 was in one room while Resident 89 was six rooms away down the hallway. Resident 90 stated that Resident 89 would wheel himself around looking for her because he did not remember her room. The Admissions Coordinator stated the facility accommodates couples in the same room to maintain a home-like environment, and the SSD stated room changes are made on an as-needed basis and residents are informed, but there was no signed consent for the room change in the records. The facility policy stated residents' individual needs and preferences are accommodated to the extent possible unless health and safety would be endangered.
Resident Medication Information Left in Public View
Penalty
Summary
The facility failed to ensure that one sampled resident’s medical information was kept private from unintended public view. During observation on 2/18/2026 at 9:32 a.m. outside another resident’s room, the resident’s medication bubble pack was left unattended on the medication cart managed by an LVN. The bubble pack contained the resident’s name and medication information, including Eliquis (apixaban) 5 mg, ordered to be given by mouth one time a day for DVT. The resident’s admission record showed the resident was originally admitted to the facility and later readmitted, and the H&P dated 5/1/2025 indicated the resident had fluctuating capacity to understand and make decisions. During interview, an LVN stated the medication card should not have been left in public view because it created a risk of violating the resident’s private medical information and could also be taken by another resident. The DON stated that leaving the medication card unattended in public view would violate the resident’s private medical information because it contained resident identifiers, and said the nurse should have kept the card with them or shredded the information if not needed.
Abdominal Binder Used Without Order or Consent
Penalty
Summary
The facility failed to ensure Resident 106 was free from the use of a physical restraint when an abdominal binder was placed on the resident without a physician's order, informed consent from the resident's representative, or an assessment showing the need for the binder. Resident 106 was admitted with diagnoses including Down syndrome, depression, and unspecified psychosis, and the H&P stated the resident did not have the capacity to understand and make decisions. The MDS dated 2/20/2026 indicated severe cognitive impairment, dependence in all ADLs, and substantial assistance needed for bed mobility, with impairments on both sides of the lower extremities. During a concurrent observation, interview, and record review, LVN 6 stated Resident 106 had an abdominal binder and that there was no physician's order for it. LVN 6 stated the resident should not have the binder without an order and noted the resident had tried to remove a g-tube but had not had any episodes of trying to remove it and did not need the binder. LVN 4 stated a physician's order was needed for anything provided to the resident and that placing the binder without an order was not acceptable. The DON stated an abdominal binder used to prevent pulling on a g-tube is considered a restraint and requires an order and informed consent, and that if a resident came from the hospital with one, the facility would need to verify the order, inform the family, and assess whether it was indicated. Facility policies on restraints/seclusions and informed consents stated informed consent is required before use of a restraint, including physical restraints.
Failure to Provide Communication Aid for Resident with Speech Difficulties
Penalty
Summary
The facility failed to ensure that Resident 3, who had communication difficulties, was provided access to a communication aid and/or alternative communication strategies to help him communicate with staff and other residents. Resident 3 was admitted and later re-admitted with diagnoses including dysarthria, anarthria, and cerebral palsy. His MDS dated 12/11/2025 indicated he was cognitively intact and had unclear speech. During an observation on 2/17/2026, Resident 3 was in bed and spoke to CNA 7, but his speech was difficult to understand. CNA 7 stated he could not understand what Resident 3 wanted and needed and said he thought Resident 3 could benefit from a communication board, but none was found in the room. During interviews, ST 1 stated Resident 3 had unclear speech and difficulty communicating and needed alternative communication strategies such as a communication board, simple yes-or-no questions, cueing to slow down speech, and questions with few word choices. The AD and SSD both stated Social Services was responsible for evaluating and providing communication boards for residents with communication difficulties. The AD stated Resident 3 could benefit from a communication board, but it was never provided by the facility. The SSD stated she evaluated Resident 3 on re-admission, identified communication difficulties, recommended a communication board, but did not issue it until a couple days later, and said it should have been issued at admission. The DON also stated residents with communication difficulties should be assessed and issued communication aids as soon as possible to facilitate communication with staff and prevent delays in care.
Tube Feeding Label Missing Start Date and Time
Penalty
Summary
The facility failed to ensure that a G-tube feeding formula was labeled with a start date and time for one of three sampled residents. Resident 72 was admitted with diagnoses including dysphagia, gastrostomy, and dementia, and the MDS indicated the resident’s decision-making ability was severely impaired and that the resident was dependent on staff for multiple activities of daily living. The care plan identified the resident as requiring tube feeding to maintain adequate nutritional and hydration status, and the physician order directed Diabetic Source 1.2 to run at 50 mL per hour for 20 hours, starting at 2:00 p.m. and continuing until complete. During observation, Resident 72 was in bed with the tube feeding infusing at 50 mL per hour, and the feeding container label did not show a start date and time. The LVN stated she had started the tube feeding at 2:00 p.m. and acknowledged the label should have included the resident’s full name, room, date and time started, and rate of formula. The DON reviewed the manufacturer’s directions for Diabetic Source 1.2 and stated the formula could be used for a maximum of 48 hours after connection, and that the label should have included the start date and time. The facility policy also stated the formula label should document the initials, date, and time the formula was hung and be checked against the order.
Oxygen Not Delivered as Ordered and Humidifier Bottle Not Changed
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not met for Resident 37, who was admitted and re-admitted with COPD. The resident’s care plan indicated shortness of breath and oxygen use at 2 L/min, and a physician’s order dated 9/19/2025 directed staff to change the oxygen/nebulizer tubing, humidification bottle, and clean the filter every week on Friday night shift. During observation on 2/17/2026, Resident 37 was receiving oxygen via nasal cannula at 3.5 L/min with a humidifier bottle attached that was dated 11/29/2025. LVN 1 confirmed the resident was receiving oxygen at 3.5 L/min and stated she was unsure why the humidifier was dated 11/29/2025. She also stated she did not verify the oxygen flow rate or check the humidifier bottle, and acknowledged the resident should have been checked because of COPD. The DON stated oxygen administration should reflect physician orders and that humidifier bottles were changed every Friday by night shift staff. The facility policy stated oxygen tubing, humidifiers, masks, and cannulas used to deliver oxygen would be changed weekly and when visibly soiled, and to check the physician’s order.
Missing Annual CNA Competency Evaluation
Penalty
Summary
The facility failed to ensure that one of two Certified Nurse Assistants, identified as Restorative Nurse Assistant 1, had a documented annual performance evaluation and skills competency review for 2025. During a concurrent interview and record review with the Director of Staff Development, RNA 1's personnel file was reviewed and no documented evidence of a CNA performance evaluation or skills competency for 2025 was found, and the DSD stated the last CNA performance evaluation for RNA 1 was in 2021. During a later interview, the Director of Nursing stated that performance evaluations were important to ensure staff was competent. Review of the facility's policy titled Competency Evaluation, dated 7/2019, showed that the facility would evaluate all employees' performance competencies annually and review the most common procedures performed in the facility. Review of the Facility Assessment Tool, dated 4/9/2025, indicated that staff training and education would be provided at least monthly and on an as-needed basis.
Controlled Medication Documentation and Disposal Lapses
Penalty
Summary
The facility failed to maintain accurate documentation for a resident’s hydrocodone-acetaminophen on the controlled medication record after the medication was administered. Resident 74 had diagnoses including type 2 diabetes mellitus and end stage renal disease, and the record also noted fluctuating capacity to understand and make decisions. The resident’s orders included pain monitoring every shift and hydrocodone-acetaminophen 5-325 mg, 1 tablet by mouth every 6 hours as needed for severe pain. During a concurrent inspection, interview, and record review, the resident’s hydrocodone-acetaminophen bubble pack contained 24 tablets, while the facility’s controlled drug record showed 25 tablets remaining with the last dose documented on 2/9/2026 at 9:10 a.m. The eMAR showed the last dose of one tablet documented as administered on 2/19/2026 at 10:39 a.m. LVN 5 stated the medication should have been documented in the controlled drug record right after administration, and the DON stated the nurse should have signed the controlled drug record after the medication was removed from the bubble pack and signed the eMAR after it was administered. The facility also failed to store discarded medications in a closed-lid container or dispose of them in an irretrievable, safe, and secure manner in two medication carts. During observation, one red container in the Station 2 medication cart and one red container in the Station 3 medication cart each contained several tablets and capsules with open lids, leaving the medications retrievable. LVN 5 stated the open red biohazard container should have been emptied or sealed, and LVN 4 stated someone could grab the bin or tablets from the cart. The DON stated loose tablets and capsules should have been discarded in a manner that made them irretrievable.
Pharmacist Recommendation for Tramadol Not Followed
Penalty
Summary
The facility failed to follow the consultant pharmacist’s monthly medication regimen review recommendation for Resident 3. On 1/12/2026, the pharmacist reviewed the resident’s medication profile and noted that Ultram (tramadol) was ordered PRN for pain in a resident with a seizure disorder, stating that tramadol has the potential to lower seizure threshold and recommending evaluation of an alternative analgesic and discontinuation of tramadol. The physician response documented agreement and discontinuation, but the order summary later continued to show tramadol 50 mg by mouth every 8 hours as needed for severe pain. Resident 3’s record showed diagnoses including epilepsy, spastic quadriplegic cerebral palsy, and Bell’s palsy. The admission record, H&P, and MDS indicated the resident had capacity to understand and make decisions and had intact cognition. The order summary also listed seizure medications including phenytoin and valproic acid, while tramadol remained on the active medication list despite the pharmacist’s recommendation and the documented physician response.
Medication Held Due to Unresolved Carvedilol Order Discrepancy
Penalty
Summary
The facility failed to prevent a significant medication error for one resident when carvedilol was not administered because the nurse relied on the pharmacy label hold parameters instead of clarifying the discrepancy with the physician order. The resident had diagnoses including chronic systolic CHF, atrial fibrillation, prior TIA, cerebral infarction without residual deficits, hypotension, and essential hypertension. The resident also had fluctuating decision-making capacity and severely impaired cognition, and required varying levels of assistance with ADLs. During medication administration, the nurse obtained a blood pressure of 106/83 with a pulse of 74 and prepared seven medications, but did not give carvedilol 3.125 mg. The pharmacy label on the medication bubble pack stated to hold carvedilol if SBP was less than 110 and HR was less than 60, so the nurse held the medication based on that label. However, the physician order in the record stated carvedilol 3.125 mg twice daily for hypertension, hold if SBP was less than 100 or pulse was less than 60. The MAR contained conflicting documentation for carvedilol, including an entry reflecting the updated hold parameters of SBP less than 100 and another older entry showing the prior hold parameter of SBP less than 110. During interview, the nurse stated the physician order and pharmacy label did not match and that the physician would need to be called to clarify the hold parameters, but the medication had already been held. The DON stated the hold parameters on the pharmacy label and physician order should be the same and that nursing staff were responsible for updating directions and informing the pharmacy when an order changed.
Failure to Report Abnormal Lab Values to Physician
Penalty
Summary
The facility failed to notify the physician of abnormal lab values for one resident after ordered CBC, BMP, and LFT testing. Resident 101 was admitted with diagnoses including atrial fibrillation, severe protein-calorie malnutrition, and dysphagia. The resident’s MDS indicated severe cognitive impairment, supervision needed when eating, moderate assistance needed for oral hygiene, and dependence for toileting hygiene, bathing, and lower body dressing. A review of the resident’s 12/16/2025 lab results and COC documentation showed a potassium level of 2.9 mmol/L, BUN of 33 mg/dL, and albumin of 2.9 g/dL. During interview and record review, the RNS stated the low potassium, high BUN, and low albumin were abnormal and should be reported to the physician and documented in the COC documentation, but only the potassium level was reported. The DON stated the facility is to notify the physician of all lab values that resulted, including abnormal lab values. The facility policy on Change of Condition Notification stated the licensed nurse will notify the attending physician when there is a need to alter treatment significantly based on lab/x-ray results.
Failure to Honor Resident Food Preference
Penalty
Summary
The facility failed to honor the dietary preferences of one resident who had documented dislike for eggs. The resident was admitted with diagnoses including depression and osteoarthritis, and the MDS dated 10/24/2025 indicated cognition was intact, the resident was independent with eating, and required assistance with some activities of daily living. During an interview, the resident stated they do not like eggs and that the facility gave scrambled eggs for breakfast, which the resident said they would not eat. During a concurrent observation and interview, the resident’s breakfast tray was observed with eggs, and the CNA stated the resident received scrambled eggs and that the tray card indicated the resident disliked eggs. The Dietary Supervisor stated dietary preferences are assessed on admission, annually, and as needed, and that if a resident does not like eggs, the resident does not receive eggs and is offered an alternative. The DON stated the resident’s dietary preferences should be honored and that if a resident dislikes eggs, they should not receive eggs. The facility policy stated the Dietary department will provide meals consistent with residents’ preferences as indicated on the tray card.
Failure to Protect Resident From Verbal Abuse During Care
Penalty
Summary
The facility failed to protect a resident’s right to be free from verbal abuse when a CNA used foul language in the resident’s presence during care. The resident had been admitted with diagnoses including cerebral infarction and PTSD, and an MDS assessment indicated intact cognition with a need for maximal assistance with toileting, bathing, and dressing. A Change in Condition note documented that the resident expressed concern about the CNA’s use of foul language in her presence. The facility’s investigation summary later confirmed that the CNA used an inappropriate word while inside the resident’s room. In an interview, the CNA stated that while in the resident’s room she spilled a cup of water and cursed in front of the resident, acknowledging that this could make the resident feel upset and uncomfortable. The DON also confirmed that the CNA used foul language in front of the resident and that the resident reported she did not appreciate the CNA blurting that out in front of her. The facility’s abuse prevention and prohibition policy stated that each resident has the right to be free from abuse and that the facility is committed to protecting residents from abuse by anyone, including staff. Another facility policy defined verbal abuse as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or within their hearing distance, regardless of age, ability to comprehend, or disability.
Failure to Report Resident’s Allegation of Sexually Inappropriate Staff Conduct
Penalty
Summary
The facility failed to report an allegation of abuse to the California Department of Public Health (CDPH) as required under F609. A cognitively intact resident with diagnoses including amyotrophic lateral sclerosis (ALS) and major depressive disorder, who was dependent for ADLs, reported that a CNA made an inappropriate sexual gesture while providing personal care. The resident stated that the CNA thrust his pelvic area against a gray stool in the room in a way the resident found offensive and felt was mocking his sexual orientation as a gay man, which made him feel angry. The resident reported this incident to the Director of Staff Development (DSD), whom he identified as a mandated reporter. The DSD confirmed in interview that the resident had reported the CNA’s inappropriate gesture and that the resident felt the CNA was mocking his lifestyle because he is gay. The DSD acknowledged she is a mandated reporter and that the allegation should have been reported for the resident’s safety and to ensure a proper investigation, but she did not report it. The DON stated that the DSD should have reported the allegation immediately, that the allegation was a form of abuse, and that it should have been reported so a proper investigation could be conducted and the resident could be monitored for emotional distress. Review of the facility’s Abuse Prevention and Prohibition Program policy indicated that allegations of abuse must be reported immediately, but no later than two hours after forming a suspicion, to the state survey agency, law enforcement, and the Ombudsman, which did not occur in this case.
Failure to Investigate Resident’s Allegation of Sexual Abuse Gesture
Penalty
Summary
The deficiency involves the facility’s failure to implement its Abuse Prevention and Prohibition Program by not investigating an allegation of sexual abuse made by a resident. The resident, who had diagnoses including amyotrophic lateral sclerosis (ALS) and major depressive disorder, had intact cognition per a recent MDS and was dependent for ADLs. During an interview, the resident reported that a CNA made an inappropriate sexual thrusting gesture with his pelvic area on a stool in the resident’s room, which the resident found offensive and perceived as mocking his sexual orientation as a gay man. The resident stated he reported this incident to the Director of Staff Development (DSD) and believed, as a mandated reporter, the DSD should have reported the allegation. The DSD confirmed in an interview that the resident had informed her about the CNA’s inappropriate gesture and that the resident felt the CNA was mocking his lifestyle, but she did not report the allegation. The DSD acknowledged she is a mandated reporter and that the allegation should have been reported. Another CNA stated that any inappropriate sexual thrusting gesture is considered a form of abuse and should be reported for resident safety. The DON stated the DSD should have reported the allegation immediately, that the conduct described was a form of abuse, and that it could have made the resident feel offended and embarrassed. Review of the facility’s abuse-related P&Ps showed that verbal abuse includes gestured language with disparaging or derogatory terms and that the facility is required to promptly and thoroughly investigate reports of resident abuse, including suspending accused staff until the investigation is complete. These required investigative steps were not initiated in response to the resident’s allegation.
Failure to Timely Notify Physician of Abnormal Lab Results
Penalty
Summary
A deficiency occurred when abnormal laboratory results for a resident were not reported to the resident's physician in a timely manner, nor were instructions for care obtained promptly. The laboratory results, which included significant abnormalities such as elevated sodium, blood urea nitrogen (BUN), creatinine, and liver enzymes, were received by the facility in the afternoon. Despite the facility's policy requiring notification of abnormal results to the physician, there was no documentation that the physician was notified on the day the results were received. The resident had a complex medical history, including acute kidney failure, cerebral infarction, and congestive heart failure, and was unable to make reasonable decisions according to the Minimum Data Set. The abnormal lab results indicated severe dehydration, hypernatremia, and impaired kidney and liver function. Nursing staff on the relevant shifts failed to document follow-up or notification of the physician. One nurse texted the results to the physician, contrary to the physician's stated preference for phone calls, and did not document the communication in the resident's progress notes. The physician acknowledged receipt of the text but did not review the results at that time, and no further action was taken until the following day. The delay in notifying the physician and obtaining care instructions resulted in a delay in transferring the resident to an acute care hospital for evaluation and treatment. When the physician was finally contacted the next day, the resident was transferred and treated for severe dehydration, hypernatremia, hypotension, and acute kidney injury. Interviews with staff and the physician confirmed that the facility's expectations and the physician's preferences for communication were not followed, leading to the delay in care.
Failure to Document Lab Results and Physician Communication
Penalty
Summary
A Licensed Vocational Nurse (LVN) failed to document laboratory results and the communication of those results for a resident with multiple serious diagnoses, including acute kidney failure, cerebral infarction, and congestive heart failure. The resident was unable to make reasonable and consistent decisions, as indicated by their Minimum Data Set assessment. Physician orders required several lab tests, which were performed and returned with multiple abnormal results, including elevated white blood cell count, abnormal electrolyte levels, high blood glucose, impaired kidney function, and abnormal liver function tests. Despite the receipt of these abnormal lab results, there was no documentation in the resident's nursing progress notes to indicate that the results were communicated to the physician on the day they were received. The LVN stated that she printed the lab results, took photos, and texted them to the physician, believing that this method was sufficient and that further documentation in the medical record was unnecessary. This practice was contrary to facility policy, which required all care and communications, including lab data and their disposition, to be documented in the resident's medical record. The Director of Nursing confirmed that it was the responsibility of all licensed nurses to document all care provided, including communication with physicians, in the resident's medical record. Facility policies reviewed also emphasized the need for accurate and complete documentation of residents' status, care, and laboratory data in the medical record. The lack of documentation resulted in an incomplete and inaccurate depiction of the resident's well-being and had the potential to disrupt continuity of care.
Failure to Provide Written Grievance Outcomes to Resident
Penalty
Summary
The facility failed to provide the results of multiple grievances filed by a resident and/or their responsible party. The resident, who was diagnosed with amyotrophic lateral sclerosis (ALS), diabetes type 2, and major depressive disorder, was cognitively intact and able to communicate effectively. Despite submitting several grievances regarding perceived violations of resident rights and substandard care, neither the resident nor their responsible party received written updates or resolutions regarding the status of these grievances, even after repeated requests. Documentation reviewed showed that the facility investigated the grievances, but there was no indication that the outcomes or resolutions were communicated in writing to the resident or their responsible party. Interviews with facility staff confirmed that while some outcomes were discussed verbally, the resident's specific request for written updates was not honored. The Social Services Director acknowledged that written communication should have been provided, and the Director of Nursing stated that timely updates are a resident right. The facility's own grievance policy required that residents or their representatives be informed of the findings and any corrective actions in a timely manner. However, the lack of written communication regarding the resolution of grievances led to the resident feeling stressed, helpless, and distrustful of the facility. The resident escalated the complaints to the state health department due to the lack of response from the facility.
Failure to Notify Physician of Complete Change of Condition and Inadequate Follow-Up
Penalty
Summary
The facility failed to ensure timely and complete communication with a resident's physician regarding a change of condition. A resident with diagnoses including ALS, diabetes type 2, and major depressive disorder experienced symptoms such as headache, cough, congestion, and expressed fear of choking and shortness of breath. The nurse on duty documented the resident's complaints and administered medications for headache and sore throat, but only notified the physician via text message about the cough and congestion, omitting the resident's fear of choking and shortness of breath. The nurse sent two text messages to the physician during the night shift, but did not receive a response during her shift and did not follow up by calling the physician, the DON, or the Medical Director as required by facility policy. The nurse endorsed the resident's care to the oncoming nurse without further escalation. The physician eventually responded to the text messages over eight hours later, but was not made aware of the full extent of the resident's symptoms, specifically the fear of choking and shortness of breath, which would have prompted different interventions. The resident remained anxious and symptomatic throughout the night, ultimately leading to the family calling 911 and the resident being transferred to a hospital, where he was diagnosed with pneumonia secondary to COVID-19 and hypoxia. Documentation was incomplete regarding the time, method of communication, and the content of the interaction with the physician, making it difficult to ascertain the sequence of events related to physician contact and response.
Failure to Ensure Timely Physician Response to Change of Condition
Penalty
Summary
A deficiency occurred when the facility failed to ensure a physician responded in a timely manner to a resident's change of condition. The resident, who had diagnoses including amyotrophic lateral sclerosis (ALS), diabetes type 2, and major depressive disorder, began experiencing symptoms such as headache, cough, congestion, and expressed fear of choking during the night shift. The resident was cognitively intact and able to communicate his symptoms and concerns, including shortness of breath and anxiety about lying down due to fear of choking. The nurse on duty administered medications for headache and sore throat, and documented the resident's complaints, but only notified the physician via text message about the cough and congestion, omitting the resident's fear of choking and shortness of breath. The nurse sent text messages to the resident's physician at two points during the night shift, but the physician did not respond until over eight hours later, after the shift had ended. The nurse did not escalate the situation by contacting the Director of Nursing (DON) or the Medical Director when the physician failed to respond, as required by facility policy. The resident continued to experience symptoms and anxiety throughout the night, remaining upright to ease breathing, and felt that the nursing staff did not believe the severity of his symptoms. The following morning, the resident's family called 911, and the resident was transferred to a general acute care hospital, where he was diagnosed with pneumonia secondary to COVID-19 and hypoxia. Interviews with the resident, the nurse, the physician, and the DON confirmed that the physician was not informed of the full extent of the resident's symptoms, particularly the fear of choking and shortness of breath. The physician stated that he would have ordered additional interventions if he had been made aware of these symptoms. Facility policy required immediate escalation to the DON or Medical Director if the attending physician could not be reached, but this was not done. Documentation and interviews confirmed the delay in physician response and the lack of appropriate escalation.
Failure to Ensure Resident Dignity and Inform Resident of Rights
Penalty
Summary
A deficiency occurred when a certified nurse assistant (CNA) removed a resident's glasses from his hands without his permission while turning him in bed. The resident, who had diagnoses including amyotrophic lateral sclerosis (ALS), major depressive disorder, and type 2 diabetes, was cognitively intact and able to make his own decisions. The CNA did not obtain consent before taking the resident's personal belonging, and the resident reported feeling violated and distrustful of the staff as a result. The Director of Nursing (DON) and the Administrator both acknowledged that staff should not remove personal items from residents without permission, and the facility's policy confirmed this requirement. Additionally, the facility failed to provide the resident with an admission packet, which included the resident's bill of rights and information about facility policies and procedures. The Admission Coordinator admitted that the resident had not received this information or an orientation, despite having been in the facility for over ten days. The resident expressed confusion about the facility's rules and expectations and stated that he was not informed about his rights or the facility's policies, which contributed to his feelings of distrust and resistance toward staff. Interviews with facility staff confirmed that it was the responsibility of the Admission Coordinator to provide the admission packet and orientation, but all staff were responsible for ensuring residents understood their rights and facility policies. The facility's policies and procedures required that residents be treated with dignity and respect, and that they be fully informed about their rights and the facility's expectations. The failure to follow these policies resulted in the resident being unaware of his rights and feeling disrespected and confused.
Resident Injury During Mechanical Lift Transfer Without Physician Order
Penalty
Summary
A deficiency occurred when a resident diagnosed with amyotrophic lateral sclerosis (ALS), who was dependent on staff for activities of daily living, was injured during a transfer from bed to wheelchair using a mechanical lift. The resident, who was cognitively intact and at risk for falls and injuries, was being assisted by four staff members when the mechanical lift tipped to the side as the resident leaned back into the sling. During the process of detaching the sling from the lift, the sling bar struck the resident on the forehead, resulting in pain and subsequent transfer to a general acute care hospital for evaluation and treatment. The resident was found to have head and chest contusions and was treated for pain before returning to the facility. The facility's policy required a physician's order for the use of a mechanical lift, but review of the clinical records revealed that no such order was present for this resident. The Director of Nursing confirmed that the absence of a physician's order and the failure to ensure the resident's safety during the transfer led to the injury. The incident was documented in the resident's care plan and clinical records, and the facility's policy on mechanical lift use was not followed.
Failure to Provide Timely Toileting Assistance and Maintain Dignity for Continent Resident
Penalty
Summary
The facility failed to provide appropriate care and services to a resident who was alert, continent of bowel and bladder, and at high risk for pressure ulcer development. Nursing staff did not assist the resident in a timely manner to use the urinal, which was necessary to maintain bladder continence. Instead, the resident was encouraged to use an incontinence brief for staff convenience, as staff were busy with other residents, resulting in the resident being left in soiled conditions and experiencing embarrassment and discomfort. The resident's care plan and Interdisciplinary Team (IDT) assessment were not implemented to address his toileting needs. The resident was not assessed for a toileting program upon admission, and his toileting habits and needs were not discussed with him. Staff did not inquire about his continence status, and he was admitted wearing an incontinence brief, leading to the assumption that he was incontinent. The resident required assistance with holding the urinal and cleaning himself due to his medical condition, but staff only responded to his needs when he specifically requested help, and there was no scheduled toileting program in place. Interviews with staff and review of facility policies confirmed that the resident's continence status was not properly assessed or documented, and a care plan addressing his bowel and bladder needs was not developed. The lack of timely assistance and failure to respect the resident's dignity resulted in the resident feeling humiliated and increased his risk for skin breakdown. Facility policies required continence assessments and individualized care plans, but these were not followed in this case.
Inaccurate Medication Administration Documentation Due to Improper Charting and Resident Refusal
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to accurately document medication administration for a resident with amyotrophic lateral sclerosis (ALS), major depressive disorder, and type 2 diabetes. The resident, who was cognitively intact and able to make decisions, refused to accept medications from one LVN due to concerns about dignity and respect. The LVN prepared the medications and pre-charted their administration in the Medication Administration Record (MAR) before actually giving them to the resident. When the resident refused to take the medications from the first LVN, the medications were handed to a second LVN. The resident also refused to take the medications prepared by the first LVN, leading the second LVN to waste those medications and prepare a new set in the resident's presence, which the resident then accepted. Despite this, the MAR reflected the first LVN's initials for the administration, and the second LVN did not update the record to accurately show who administered the medications. Interviews with both LVNs confirmed that the first LVN pre-charted the medications and did not document the resident's refusal as required by facility policy. The second LVN acknowledged not correcting the MAR to reflect the actual administration. The facility's policy and job descriptions require accurate, timely documentation by the nurse who administers medications, including proper notation of refusals and the identity of the administering nurse. This failure resulted in inaccurate documentation of medication administration for the resident.
Failure to Secure Controlled Drugs
Penalty
Summary
The facility failed to ensure proper safeguards for controlled drugs, leading to potential risks of theft, loss, and unauthorized consumption. Specifically, the facility did not double lock Oxycodone Hydrochloride 5 mg, a narcotic for pain relief, belonging to a resident. The medication was found in an unlocked drawer in the medication room, contrary to the facility's policy requiring double locking of Schedule II medications. The resident was admitted with a diagnosis of fibromyalgia and was alert and oriented at the time of the incident. Additionally, the facility did not secure Lorazepam, a Schedule IV drug used for treating anxiety, in a locked medication refrigerator as per the facility's policy. The medication refrigerator's padlock was found lying on top of the refrigerator, leaving the medication accessible. This oversight involved another resident with epilepsy, who had severely impaired cognition and required substantial assistance with daily activities. The Director of Nursing acknowledged the failure to secure these medications properly during interviews.
Deficiencies in Food Storage and Handling Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by several deficiencies in food storage and handling. During an observation and interview with the Dietary Supervisor (DS), it was noted that five sack lunches prepared for residents going out for dialysis lacked labels indicating the preparation date. Additionally, a 32-ounce container of pasteurized liquid whole eggs in the walk-in refrigerator was found open without an open date, which the DS confirmed should have been labeled to ensure freshness and proper discard timing. DA 1, who prepared the lunches, acknowledged the oversight in not dating the lunches. Further inspection revealed a large stationary can opener with a black sticky substance on its blade and base, indicating inadequate cleaning. The DS confirmed the presence of the substance and acknowledged the need for daily cleaning of the can opener. A review of the facility's policy and procedure documents indicated that the can opener should be sanitized between uses and that all food storage products should be labeled and dated. These practices, or lack thereof, had the potential to expose residents to pathogens and increase the risk of foodborne illnesses.
Failure to Complete Advance Directives for Residents
Penalty
Summary
The facility failed to ensure that two residents, Resident 89 and Resident 2, had completed advance directive acknowledgments and POLST forms in their medical records. Resident 89, who was admitted with developmental disorder and psychosis, lacked the capacity to make decisions. The Social Service Director (SSD) stated that forms were sent to the Regional Center for completion but had no documentation to prove follow-up. The Medical Records Director (MRD) confirmed that the forms were faxed but had not received a response, leaving the advance directives incomplete in the resident's medical record. Resident 2, diagnosed with mild intellectual disability, paranoid schizophrenia, major depressive disorder, and cerebral infarction, was also found to be severely cognitively impaired and dependent on staff for self-care. The SSD indicated that paperwork was sent to the Regional Center for the advance directive acknowledgment form, but there was no record of when the fax was sent. The Director of Nursing (DON) emphasized the importance of having these forms to ensure proper treatment during emergencies. The facility's policy and procedure on advance directives require that residents be informed of their rights to execute an advance directive upon admission, and a copy should be maintained in their medical records. The policy also mandates that the Social Service Designee educate residents and families about healthcare decision-making and maintain communication to ensure resident self-determination. However, the lack of follow-up and documentation resulted in the failure to have completed advance directives for the residents, potentially delaying care and treatment during emergencies.
Failure to Implement Comprehensive Care Plans for Residents with Specific Needs
Penalty
Summary
The facility failed to implement a comprehensive care plan for two residents, leading to deficiencies in their care. Resident 2, who has an intellectual/developmental disability (IDD), did not have a care plan addressing their specific needs. The resident was admitted with multiple diagnoses, including mild intellectual disability, paranoid schizophrenia, major depressive disorder, and cerebral infarction due to thrombosis. Despite these conditions, the comprehensive care plans did not focus on the resident's IDD, likes, and dislikes. Interviews with the Registered Nurse Supervisor and the Director of Nursing highlighted the importance of a tailored care plan for communication, activities of daily living, and psychosocial needs, which were not addressed for Resident 2. Resident 50, who uses a bipap machine, also lacked a comprehensive care plan for their specific needs. The resident was admitted with diagnoses including paraplegia, acute and chronic respiratory failure with hypoxia, hypertension, and amyotrophic lateral sclerosis. The resident reported issues with the bipap machine's humidifier not being refilled by staff, causing distress and requiring the resident to set an alarm to check the humidifier at night. The MDS Coordinator confirmed the absence of a care plan for bipap use and emphasized the need for staff to conduct regular checks and interventions to ensure the resident's needs were met. The facility's policy on care planning requires a comprehensive, person-centered care plan for each resident based on their assessed needs. However, the facility failed to develop and implement such plans for Residents 2 and 50, potentially affecting their quality of life and well-being. The Director of Nursing acknowledged the importance of individualized care plans to guide staff in meeting each resident's unique needs, which was not achieved in these cases.
Inadequate Dialysis Care and Documentation for a Resident
Penalty
Summary
The facility failed to provide adequate dialysis care for a resident with end-stage renal disease and type 2 diabetes mellitus. The resident's medical records were not updated to reflect a change in the hemodialysis schedule, which was reduced to twice a week per the resident's preference. This change was not documented by the Licensed Vocational Nurse, who admitted to forgetting to chart the new schedule. Additionally, the resident's refusal to attend hemodialysis sessions on multiple occasions was not documented, and no follow-up appointments were scheduled. The medical doctor was not notified of these refusals, and there was no monitoring of the resident post-refusal. The facility also failed to report out-of-range Hemoglobin A1C levels to the medical doctor. The resident's A1C levels were significantly higher than normal on two occasions, but the physician was not informed to obtain further orders or recommendations. This lack of communication and documentation could have impacted the resident's diabetes management and overall health. Furthermore, the facility did not provide appropriate snacks for the resident on hemodialysis days. The resident reported not receiving the necessary snacks, only a protein drink, which contradicted the dialysis center's recommendations. The facility lacked a system to track and document the provision of snacks, and the kitchen was closed during the resident's early morning dialysis sessions, leading to inadequate nourishment. This oversight could have resulted in potential health issues for the resident during dialysis.
Medication Administration Deficiency for Two Residents
Penalty
Summary
The facility failed to administer prescription medications as ordered for two residents, leading to a deficiency in pharmaceutical services. Resident 20, who was admitted with diagnoses including schizophrenia, anxiety disorder, major depressive disorder, and dementia, had several medications not documented as administered in November 2024. These medications included Mirtazapine, Vitamin C, Vitamin D, Colace, multivitamin, Sucralfate, and Quetiapine. The Minimum Data Set (MDS) for Resident 20 indicated severely impaired cognitive skills for daily decision-making, requiring assistance with various activities of daily living. Similarly, Resident 75, admitted with diagnoses of dementia, major depressive disorder, generalized anxiety disorder, and psychotic disorder, also experienced lapses in medication administration. The Medication Administration Record (MAR) for November 2024 showed that doses of Atenolol, Buspirone, Fluoxetine, Memantine, and Olanzapine were not documented as given. The MDS for Resident 75 indicated intact cognitive skills for daily decision-making, with varying levels of assistance required for daily activities. The Director of Nursing confirmed that physician orders should always be implemented as ordered, including medication administration, as per the facility's policy and procedure.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Norwalk
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Intercommunity Healthcare & Rehabilitation Center | 0.4 mi | ★★★★★ | 3 | 0 |
| Norwalk Skilled Nursing & Wellness Centre, Llc | 0.7 mi | ★★★★★ | 4 | 0 |
| The Springs Post-acute | 0.7 mi | ★★★★★ | 31 | 0 |
| Southland | 1.1 mi | ★★★★★ | 33 | 0 |
| Cottage Crest Post Acute | 1.8 mi | ★★★★★ | 21 | 0 |
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